You will wake up in the operating room and will be transported in your hospital bed to the Post Anesthesia Care Unit (PACU). You will remain in the PACU for at least an hour, and then you will be taken to your hospital room on the surgical unit where your family/friends can meet you. If you have issues, you may need to be in the ICU or IMC. For example if you are starting CPAP, or you have shortness of breath, or complex medical conditions requiring intensive care, these require ICU or IMC admission. Sometimes we will keep patients in the PACU overnight.
You will remain drowsy for the rest of the day. Medications will be given through your IV for pain and/or nausea. You will be given oxygen through a nasal cannula. Your vital signs will be monitored frequently by the nursing staff. Compression stockings will be in place on your legs while you are in bed. You will probably have a catheter in place to keep your bladder empty. An incentive spirometry device will be demonstrated to you to help with deep breathing, which is very important after surgery to keep your lungs clear.
Depending on the details of your surgery, you may have a tube in your nose that passes in the back of your throat and into your new stomach/pouch (NG tube). A decision will be made either to leave an NG tube in place or to remove it, or to give you a liquid diet or not. See the "LIQUIDS" section below for details about acceptable liquids. Also, it may be necessary to perform an "X-ray leak test" after surgery. This is usually done on the first or second day after surgery. If so, you will be taken to the radiology department where you will be asked to sip on a clear x-ray contrast medium. The radiologist and technician will perform several x-rays while you swallow. If you have an NG tube, you will ignore it during the test and swallow around it. The x-rays will be reviewed by the radiologist and your surgeon, and a decision will be made either to leave an NG tube in place or to remove it, or to give you a liquid diet or not.
About the morning after surgery
You will be encouraged to use your incentive spirometer 10 times per hour
You will sit up in a chair and ambulate with the help of the nursing staff
Your urinary catheter will be removed
You will receive clear liquids (low-carb, non-carbonated), beginning with small sips
As you tolerate liquids, you will begin taking oral meds
A duragesic pain patch will be applied to control pain
An abdominal binder will be provided for extra support and comfort, if needed
If you have a drain in place, it will be removed before you are discharged
If everything is going as planned, you may not need to see Dr. Elariny prior to being discharged
You may be discharged home later in the day if you are tolerating liquids, ambulating well and have adequate pain management
Your First Post-Operative Day: Clear Liquids
You will be on Clear liquids in the hospital. See the section below for details about acceptable liquids.
Your Second and Third Post-Operative Days: Full Liquids
You will be expected to walk around daily and regularly, and be up in your chair when not walking. If you tolerated clear liquids well, you will be advanced to a Low Carbohydrate/ Full Liquid Diet. You will stay on this diet for two days.
You will need to crush or open your medicines today. Meds: Actigall (if gallbladder is not removed), Pain medication. Prevacid. Other meds for chronic medical conditions.
Your Fourth, Fifth & Sixth Post-Operative Days: Pureed Foods
You should now be able to safely begin Pureed foods. This includes baby foods, applesauce, and pureed (blended) soft foods. You will need to drink constantly to stay hydrated. You will not need to supplement with protein powder unless you have trouble eating. You will continue to crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, 2 children's chewable multivitamins with Iron. Other meds for chronic medical conditions.
Your Second Week Post-Operative: Soft Foods
You should now be able to safely begin Soft foods. This includes all items listed as pureed, all allowed liquids and items listed as soft below. This does not include New York Strip. Continue to drink constantly to stay hydrated and crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, 2 children's chewable multivitamins with Iron. Other meds for chronic medical conditions.
Your Third Week: Regular food TRIAL Period
You should now be able to safely begin "Regular" foods. This includes all previously allowed items plus red meat, chicken, well-cooked vegetables and others in the list below. This is called the TRIAL period because you are expected to try only one new item at a time. Do not rush. If you do not tolerate a regular food, avoid it and try it again in a few weeks. You may also begin trying whole pills during this time (go slow.)
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, Daily Multivitamin with Iron. Other meds for chronic medical conditions.
**You will need to take Zantac for an additional 5 months after your 1 month course of Prevacid is completed, and you will continue Actigall for 6 months after surgery.
Caloric Needs and Average Expectations
At 2 weeks: 400 Calories/day
At 3 weeks: 500 Calories/day
At 4 weeks: 600 Calories/day
At 10 weeks: 800 Calories/day
At 12 weeks: 1000 Calories/day
At 6 months: 1100 Calories/day
At 8 months: 1300 Calories/day
At 12 months: 1500 Calories/day
You will probably not need protein supplements unless you have problems with nausea and vomiting or other complications. Your "normal food" intake may be enough so that you don't need the protein powder supplement. Count your protein grams from regular foods. If you are getting 60-80 grams daily, then you are doing very well. You may be required to have blood work if your intake is not up to par. Avoid pre-mixed drinks like Ensure or other such shakes they tend to have a lot of carbohydrates and fats compared to pure protein powder mixed into water or skim milk. Your taste will determine the powder that is right for you. Options include: Designer Whey Protein, Isopure, Promod, others. Look at the ingredients: we want nearly 100% protein powder, low in carbohydrates (less then 8 grams per serving), and low in fat.
What are Clear Liquids?
· Fruit juices without added sugar - no citrus or tomato juice for the first three weeks
· Broths and thin egg-drop soup (NO crunchies or solid pieces)
· Crystal Light liquid or popsicles, Nutrasweet Kool-Aid or other sugar-free diet drinks
· Sugar-free or all-fruit popsicles
· Coffee and tea
· Sugar-free Jello
· AVOID SODAS AND CARBONATED BEVERAGES!!
What are Full Liquids?
· Skim or 1% milk
· Protein mix with water or milk
· Low fat, thin, strained cream soups such as Campbell's Cream Soup with skim milk
· Low-fat/sugar-free yogurt, puddings and ice cream with no fruit pieces
· Liquids that you cannot see through are Full Liquids
· Remember to avoid carbohydrates, sugars, fats and sodas
· Skim or 1% milk shakes --8 oz of milk with cracked ice & soft fruit processed in a blender. Add a scoop of sugar-free/fat-free ice cream if desired - you may add two tablespoons of skim milk powder for additional protein
How am I expected to consume Liquids (Both Clear and Full)?
The main goal for consuming liquids is to prevent becoming dehydrated. Liquids should be ingested slowly, but constantly throughout the day. Aim for 64-80 ozs a day.
Sip as much liquid as you can tolerate slowly and constantly. Watch your urine for a dark color or strong odor. If these develop, you need to drink more until the urine is a clear light yellow.
You may have unlimited amounts (up to 1½ gallons/day) of any liquids such as water, Crystal Light, Nutrasweet Kool-Aid, Ocean Spray Lite drinks (NOT the regular) and chicken or beef broth. You don't need to actually reach this maximum every day. If you have heart or liver problems you may be more restricted. Use your thirst and your urine output as a guide . You will be given a urinal (MEN) or a toilet "hat" (LADIES) to measure your urine in the hospital. Take this home and be sure you are making at least 240 cc's of urine every 8 hours. (Or 720 cc's per day at least).
Unsweetened juices--dilute them with water if they taste too sweet
Avoid all citrus juices and tomato juice especially during the first 3 weeks.
Try to avoid swallowing air with liquids, which occurs when you use a straw.
Avoid ALL foods and liquids with added sugar, or if sugar is one of the first three in-gredients listed. Sugars include any compound ending with -ose such as glucose, dex-trose, sucrose, fructose, maltose, as well as corn syrup and hydrolyzed starch extract.
If vomiting or retching occurs, you should stop eating for at least 2 hours and then start again slowly with sips of water.
Avoid soda and carbonated beverages forever! Carbonation is hard on your new stomach. Avoid it in any form!
What are Pureed Foods?
· Low-fat or non-fat cottage cheese
· Unsweetened applesauce or fruit puree
· Blended canned peaches in their own juice.
· Over-boiled Soups with NO MEAT such as Blended Healthy Choice, Healthy Request® and Progresso Lite
· Heavily overcooked vegetables (except corn) including potatoes cooked to a MUSH and mashed with the back of a fork
· Chopped up soft poached eggs
· Cream of Wheat®, cream of rice and grits
· Blended soft fruits -- watermelon, honeydew, cantaloupe, banana, strawberries (without seeds) or ripe peaches. These can be especially nice to add to protein supplements.
· Non-fat, sugar-free yogurt, puddings or ice cream - frozen or regular (no fruit pieces)
· Baby foods with no meat chunks
· Very tender chicken or turkey blended with broth added
What are Soft Foods?
· Canned peaches and pears in their own juice (no sweetened syrups)
· Healthy Choice, Healthy Request® and Progresso Lite. (chew chunks very well before swallowing)
· Any well-cooked vegetables (except corn), chewed very well
· Chopped up eggs: boiled, scrambled or as egg salad
· Soft fruits such as bananas, strawberries, or ripe peaches. Please be extra careful with watermelon, honeydew, cantaloupe, and the like as these are very fibrous and can cause problems if not chewed to a thin paste before swallowing.
· Canned tuna packed in water, fresh fish filets, imitation crab or real crab - cooked very soft & moist ABSOLUTELY NO BONES!
· At this point, you should be avoiding nuts, seeds and high fiber foods such as bran flakes, apples and pears, fresh vegetables and tough meats such as beef. Dry, hard or chewy foods will be very hard for your new stomach to tolerate. Make sure meats are moistened with low-fat gravy, broth or fat-free mayonnaise.
Ah yes at last! Regular foods include meats and salad items that have been restricted during the first three weeks. Remember to go very slow. Try only one thing at a time. Follow the Nibble AFTER you Dribble rule to avoid the stopped up sink effect (see below).
Acceptable Additions : Feel free to use spices, reduced-fat margarine or I Can't Believe It's Not Butter® spray, Molly McButter®, Butterbuds® garlic or onion powder, or fat-free sour cream to make your food taste better! "No sugar added" does not mean sugar-free. Artificial sweeteners are ok to use.
What about Crispy and Crunchy Foods?
CRISPY: These are allowed after one week.
· Crispy becomes MUSHY when wet
· Toasted white bread
· Corn Flakes
· Rice Krispies
CRUNCHY: These are not allowed for the first three weeks.
· Crunchy does not melt into mush quickly
· Crunchy can get stuck in your pouch and ulcerate or perforate it
· Crunchy includes uncooked veggies that crunch but don't dissolve. These fibrous items can obstruct your pouch.
· Tortillas and hard taco shells, Potato Chips, popcorn, corn chips and snack chips
· Nuts and seeds
· Grain and whole grain bread (pieces of incompletely ground grain)
Main points to remember
· Eat small bites, chew foods thoroughly and eat slowly. You need to eat (nibble) very small amounts (3-4 ounces) 3 times a day. When you try a food you have not eaten since surgery, take 1 bite to see if it is comfortable for you. Be patient--you will fill up after just a few bites at first, but this is normal; your capacity will increase during the next few days to weeks.
· If a food item is not on the prescribed list, or does not fit the food category criteria, DO NOT EAT IT! If you are not sure, write it down, and call the office during regular hours or email me anytime and ASK.
· Nibble AFTER you Dribble or DO NOT EAT AND DRINK AT THE SAME TIME! Do not eat and drink at the same time. Imagine if you put a GLOB of pudding in your sink and then turned on the water. The water would BACK UP and sit there in the sink for while before eventually going down once the pudding thinned out and decided to go down. If this were your stomach tube, that water would fill it, stretch it, back up in your throat, and cause pain and discomfort, possibly vomiting, and other problems. Now do the opposite. Put the water in there first. It will go straight through. Then put a glob of pudding in. Walk away and wait 20 to 30 minutes and come back. The pudding will have gone down. This time without all the problems associated with BACK UP. So NIBBLE AFTER you DRIBBLE to avoid the "sink effect" (Also called the GLOB effect).
· Recommendation for eating and drinking: sip slowly and constantly throughout the day. Stop drinking about 15-30 minutes before you plan to eat, eat your meal over a course of 20-35 minutes, and resume drinking fluids an hour after you have finished eating.
Post-Operative Activity Instructions
1. Be as active as possible and push yourself a little more each time you walk, etc. Wear an abdominal binder while active. A good goal to aim for is to walk at least 1 mile a day by your next office visit, taking no more than 15 - 20 minutes. You can use a treadmill (elevated a few degrees is better than flat); ride a regular or stationary bike; use the shallow end of a swimming pool for walking against resistance, but don't soak the incisions for 2 - 3 weeks. You may dangle your legs in the water if the shallow end is too deep and covers your incision.
2. Avoid any straining or heavy lifting for 3 - 6 weeks to allow your incision to heal solidly. Increase your work around the house gradually as you are able to tolerate more, but do not do ANY activity that causes you pain in your incision!
3. You may return to work as soon as you feel up to it, again avoiding putting too much stress on your wound (s) too early. You may climb stairs one at a time, and ride in a car for short trips.
4. Rest when you feel tired, but try not to sleep during the day -- it may then be more difficult to sleep at night. (6)
5. Do not drive for several days and then take only short trips at first – if you are a passenger on a long car trip, get out of the car at least once an hour and walk around to exercise your leg muscles and prevent blood clots.
6. You may resume sexual activity as soon as you want to, but be careful not to strain your incision. Remember do not become pregnant within the first 18 months.
The bottom line for any activity is: If it hurts, DON'T do it!
Post-Operative Wound Care
1. You may shower or bathe -- do not let the shower stream hit directly on the tape strips and do not rub them with your washcloth or towel; just blot them dry. They'll begin to peel up at the edges in a few days; you can then trim off the peeled-up part. If you get any blisters, peel up that portion of the strip to reduce irritation. The strips will fall off by themselves when they have done their job or we will take them off for you at your first office visit.
2. If you have any drainage from the incision, cleanse with soap & water and put on a small dressing to protect your wound and clothing. If you have a LOT of drainage, please call me.
3. You may wear tight clothing if you like a snug fit O® loose clothing if you prefer no pressure on your abdomen.
1. If you develop diarrhea (more likely if your gallbladder was just removed) for more than 24 hours, call the office for a prescription and take 3 tablets of 10 meq Potassium per day until the diarrhea is gone or for three days.
2. Do not ever take aspirin or aspirin-containing medicines such as Alka-Seltzer®, BC Powder®, Stan back Powder®, or Goody's Powder®.
3. Avoid any and all anti-inflammatory medications – over-the-counter or prescription -- such as Ibuprofen (Motrin IB®, Advil®, Nuprin®), Naprosyn®, Anaprox®, Aleve®, Voltaren®, Feldene®, Orudis®, Daypro®, Lodine® etc. unless you notify the office in advance. These products can easily cause ulcerations in your pouch. You should use Tylenol® instead of these products.
4. Use your liquid or ground pain medicine as needed.
5. Use over-the-counter chewable Dramamine® for mild nausea. Call for severe nausea or vomiting and a prescription for suppositories will be called in for you.
6. For gas pains try Gas-X®, Di-Gel®, Mylanta® (liquid or chewable form).
7. For diarrhea try Imodium AD® or Pepto-Bismol®.
8. For constipation try Benefiber, Citrucel® powder, Phillip's Milk of Magnesia®, Dulcolax® suppository, any chewable laxative, or Fleets® Oil Enema.
9. You will take an adult multivitamin with iron daily.
Follow-Up and General Info
· Food Diary : You are expected to keep a record of exactly what you eat and drink and how much of it every single meal for the first 3 weeks after surgery. This is the only way we can tell if you are getting what you need and if we need to add a protein supplement to your diet.
· Follow – Up visit : You should come in for follow-up at the office 8 to 12 days after surgery. Bring your diet log with you. Follow-ups after the one-week will be as follows: 1 month, 3 months (bring labs with you), 6 months and 1 year (bring labs with you.) You may follow up more often if you are having issues.
· Diabetes : If you have Diabetes, we will probably have reduced or discontinued your medicines. We want you to check your sugar twice daily at different times, record, and bring with you at follow-up.
· Temperature : You are expected to check your temperature at home daily and report any temperatures > 101.0 degrees.
· Incentive Spirometer : You will use at home regularly; at least 4 times daily. (This will be provided in the hospital)
· Exercise : You will exercise your calves and walk several times daily to prevent blood clots (thrombosis and pulmonary embolism.)
· Problems : You should report to the office if you are experiencing any excessive nausea, pain, dumping, vomiting, fever or wound drainage.
· Weight Checks : You may come in to the office once a month for the first year for a weight check-up. You may do this at home if your scale at home can be correlated to ours at the office. We want to know how you are doing and how you are eating. We want to know about your energy level at various times after surgery.
· Lab Values : We would like to obtain labs (Hemoglobin, Albumin, electrolyte, and sometimes vitamin levels) 3 months after surgery, sooner if you are eating poorly. You are unlikely to develop deficiencies with this type of procedure, but if symptoms develop, lab values should be checked. You will have a 1 year follow up appointment where we would again like for you to bring recent lab values with you.
o Protein – 70 grams a day on average
o Fluids – 64-80 ounces a day of good fluids such as water, crystal light, and low sugar juices. Sip on fluids slowly and constantly all day, but never at meals. Limit coffee and tea, and AVOID SODAS FOREVER!!!
o Vitamins – it is a good idea for you to take a daily multivitamin with iron. You should take 2 a day if your intake is poor or if you have complications such as nausea.
· Support: We would like for you to attend support group meetings as often as possible. A support group meeting is held every first Tuesday of the month at Fairfax Hospital in Northern Virginia. If you do not live in the area, you can keep in touch through websites or attend a WLS support group meeting in your local area.