This is just a note for my friends, you know who you are, and my family. You guys have been really supportive. I especially want to thank my husband Danny and my bestest friend Kristy. This whole situation has been tough on my and you guys have always been there to listen.
Without making this the mushiest thing I've ever written, Thank you guys!
Thursday, April 23, 2009
Endoscopy
I went for my endoscopy yesterday. I was a little scared 'cause I've never been under any anesthesia and I really didn't know what to expect. It went good though. I was in the doctor's office and they were all really nice. I went in with a killer headache though (I suffer from migraines). I threw up 2x before and it was all bile (not to be gross) because I hadn't eaten anything since about 9pm the night before.
I laid on the gurney/bed and got my IV, they stuck heart things on my chest, on each side, and on my wrist and I got a blood pressure cuff. Really, the last thing I remember is seeing the doctor and he said "let's go" and I was waking up and talking to the nurse. I still had a bit of a headache but for the most part it was gone and I was a little groggy, and hungry!
The doctor came in and told me that I had a small hiatal hernia but it was nothing to worry about. Dr. Kurian (my surgeon) said that if she saw anything, she would repair it during surgery so I'm not worried.
The only thing I don't get is that my throat, on the left side is sore but not inside, to the touch. It's a little weird but I'm not worried about it. It's just another step closer to my goal!!
I laid on the gurney/bed and got my IV, they stuck heart things on my chest, on each side, and on my wrist and I got a blood pressure cuff. Really, the last thing I remember is seeing the doctor and he said "let's go" and I was waking up and talking to the nurse. I still had a bit of a headache but for the most part it was gone and I was a little groggy, and hungry!
The doctor came in and told me that I had a small hiatal hernia but it was nothing to worry about. Dr. Kurian (my surgeon) said that if she saw anything, she would repair it during surgery so I'm not worried.
The only thing I don't get is that my throat, on the left side is sore but not inside, to the touch. It's a little weird but I'm not worried about it. It's just another step closer to my goal!!
Monday, April 20, 2009
Nutritional Informatiom
NUTRITION GUIDELINES FOR THE GASTRIC BYPASS
NOTE: Liquid diet two weeks prior to surgery
Pre-Op Liquid Diet Instructions – Start 2 weeks before surgery
Ø You will have 1000 calories per day and at least 50 grams of protein. No more than 35 grams of fat daily.
Ø Your calories will come from protein/meal replacement shakes. You are permitted to have low calorie vegetables in small portions at lunch and dinner time.
Ø We suggest the following protein/meal replacement shakes:
Brand Name Calories/ Serving Protein Drinks per day
Optifast (premade or powder available) 160 calories (may be purchased in our office) 14 g/per serving 6 per day provide 960 calories & 84 g protein
Carnation Instant Breakfast – No sugar added 150 calories (premade box or from 1 packet with skim milk) 12 g/per serving 6 per day provide 900 calories & 72 g protein
Slim Fast Optima (premade or powder) 180 calories (sold @ pharmacies or supermarket) 10 g/per serving 5 per day provide 900 calories & 50 g protein
Ensure (lactose free)
Glucerna (lactose free; diabetic formula) 240 calories (sold @ pharmacies or supermarket) 10 g/per serving 4 per day provide 960 calories & 40 g protein
Shaklee Cinch Shake Mix (kosher) 2 scoops or 1 packet 180 calories (sold health food stores) * with water 16 g/per serving 5 per day provide 900 calories & 80 g protein
Herbalife Formula 1 Shapeworks Nutritional Shake Mix (kosher) 2 scoops 90 calories (sold at health food stores) * mix with 8oz skim milk 9 g/per serving 5 per day provide 990 calories & 85 g protein
Maxi Health Naturemax Protein Powder (kosher) 1 scoop 101 calories (sold at health food stores) * mix with 8oz skim milk 28 g/per serving 5 per day provide 955 calories & 140 g protein
OTHER OPTIONS (to be used for protein supplementation or to help meet protein needs)
Pure Protein by World Wide Challenge (11 oz can) 160 calories (sold at GNC like stores) 35 g/per serving * pre-made and ready to drink
Unjury by Proynthesis Labs – 1 packet 90 calories (www.unjury.com or 800-517-5111) 20 g/per serving 180 calories & 28 g protein if mixed with skim milk
GNC Next Proteins Designer Whey 1 scoop 90 calories 18 g/per serving 180 calories & 26 g protein if mixed with skim milk
Try blending a premade shake with ice in a blender for variety.
More Pre-op Diet Instructions
(Free foods allowed on pre-op diet)
Ø You may also drink sugar free beverages throughout the day. Water, diet caffeine free soda, caffeine free diet ice tea, Crystal Light, diet lemonade, diet Snapple and the like are unlimited. You may chew sugar free gum.
Ø You may have sugar free ices. Limit to 30 calories per day.
Ø Sugar Free Jell-o is OK.
Ø Low salt broth (i.e. Herb Ox) is OK.
Ø Limit caffeinated beverages as they will make it more difficult to stay hydrated. Limit to 2 cups coffee or soda daily. Caffeine free is OK. You may have skim milk in coffee.
Ø If hungry, you are permitted to have vegetables (raw or cooked). Steamed, boiled, grilled or in a soup. Limit 2 cups daily.
Ø Permitted vegetables include lettuce, spinach, cucumber, onion, tomato, broccoli, cauliflower, carrots, mushroom, zucchini, string beans, okra, cabbage, asparagus, Brussels sprouts and peppers.
No corn, peas, potatoes, or beans - too many calories.
· Mustard, salsa, vinegar are permitted in small amounts.
· Limit fat free dressing to 2 tablespoons daily.
· NO added fats, oils, butter, margarine, mayonnaise, etc.
Ø NO ALCOHOLIC BEVERAGES ALLOWED during this time as it also impacts your liver adversely.
Ø Compliance to this pre-op diet is mandatory. Remember, this is to help shrink or "de-fat" your liver. Shrinkage of the liver makes the surgery significantly easier.
Ø Start Juice Plus supplementation. Contact Ilan Pacher for Juice Plus.
Office: (845) 425-5034; E-mail: Ilangil@aol.com
First 10 days After Surgery – Thin Liquid Diet
w For the first 10 days after the surgery you will be on a thin liquid diet. Anything that is thin enough to be sipped through a straw is fine. For example, choose caffeine-free beverages like Wyler’s Light, diet ice tea, Crystal Light, broth, skim milk, sugar free hot chocolate, tomato juice, tomato soup, water, V8 vegetable juice, Vitamin Water, Decaf coffee/tea, ices, Propel. No Jello. Avoid carbonated drinks as they may stretch your new pouch and cause gas. Drinking straws may cause gas too, and should be avoided.
w Include AT LEAST, but not limited to, 2 protein shakes per day. You should opt for a high protein shake Ensure High Protein, Slim Fast High Protein, World Wide Pure Protein, Herbalife, Shaklee or prepare your own. To prepare your own, blend one scoop of a protein powder such as Designer Whey Protein or Unjury into 4 oz. of liquid (preferably milk) with some ice. Carnation Instant Breakfast, ALBA mix, Weight Watcher shake mix can be used as well.
w Limit fluid intake to sips at a time. Sip your fluid slowly all day long. Do not gulp. HINT: Drink fluid as if you were drinking hot tea. This will prevent your pouch from stretching, and prevent nausea/vomiting. It may take 1 hour to drink 8 ounces of fluid.
w Adequate hydration prevents dehydration and constipation. Have a goal of consuming 6-8, eight oz glasses of fluid per day.
w Medications (if large) will be chewed or crushed for the first 3 weeks after surgery. You are advised to take a multivitamin supplement after surgery due to your low caloric and nutrition intake. Take 2 chewable children’s multivitamins (i.e. Flinstones). Or take an adult liquid or chewable multivitamin each day (i.e. Centrum adult multivitamin chewable or liquid, Maxi Health chewable multivitamins (kosher) or Freeda Monocaps multivitamin (kosher and vegetarian) in chewable or liquid form. Start taking a chewable calcium: Tums 400 or (chew 1 with breakfast, 1 with lunch and 1 with dinner). Take calcium 3 times/day,
* YOU WILL COME BACK IN 7-10 DAYS AFTER SURGERY FOR A CHECK UP.
Second 10 days After Surgery – Puree/Soft Diet
w You can begin eating pureed foods after your 10 days of liquids is completed. From this point on you will begin to avoid drinking with meals.
o Remember to stop drinking 30 minutes before your meal and wait 30 minutes after your meal to drink.
w Focus on a balanced healthy diet with an emphasis on protein and nutrient rich foods. Sample food ideas are below.
w To puree food, cut food into small pieces (size of an eraser) and then cook. Drain the fluid and set it aside. Blend the food and liquid (can be juice or broth, too) in a blender/food processor. Blend until applesauce consistency. Strain any lumps or pieces. Usw spices to flavor food. Final consistency should be smooth. Food Group Food Choices
HIGH PROTEIN CHOICES -> Meat, Poultry, Fish, Nuts, Beans and Eggs Chopped up soft poached eggs or scrambled eggs. Blenderized meat or poultry and flaked fish cooked very soft and moist, blenderized tuna salad with no added vegetables. Very soft meatloaf (blended), fork mashed gefilte fish and silken tofu. Non fat refried beans, hummas, creamy peanut butter.
HIGH PROTEIN CHOICES -> Milk, Cheese and Yogurt Low fat or non fat cottage cheese or ricotta cheese, sugar free custards and puddings, non-fat sweetened/sugar free yogurt, sugar free frozen yogurt and sugar free fat free ice cream
Vegetable Any vegetable (except corn) cooked soft and blended or mashed with the back of a fork. Make sure broccoli and cauliflower are cooked very well
Fruit Unsweetened applesauce, pureed canned/jarred peaches and peas in their own juice (not syrup), any fruit pureed with out the skin, mashed ripe banana
Bread, Cereal, Pasta and Rice Hot cereal – unsweetened oatmeal, cream of wheat, grits or mashed potatoes without skin
Fats and Oils Limit all
Miscellaneous Blended soups (no chunks of vegetables or meat) – limit cream soups. Try Healthy Choice, Progresso Lite and Healthy Request, egg drop soup and miso soup
Liquids (Do not drink during meals. Try and drink at least 8 (8 oz) cups of fluid per day No carbonation. Flat diet soda, skim milk or Skim Plus, Crystal Light, nutrasweet Kool-Aid, coffee, tea, all broths, any sugar free beverages, diet Snapple, Gatorade and water!
Bypass Basics
THE POST-OP DIET:
· For the first 10 days after surgery you will be on a liquid diet.
· For the second 10 days after surgery you will be on a pureed diet.
· Meals should include protein first, then fruits and vegetables, and then whole grains. Protein will help preserve lean muscle and help promote wound healing.
· Protein rich foods usually come from animal products (chicken, fish, eggs, cheese, yogurts, etc). Beans, nuts (peanut butter) and tofu and also great sources of protein.
· Avoid concentrated sugars; they can cause the "Dumping Syndrome"
· Limit fats; they can lead to nausea and weight gain
· Eat 3 small nutrient dense meals daily.
IMPORTANT EATING BEHAVIORS:
· Eat slowly - it should take 1/2 hour for each meal!
· Chew slowly and thoroughly - at least 25 times!
· Remember the stomach can only hold a few tablespoons right after surgery. Eventually it can hold abouu 1/2 to 1 cup per meal. (After 6 months a 1/2 sandwich could be a meal. After 1 year a Lean Cuisine sized entrée can be a meal.)
· Stop eating when you feel full – if ignored, vomiting will follow.
PREVENTING FOOD INTOLERANCES
· Introduce new foods one at a time in order to rule out intolerances. If a food is not tolerated, take it out of your diet for a week and reintroduce it one week later.
· If you cannot tolerate dairy, substitute Lactaid for milk. You may need to take Lactase pills with dairy to help digest the lactose.
FLUIDS:
· Drink at least 6-8 cups (8 oz) of fluid per day to prevent dehydration and constipation. You can carry a water bottle around with you.
· Stop drinking liquids 30 minutes before meals and resume 30 minutes after meals.
SUPPLEMENTS:
· Set up a schedule for supplements (refer to supplement form) and medications; remember to take Calcium with meals and separate from Iron supplements.
PHYSICAL ACTIVITY:
· Exercise! This is the key to long term maintenance of weight loss. Walking should be the main exercise for the first 6 weeks. After 6 weeks, more strenuous exercises can be added. After 6 weeks, weight lifting or using weights in your aerobic exercise is encouraged as it helps build muscle.
Dumping Syndrome
The "Dumping Syndrome" occurs when food passes rapidly from the stomach into the small intestine. Dumping can be provoked by: ingestion of concentrated sweets, overeating and consuming liquids with meals. The partially digested food in the small intestine draws water out of the blood vessels from the body into the small intestine, thereby causing the following symptoms: nausea, fullness, cramping, diarrhea, weakness, sweating and a rapid heart rate. The following foods and beverages should be avoided.
Foods to Avoid
Sugar free and artificial sweeteners are ok Ice cream Doughnut Lemonade Candy
Chocolate milk Popsicles Kool-Aid Regular Jell-O
Pudding Cakes Snapple fruit drinks Sugar gum
Sweetened, fruited/frozen yogurt Pies Sugared ice tea Molasses
Dried fruits Cookies Table Sugar Syrups
Sugar coated cereal Regular soft drinks Honey Sherbet/Sorbet
Should this syndrome occur, it usually passes within 15-20 minutes but can last for 4-6 hours. Drink lots of water or take Imodium AD or Pepto Bismol and wait for symptoms to pass.
Diet Progression after Gastric Bypass
This is a general guideline on when to add in various foods. Individual tolerance of certain foods will vary.
Ø Day 1 Post-Op: Nothing by mouth
Ø Day 2 – Day 10 Post-Op: Progress from Clears to No concentrated sweets liquid diet. Try to consume 2 oz of fluid every hour.
Ø Second 10 Days Post-Op: Puree/soft high protein diet (see attached sheet). Try and consume 4-6 oz fluids every hour. Start the habit of eating protein first and avoiding drinking with your meals. Your goal is 60 grams of protein daily.
Ø 3 Weeks Post-Op: Firm tofu, and seafood, thinly sliced deli turkey or ham, boiled dark meat chicken (cut up into small pieces) in broth, crisp toast and crackers, beans and peas, and well cooked pasta. The goal is 75 grams of protein per day. A high protein diet may prevent hair loss.
Ø 2 Months Post-Op: Rice, soft bread, lean ground meat and turkey, duck.
Ø 4 Months Post-Op: Veal, crunchy fruits and vegetables including salads.
Ø 6 Months Post-Op: Beef and pork (choose poultry and fish more often in view of lower fat content).
*** The diet should always be high in protein and low in refined carbohydrates. Protein first, then vegetables, fruits and then preferably whole grains.
Nutritional Supplements
You will require vitamin and mineral supplements for the rest of your life in order to prevent deficiencies. Remember, you are eating much less food, as well as absorbing fewer nutrients, and therefore requires supplemental vitamins, minerals and protein.
First 3 Weeks After Surgery: All pills must be chewed or crushed!
v Chewable Multi-Vitamin (chewable children’s): Flinstones Complete or Centrum Jr. with iron (chew 1 in the AM and 1 in the PM). 2/day.
v Chewable Calcium: Tums 400 or Citracel Creamy Bites 1200mg per day (chew 1 with breakfast, 1 with lunch and 1 with dinner). 3/day.
v Protein Shake: Make protein shake by choosing a protein powder (i.e.: Designer Protein, GNC Challenge 95, Whey Supreme). *1 scoop powder equals about 20 grams of protein and 100 calories. Blend 1 scoop of protein powder with ½ cup mile, ice and 2 tsp. fruit. Premade shakes are also available (i.e.: Isopure – in the clear glass bottle, Ultra Pure Protein) Have 1 shake per day as a meal replacement.
3 Weeks After Surgery: You may start swallowing pills.
v Adult Multi-Vitamin: Centrum with Iron, Geritol Complete, or GNC Ultra Mega (may need to be broken in half) once daily
v Calcium: 1200mg Calcium Citrate (i.e.: Citrical Ultra dense with Vitamin D, www.Vitalady.com brand). You can only absorb 500 mg of calcium at a time. Take throughout the day. Example: take a calcium supplement with each meal and one with a snack. If you are taking thyroid medication, take separately.
v Iron: As prescribed by your doctor. Take on an empty stomach (i.e. first thing in the morning and/or before bed). Take with vitamin C to increase absorption (chewable). Do not take with milk, calcium supplements, coffee, tea or antacids!
v Protein Shake: If unable to consume 60-70 grams of protein/day from diet, then protein supplement may be indicated (protein bar or shake).
(Labs will be followed and other supplements may be prescribed as needed.)
Sample Liquid Diet
(Day 2-Day 10 after surgery)
MORNING IDEAS
1 cup protein shake
1 cup Propel or tea or coffee
AFTERNOON IDEAS
1 cup protein shake
1/2 cup vegetable juice or water
1/2 cup "Cream" of tomato soup (tomato soup with skim milk-no chunks)
EVENING IDEAS
1 cup protein shake
1/2 cup Crystal Light or Wyler’s Light
½ cup broth
1 diet ice pop
REMINDER!
· Try to consume at least 2 high protein shakes (Slim Fast Optima High Protein, Ensure High Protein, Pure Protein, Myoplex Lite, etc.) every day! They will help give you energy and protein. It will help promote would healing and help preserve muscle.
· Shake idea: take 4 oz milk, cruhed ice, and blend with 1 scoop protein powder (i.e. Designer Whey or Isopure) to make a protein smoothie.
· HINT: The first two weeks are the most challenging! It is suggested that you avoid watching TV during this time due to the large number of food commercials. Choose other activities such as reading books, knitting, writing, using the Internet, talking on the telephone, etc., to help keep your mind off of food.
Sample Puree Diet
(Second 10 days after surgery)
BREAKFAST
2 chopped poached eggs
or
3 oz cottage cheese
or
Protein shake
LUNCH
2-3 oz moist tuna (use reduced fat mayo), 1-2 tbsp. pureed peaches
or
2-3 oz silken tofu, 1-2 tablespoons pureed broccoli
or
Protein shake
DINNER
2-3 oz flaky, moist fish, 1-2 tablespoons pureed vegetables
or
2-3 oz blended meatloaf (soft, moist), 1-2 tablespoons pureed cauliflower
** NOTE: You can always replace a meal with a shake
Estimating Your Protein Intake
Your average protein intake for the first 3 weeks after surgery is about 60 grams per day. After 3 weeks it increases to 75 grams.
v Every 1-ounce of protein (meat, poultry, fish, cheese) will have about 7 grams of protein. (i.e. 2 oz of tuna fish has about 14 grams of protein in it).
v An ounce looks like a thin deli slice of turkey or cheese or 1 prepackaged wrapped slice of cheese.
v An ounce looks like the size of a small matchbook or the size of a thumb.
v A cup of milk or yogurt has about 8 grams of protein in it.
v An egg has about 7 grams of protein.
v ½ cup of cottage cheese has 14 grams of protein.
v Read your food labels to help estimate the protein content of other foods.
IMPORTANT REMINDERS!
w Keep in mind that your diet needs to be low fat, low calorie, sugar free and portion controlled for the rest of your life. This is the commitment you must make to achieve maximal weight loss.
w If you experience increased hunger in the first 2 weeks, drink more calorie rich drinks (i.e. protein shakes, milk). Do NOT advance your diet prematurely as you will increase your chances of vomiting. You are on a thin pureed diet to help promote healing.
w If you experience excess gas make sure you are not using drinking straws as it promotes swallowing excessive air. Other possible causes of gas include Lactose Intolerance, high consumption of sugar free foods, excess dietary fiber, and calcium carbonate. Make the appropriate changes if needed. For example, try Dairy Care, lactaid milk or soy milk if you are lactose intolerant. Talk to the MD or RD about products such as GasX, Mylanta or Beano to help reduce gas.
w If you experience constipation, increase fluid, dietary fiber and physical activity as medically feasible. Fiber rich foods include beans, oatmeal, fruits, whoe grain breads and high fiber cereals. Add fiber slowly to your diet to avoid stomach upset. Increase your fluid intake as you increase your fiber intake. Talk to the MD or RD about products such as Philip’s Milk of Magnesia, Colace, or Benefiber to help with constipation.
w It is recommended that you keep a food journal. This will help you keep track of your eating habits. Bring the food journal to your nutrition followup visits to review your progress with the nutritionist.
w It is very common to hit a weight loss plateau (weight loss stops for a period of time). Most people will experience one or more plateaus during their weight loss journey. This is NORMAL!! Your body is becoming more adjusted to consuming fewer calories. At this time review your diet and your eating behaviors. Are you eating protein first? Are you limiting your fats and starches? Are you consuming “soft calorie” foods (i.e. ice cream)? Are you drinking at your meals? Review the original guidelines in this packet and adhere to them. Meet with your nutritionist to review your diet.
Ö
TOP TIPS FOR SUCCESS
Ö Chew food well (until its pureed)
§ Try cutting food into small pieces (the size of a pencil eraser).
§ Liquefy food in mouth before swallowing (chew food 15 times before you swallow).
§ Put your fork down between bites (count to 60 before you take another bite).
§ Try using cocktail forks or baby utensils to help take small bites.
Ö Watch your portion sizes at meals.
§ The less food you put in front of you, the less you will eat.
§ Use saucer plate for meals or buy small Tupperware for portion control.
Ö Stop eating when you feel comfortable satisfied.
§ It takes 20 minutes for your brain to identify that your stomach is full. When you feel a pressure in your upper stomach area, this is your new full feeling. If it is painful, you probably took one too many bites! DO NOT OVEREAT!
§ Eat slowly to recognize this feeling.
§ Keep a timer on your table when eating. Set it for 20 minutes. This visual will be a constant reminder to SLOW DOWN!
Ö Only eat when hungry.
Ö Drink adequate fluids to prevent dehydration.
§ Aim for 48-64 oz (6-8 cups) of fluid a day.
§ Do not drink and eat at the same time. Stop drinking 30 minutes before your meal then wait 30 minutes after a meal to resume drinking.
§ For the first week post-op your stomach is swollen and it may take 30-60 minutes to drink a cup of liquid. Keep sipping all day to help prevent dehydration; it gets easier as the weeks pass. Soon it will only take 5-15 minutes to finish a cup. Beverages must be sipped, no gulping!
§ Try sippy cups or sports top water bottles to slow you down, keep fluids with you all day long and keep sipping.
§ Avoid setting a glass at your place setting. It is too tempting to drink if there is a beverage at your meal.
§ Increase your fluid intake if any of the following signs are present: dark urine, headache, dizziness, confusion, a white coating on the tongue. And call your doctor.
Ö Avoid carbonated beverages and beverages containing sugar.
§ The bubbles may cause irritation and gas.
§ Choose sugar free/calorie free, non carbonated drinks such as: Crystal Light, Fruit 2O, Diet Snapple, Light Minute Mais, etc…
§ Limit caffeinated beverages to no more than 16 oz a day.
§ Caffeine can irritate the lining of the stomach and may increase your risk of developing ulcers after surgery.
§ Wean off carbonated and caffeinated beverages before surgery to help prevent withdrawals.
Ö Avoid alcohol beverages.
§ Alcohol, beer and wine, in excess, can cause weight gain and result in poor nutrition since they are high in calories and low in nutrients. Alcohol may be absorbed more quickly than before due to your small stomach. You may feel the effects of the alcohol after consuming a small amount.
Ö Read food labels.
§ Food choices should be no sugar and low in fat.
§ Foods that are high in sugar and fat may cause diarrhea and abdominal discomfort or cause “Dumping Syndrome”.
§ These poor food choices can slow down the rate of weight loss and may even cause weight gain.
§ Avoid concentrated sugar. (It’s high in calories and leaves you hungry for more!)
§ Keep sugar out of the first 3 ingredients on the food label.
§ The following ingredients are also known as sugar and commonly found on food labels: dextrose, high fructose corn syrup, glucose, sucrose molasses and honey.
§ Artificial sweeteners such as Nutrasweet/Equal, saccharine/Sweet & Low and sucralose/Splenda are acceptable to use.
§ Watch for foods containing sugar alcohol such as sorbitol. Large amount of sugar alcohol found in sugar-free candies, cookies, or ice cream may lead to cramping, abdominal pain, excess gas or diarrhea.
Ö Limit high fat foods.
§ Low fat is 3 grams or less per serving on a food label.
Ö Protein is the most important nutrient you need to consume after surgery.
§ You need at least 60-80 grams of protein a day.
§ Protein should be consumed first at each meal, then vegetables and fruits, then “whole” grains.
§ You may drink a protein supplement if you are not able to consume adequate amounts of protein.
§ Look for drinks made with whey protein isolate (this is absorbed well).
§ Strive for a protein shake with at least 20 grams of protein per serving.
§ Mix with skim or 1% milk for an additional 8 grams of protein per serving.
§ Aim for a product with less than 3 grams of sugar per serving.
Ö Exercise!
§ Aim for at least 30 minutes every day.
§ Exercise helps maintain long term weight loss.
§ The first 6 weeks, walking should be used as the primary exercise.
§ After 6 weeks, try introducing strength exercises.
§ Always speak to your doctor if you have never exercised.
NOTE: Liquid diet two weeks prior to surgery
Pre-Op Liquid Diet Instructions – Start 2 weeks before surgery
Ø You will have 1000 calories per day and at least 50 grams of protein. No more than 35 grams of fat daily.
Ø Your calories will come from protein/meal replacement shakes. You are permitted to have low calorie vegetables in small portions at lunch and dinner time.
Ø We suggest the following protein/meal replacement shakes:
Brand Name Calories/ Serving Protein Drinks per day
Optifast (premade or powder available) 160 calories (may be purchased in our office) 14 g/per serving 6 per day provide 960 calories & 84 g protein
Carnation Instant Breakfast – No sugar added 150 calories (premade box or from 1 packet with skim milk) 12 g/per serving 6 per day provide 900 calories & 72 g protein
Slim Fast Optima (premade or powder) 180 calories (sold @ pharmacies or supermarket) 10 g/per serving 5 per day provide 900 calories & 50 g protein
Ensure (lactose free)
Glucerna (lactose free; diabetic formula) 240 calories (sold @ pharmacies or supermarket) 10 g/per serving 4 per day provide 960 calories & 40 g protein
Shaklee Cinch Shake Mix (kosher) 2 scoops or 1 packet 180 calories (sold health food stores) * with water 16 g/per serving 5 per day provide 900 calories & 80 g protein
Herbalife Formula 1 Shapeworks Nutritional Shake Mix (kosher) 2 scoops 90 calories (sold at health food stores) * mix with 8oz skim milk 9 g/per serving 5 per day provide 990 calories & 85 g protein
Maxi Health Naturemax Protein Powder (kosher) 1 scoop 101 calories (sold at health food stores) * mix with 8oz skim milk 28 g/per serving 5 per day provide 955 calories & 140 g protein
OTHER OPTIONS (to be used for protein supplementation or to help meet protein needs)
Pure Protein by World Wide Challenge (11 oz can) 160 calories (sold at GNC like stores) 35 g/per serving * pre-made and ready to drink
Unjury by Proynthesis Labs – 1 packet 90 calories (www.unjury.com or 800-517-5111) 20 g/per serving 180 calories & 28 g protein if mixed with skim milk
GNC Next Proteins Designer Whey 1 scoop 90 calories 18 g/per serving 180 calories & 26 g protein if mixed with skim milk
Try blending a premade shake with ice in a blender for variety.
More Pre-op Diet Instructions
(Free foods allowed on pre-op diet)
Ø You may also drink sugar free beverages throughout the day. Water, diet caffeine free soda, caffeine free diet ice tea, Crystal Light, diet lemonade, diet Snapple and the like are unlimited. You may chew sugar free gum.
Ø You may have sugar free ices. Limit to 30 calories per day.
Ø Sugar Free Jell-o is OK.
Ø Low salt broth (i.e. Herb Ox) is OK.
Ø Limit caffeinated beverages as they will make it more difficult to stay hydrated. Limit to 2 cups coffee or soda daily. Caffeine free is OK. You may have skim milk in coffee.
Ø If hungry, you are permitted to have vegetables (raw or cooked). Steamed, boiled, grilled or in a soup. Limit 2 cups daily.
Ø Permitted vegetables include lettuce, spinach, cucumber, onion, tomato, broccoli, cauliflower, carrots, mushroom, zucchini, string beans, okra, cabbage, asparagus, Brussels sprouts and peppers.
No corn, peas, potatoes, or beans - too many calories.
· Mustard, salsa, vinegar are permitted in small amounts.
· Limit fat free dressing to 2 tablespoons daily.
· NO added fats, oils, butter, margarine, mayonnaise, etc.
Ø NO ALCOHOLIC BEVERAGES ALLOWED during this time as it also impacts your liver adversely.
Ø Compliance to this pre-op diet is mandatory. Remember, this is to help shrink or "de-fat" your liver. Shrinkage of the liver makes the surgery significantly easier.
Ø Start Juice Plus supplementation. Contact Ilan Pacher for Juice Plus.
Office: (845) 425-5034; E-mail: Ilangil@aol.com
First 10 days After Surgery – Thin Liquid Diet
w For the first 10 days after the surgery you will be on a thin liquid diet. Anything that is thin enough to be sipped through a straw is fine. For example, choose caffeine-free beverages like Wyler’s Light, diet ice tea, Crystal Light, broth, skim milk, sugar free hot chocolate, tomato juice, tomato soup, water, V8 vegetable juice, Vitamin Water, Decaf coffee/tea, ices, Propel. No Jello. Avoid carbonated drinks as they may stretch your new pouch and cause gas. Drinking straws may cause gas too, and should be avoided.
w Include AT LEAST, but not limited to, 2 protein shakes per day. You should opt for a high protein shake Ensure High Protein, Slim Fast High Protein, World Wide Pure Protein, Herbalife, Shaklee or prepare your own. To prepare your own, blend one scoop of a protein powder such as Designer Whey Protein or Unjury into 4 oz. of liquid (preferably milk) with some ice. Carnation Instant Breakfast, ALBA mix, Weight Watcher shake mix can be used as well.
w Limit fluid intake to sips at a time. Sip your fluid slowly all day long. Do not gulp. HINT: Drink fluid as if you were drinking hot tea. This will prevent your pouch from stretching, and prevent nausea/vomiting. It may take 1 hour to drink 8 ounces of fluid.
w Adequate hydration prevents dehydration and constipation. Have a goal of consuming 6-8, eight oz glasses of fluid per day.
w Medications (if large) will be chewed or crushed for the first 3 weeks after surgery. You are advised to take a multivitamin supplement after surgery due to your low caloric and nutrition intake. Take 2 chewable children’s multivitamins (i.e. Flinstones). Or take an adult liquid or chewable multivitamin each day (i.e. Centrum adult multivitamin chewable or liquid, Maxi Health chewable multivitamins (kosher) or Freeda Monocaps multivitamin (kosher and vegetarian) in chewable or liquid form. Start taking a chewable calcium: Tums 400 or (chew 1 with breakfast, 1 with lunch and 1 with dinner). Take calcium 3 times/day,
* YOU WILL COME BACK IN 7-10 DAYS AFTER SURGERY FOR A CHECK UP.
Second 10 days After Surgery – Puree/Soft Diet
w You can begin eating pureed foods after your 10 days of liquids is completed. From this point on you will begin to avoid drinking with meals.
o Remember to stop drinking 30 minutes before your meal and wait 30 minutes after your meal to drink.
w Focus on a balanced healthy diet with an emphasis on protein and nutrient rich foods. Sample food ideas are below.
w To puree food, cut food into small pieces (size of an eraser) and then cook. Drain the fluid and set it aside. Blend the food and liquid (can be juice or broth, too) in a blender/food processor. Blend until applesauce consistency. Strain any lumps or pieces. Usw spices to flavor food. Final consistency should be smooth. Food Group Food Choices
HIGH PROTEIN CHOICES -> Meat, Poultry, Fish, Nuts, Beans and Eggs Chopped up soft poached eggs or scrambled eggs. Blenderized meat or poultry and flaked fish cooked very soft and moist, blenderized tuna salad with no added vegetables. Very soft meatloaf (blended), fork mashed gefilte fish and silken tofu. Non fat refried beans, hummas, creamy peanut butter.
HIGH PROTEIN CHOICES -> Milk, Cheese and Yogurt Low fat or non fat cottage cheese or ricotta cheese, sugar free custards and puddings, non-fat sweetened/sugar free yogurt, sugar free frozen yogurt and sugar free fat free ice cream
Vegetable Any vegetable (except corn) cooked soft and blended or mashed with the back of a fork. Make sure broccoli and cauliflower are cooked very well
Fruit Unsweetened applesauce, pureed canned/jarred peaches and peas in their own juice (not syrup), any fruit pureed with out the skin, mashed ripe banana
Bread, Cereal, Pasta and Rice Hot cereal – unsweetened oatmeal, cream of wheat, grits or mashed potatoes without skin
Fats and Oils Limit all
Miscellaneous Blended soups (no chunks of vegetables or meat) – limit cream soups. Try Healthy Choice, Progresso Lite and Healthy Request, egg drop soup and miso soup
Liquids (Do not drink during meals. Try and drink at least 8 (8 oz) cups of fluid per day No carbonation. Flat diet soda, skim milk or Skim Plus, Crystal Light, nutrasweet Kool-Aid, coffee, tea, all broths, any sugar free beverages, diet Snapple, Gatorade and water!
Bypass Basics
THE POST-OP DIET:
· For the first 10 days after surgery you will be on a liquid diet.
· For the second 10 days after surgery you will be on a pureed diet.
· Meals should include protein first, then fruits and vegetables, and then whole grains. Protein will help preserve lean muscle and help promote wound healing.
· Protein rich foods usually come from animal products (chicken, fish, eggs, cheese, yogurts, etc). Beans, nuts (peanut butter) and tofu and also great sources of protein.
· Avoid concentrated sugars; they can cause the "Dumping Syndrome"
· Limit fats; they can lead to nausea and weight gain
· Eat 3 small nutrient dense meals daily.
IMPORTANT EATING BEHAVIORS:
· Eat slowly - it should take 1/2 hour for each meal!
· Chew slowly and thoroughly - at least 25 times!
· Remember the stomach can only hold a few tablespoons right after surgery. Eventually it can hold abouu 1/2 to 1 cup per meal. (After 6 months a 1/2 sandwich could be a meal. After 1 year a Lean Cuisine sized entrée can be a meal.)
· Stop eating when you feel full – if ignored, vomiting will follow.
PREVENTING FOOD INTOLERANCES
· Introduce new foods one at a time in order to rule out intolerances. If a food is not tolerated, take it out of your diet for a week and reintroduce it one week later.
· If you cannot tolerate dairy, substitute Lactaid for milk. You may need to take Lactase pills with dairy to help digest the lactose.
FLUIDS:
· Drink at least 6-8 cups (8 oz) of fluid per day to prevent dehydration and constipation. You can carry a water bottle around with you.
· Stop drinking liquids 30 minutes before meals and resume 30 minutes after meals.
SUPPLEMENTS:
· Set up a schedule for supplements (refer to supplement form) and medications; remember to take Calcium with meals and separate from Iron supplements.
PHYSICAL ACTIVITY:
· Exercise! This is the key to long term maintenance of weight loss. Walking should be the main exercise for the first 6 weeks. After 6 weeks, more strenuous exercises can be added. After 6 weeks, weight lifting or using weights in your aerobic exercise is encouraged as it helps build muscle.
Dumping Syndrome
The "Dumping Syndrome" occurs when food passes rapidly from the stomach into the small intestine. Dumping can be provoked by: ingestion of concentrated sweets, overeating and consuming liquids with meals. The partially digested food in the small intestine draws water out of the blood vessels from the body into the small intestine, thereby causing the following symptoms: nausea, fullness, cramping, diarrhea, weakness, sweating and a rapid heart rate. The following foods and beverages should be avoided.
Foods to Avoid
Sugar free and artificial sweeteners are ok Ice cream Doughnut Lemonade Candy
Chocolate milk Popsicles Kool-Aid Regular Jell-O
Pudding Cakes Snapple fruit drinks Sugar gum
Sweetened, fruited/frozen yogurt Pies Sugared ice tea Molasses
Dried fruits Cookies Table Sugar Syrups
Sugar coated cereal Regular soft drinks Honey Sherbet/Sorbet
Should this syndrome occur, it usually passes within 15-20 minutes but can last for 4-6 hours. Drink lots of water or take Imodium AD or Pepto Bismol and wait for symptoms to pass.
Diet Progression after Gastric Bypass
This is a general guideline on when to add in various foods. Individual tolerance of certain foods will vary.
Ø Day 1 Post-Op: Nothing by mouth
Ø Day 2 – Day 10 Post-Op: Progress from Clears to No concentrated sweets liquid diet. Try to consume 2 oz of fluid every hour.
Ø Second 10 Days Post-Op: Puree/soft high protein diet (see attached sheet). Try and consume 4-6 oz fluids every hour. Start the habit of eating protein first and avoiding drinking with your meals. Your goal is 60 grams of protein daily.
Ø 3 Weeks Post-Op: Firm tofu, and seafood, thinly sliced deli turkey or ham, boiled dark meat chicken (cut up into small pieces) in broth, crisp toast and crackers, beans and peas, and well cooked pasta. The goal is 75 grams of protein per day. A high protein diet may prevent hair loss.
Ø 2 Months Post-Op: Rice, soft bread, lean ground meat and turkey, duck.
Ø 4 Months Post-Op: Veal, crunchy fruits and vegetables including salads.
Ø 6 Months Post-Op: Beef and pork (choose poultry and fish more often in view of lower fat content).
*** The diet should always be high in protein and low in refined carbohydrates. Protein first, then vegetables, fruits and then preferably whole grains.
Nutritional Supplements
You will require vitamin and mineral supplements for the rest of your life in order to prevent deficiencies. Remember, you are eating much less food, as well as absorbing fewer nutrients, and therefore requires supplemental vitamins, minerals and protein.
First 3 Weeks After Surgery: All pills must be chewed or crushed!
v Chewable Multi-Vitamin (chewable children’s): Flinstones Complete or Centrum Jr. with iron (chew 1 in the AM and 1 in the PM). 2/day.
v Chewable Calcium: Tums 400 or Citracel Creamy Bites 1200mg per day (chew 1 with breakfast, 1 with lunch and 1 with dinner). 3/day.
v Protein Shake: Make protein shake by choosing a protein powder (i.e.: Designer Protein, GNC Challenge 95, Whey Supreme). *1 scoop powder equals about 20 grams of protein and 100 calories. Blend 1 scoop of protein powder with ½ cup mile, ice and 2 tsp. fruit. Premade shakes are also available (i.e.: Isopure – in the clear glass bottle, Ultra Pure Protein) Have 1 shake per day as a meal replacement.
3 Weeks After Surgery: You may start swallowing pills.
v Adult Multi-Vitamin: Centrum with Iron, Geritol Complete, or GNC Ultra Mega (may need to be broken in half) once daily
v Calcium: 1200mg Calcium Citrate (i.e.: Citrical Ultra dense with Vitamin D, www.Vitalady.com brand). You can only absorb 500 mg of calcium at a time. Take throughout the day. Example: take a calcium supplement with each meal and one with a snack. If you are taking thyroid medication, take separately.
v Iron: As prescribed by your doctor. Take on an empty stomach (i.e. first thing in the morning and/or before bed). Take with vitamin C to increase absorption (chewable). Do not take with milk, calcium supplements, coffee, tea or antacids!
v Protein Shake: If unable to consume 60-70 grams of protein/day from diet, then protein supplement may be indicated (protein bar or shake).
(Labs will be followed and other supplements may be prescribed as needed.)
Sample Liquid Diet
(Day 2-Day 10 after surgery)
MORNING IDEAS
1 cup protein shake
1 cup Propel or tea or coffee
AFTERNOON IDEAS
1 cup protein shake
1/2 cup vegetable juice or water
1/2 cup "Cream" of tomato soup (tomato soup with skim milk-no chunks)
EVENING IDEAS
1 cup protein shake
1/2 cup Crystal Light or Wyler’s Light
½ cup broth
1 diet ice pop
REMINDER!
· Try to consume at least 2 high protein shakes (Slim Fast Optima High Protein, Ensure High Protein, Pure Protein, Myoplex Lite, etc.) every day! They will help give you energy and protein. It will help promote would healing and help preserve muscle.
· Shake idea: take 4 oz milk, cruhed ice, and blend with 1 scoop protein powder (i.e. Designer Whey or Isopure) to make a protein smoothie.
· HINT: The first two weeks are the most challenging! It is suggested that you avoid watching TV during this time due to the large number of food commercials. Choose other activities such as reading books, knitting, writing, using the Internet, talking on the telephone, etc., to help keep your mind off of food.
Sample Puree Diet
(Second 10 days after surgery)
BREAKFAST
2 chopped poached eggs
or
3 oz cottage cheese
or
Protein shake
LUNCH
2-3 oz moist tuna (use reduced fat mayo), 1-2 tbsp. pureed peaches
or
2-3 oz silken tofu, 1-2 tablespoons pureed broccoli
or
Protein shake
DINNER
2-3 oz flaky, moist fish, 1-2 tablespoons pureed vegetables
or
2-3 oz blended meatloaf (soft, moist), 1-2 tablespoons pureed cauliflower
** NOTE: You can always replace a meal with a shake
Estimating Your Protein Intake
Your average protein intake for the first 3 weeks after surgery is about 60 grams per day. After 3 weeks it increases to 75 grams.
v Every 1-ounce of protein (meat, poultry, fish, cheese) will have about 7 grams of protein. (i.e. 2 oz of tuna fish has about 14 grams of protein in it).
v An ounce looks like a thin deli slice of turkey or cheese or 1 prepackaged wrapped slice of cheese.
v An ounce looks like the size of a small matchbook or the size of a thumb.
v A cup of milk or yogurt has about 8 grams of protein in it.
v An egg has about 7 grams of protein.
v ½ cup of cottage cheese has 14 grams of protein.
v Read your food labels to help estimate the protein content of other foods.
IMPORTANT REMINDERS!
w Keep in mind that your diet needs to be low fat, low calorie, sugar free and portion controlled for the rest of your life. This is the commitment you must make to achieve maximal weight loss.
w If you experience increased hunger in the first 2 weeks, drink more calorie rich drinks (i.e. protein shakes, milk). Do NOT advance your diet prematurely as you will increase your chances of vomiting. You are on a thin pureed diet to help promote healing.
w If you experience excess gas make sure you are not using drinking straws as it promotes swallowing excessive air. Other possible causes of gas include Lactose Intolerance, high consumption of sugar free foods, excess dietary fiber, and calcium carbonate. Make the appropriate changes if needed. For example, try Dairy Care, lactaid milk or soy milk if you are lactose intolerant. Talk to the MD or RD about products such as GasX, Mylanta or Beano to help reduce gas.
w If you experience constipation, increase fluid, dietary fiber and physical activity as medically feasible. Fiber rich foods include beans, oatmeal, fruits, whoe grain breads and high fiber cereals. Add fiber slowly to your diet to avoid stomach upset. Increase your fluid intake as you increase your fiber intake. Talk to the MD or RD about products such as Philip’s Milk of Magnesia, Colace, or Benefiber to help with constipation.
w It is recommended that you keep a food journal. This will help you keep track of your eating habits. Bring the food journal to your nutrition followup visits to review your progress with the nutritionist.
w It is very common to hit a weight loss plateau (weight loss stops for a period of time). Most people will experience one or more plateaus during their weight loss journey. This is NORMAL!! Your body is becoming more adjusted to consuming fewer calories. At this time review your diet and your eating behaviors. Are you eating protein first? Are you limiting your fats and starches? Are you consuming “soft calorie” foods (i.e. ice cream)? Are you drinking at your meals? Review the original guidelines in this packet and adhere to them. Meet with your nutritionist to review your diet.
Ö
TOP TIPS FOR SUCCESS
Ö Chew food well (until its pureed)
§ Try cutting food into small pieces (the size of a pencil eraser).
§ Liquefy food in mouth before swallowing (chew food 15 times before you swallow).
§ Put your fork down between bites (count to 60 before you take another bite).
§ Try using cocktail forks or baby utensils to help take small bites.
Ö Watch your portion sizes at meals.
§ The less food you put in front of you, the less you will eat.
§ Use saucer plate for meals or buy small Tupperware for portion control.
Ö Stop eating when you feel comfortable satisfied.
§ It takes 20 minutes for your brain to identify that your stomach is full. When you feel a pressure in your upper stomach area, this is your new full feeling. If it is painful, you probably took one too many bites! DO NOT OVEREAT!
§ Eat slowly to recognize this feeling.
§ Keep a timer on your table when eating. Set it for 20 minutes. This visual will be a constant reminder to SLOW DOWN!
Ö Only eat when hungry.
Ö Drink adequate fluids to prevent dehydration.
§ Aim for 48-64 oz (6-8 cups) of fluid a day.
§ Do not drink and eat at the same time. Stop drinking 30 minutes before your meal then wait 30 minutes after a meal to resume drinking.
§ For the first week post-op your stomach is swollen and it may take 30-60 minutes to drink a cup of liquid. Keep sipping all day to help prevent dehydration; it gets easier as the weeks pass. Soon it will only take 5-15 minutes to finish a cup. Beverages must be sipped, no gulping!
§ Try sippy cups or sports top water bottles to slow you down, keep fluids with you all day long and keep sipping.
§ Avoid setting a glass at your place setting. It is too tempting to drink if there is a beverage at your meal.
§ Increase your fluid intake if any of the following signs are present: dark urine, headache, dizziness, confusion, a white coating on the tongue. And call your doctor.
Ö Avoid carbonated beverages and beverages containing sugar.
§ The bubbles may cause irritation and gas.
§ Choose sugar free/calorie free, non carbonated drinks such as: Crystal Light, Fruit 2O, Diet Snapple, Light Minute Mais, etc…
§ Limit caffeinated beverages to no more than 16 oz a day.
§ Caffeine can irritate the lining of the stomach and may increase your risk of developing ulcers after surgery.
§ Wean off carbonated and caffeinated beverages before surgery to help prevent withdrawals.
Ö Avoid alcohol beverages.
§ Alcohol, beer and wine, in excess, can cause weight gain and result in poor nutrition since they are high in calories and low in nutrients. Alcohol may be absorbed more quickly than before due to your small stomach. You may feel the effects of the alcohol after consuming a small amount.
Ö Read food labels.
§ Food choices should be no sugar and low in fat.
§ Foods that are high in sugar and fat may cause diarrhea and abdominal discomfort or cause “Dumping Syndrome”.
§ These poor food choices can slow down the rate of weight loss and may even cause weight gain.
§ Avoid concentrated sugar. (It’s high in calories and leaves you hungry for more!)
§ Keep sugar out of the first 3 ingredients on the food label.
§ The following ingredients are also known as sugar and commonly found on food labels: dextrose, high fructose corn syrup, glucose, sucrose molasses and honey.
§ Artificial sweeteners such as Nutrasweet/Equal, saccharine/Sweet & Low and sucralose/Splenda are acceptable to use.
§ Watch for foods containing sugar alcohol such as sorbitol. Large amount of sugar alcohol found in sugar-free candies, cookies, or ice cream may lead to cramping, abdominal pain, excess gas or diarrhea.
Ö Limit high fat foods.
§ Low fat is 3 grams or less per serving on a food label.
Ö Protein is the most important nutrient you need to consume after surgery.
§ You need at least 60-80 grams of protein a day.
§ Protein should be consumed first at each meal, then vegetables and fruits, then “whole” grains.
§ You may drink a protein supplement if you are not able to consume adequate amounts of protein.
§ Look for drinks made with whey protein isolate (this is absorbed well).
§ Strive for a protein shake with at least 20 grams of protein per serving.
§ Mix with skim or 1% milk for an additional 8 grams of protein per serving.
§ Aim for a product with less than 3 grams of sugar per serving.
Ö Exercise!
§ Aim for at least 30 minutes every day.
§ Exercise helps maintain long term weight loss.
§ The first 6 weeks, walking should be used as the primary exercise.
§ After 6 weeks, try introducing strength exercises.
§ Always speak to your doctor if you have never exercised.
Things to expect on day of and following days
THINGS TO EXPECT TODAY
· You will be transferred from the Post-Anesthesia Care Unit (PACU) to a room on one of the surgical units.
· Your nurse will take your vital signs (blood pressure, pulse, respiration and temperature) frequently and check the dressing over your incision.
· You will not be allowed to eat or drink today.
· You may have a Sequential Compression Device (SCD) on your legs to prevent inflammation (phlebitis) and the formation of blood clots (thrombus) in your legs while you are in bed. SCDs are like loose blood pressure cuffs that massage your legs.
· You may have a Foley catheter to drain urine from your bladder.
· You will have 1 or 2 surgical drains called Jackson Pratts (JP) draining from your abdomen.
Things To Do Today
Read the section "While in the Hospital." It will explain what to expect during your hospital stay.
o Use the incentive spirometer 10 times every hour while awake. In addition, do the coughing and deep breathing exercise every 2 hours while awake.
o Turn from side to side while you are in bed, and move your legs and feet frequently. You must get out of bed and ambulate at least once. The nursing staff will assist you.
o Take your pain medication to make sure you are comfortable to increase your activity. Do the coughing and deep breathing exercises. The nurse will ask you to rate your pain using the pain scale.
If you need anything, please ask.
DAY 1 AFTER SURGERY
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will have a blood test done in the morning.
· Your Foley catheter will be removed today, if you have one.
· You will be helped to get out of bed and you should increase your activity.
· You will start ice chips today.
· You will be seen by a nutritionist for diet instructions today or tomorrow.
· The doctor and nurse will discuss the discharge plan with you. A social worker is available if needed.
· You will continue to wear the SCD’s while in bed.
Things To Do Today
Review the section “While in the Hospital.”
Days:
o Use the incentive spirometer 10 times every hour while awake. How high did you raise the ball? _____ Do coughing and deep breathing exercises every 2 hours.
o Get out of bed and ambulate (walk) in the hallway at least three times with the nursing staff’s help. When sitting out of bed, change your position frequently. Try to sit in the chair for 2 hours. You can walk to the bathroom.
o Take your pain medication as needed to enable you to increase your activity. Remember, the nurse will ask you to rate your pain before and after taking your pain medication.
o You will be discharged the day after tomorrow. Speak with your nurse or social worker if you have any concerns or questions.
Evening/Nights:
o Sit in the chair for dinner. Take a short walk in the hallway. Have a family member or friend walk with you.
o Use your incentive spirometer 10 times every hour. Do coughing and deep breathing exercises every 2 hours while awake.
o Prepare for discharge the day after tomorrow. Who will accompany you? Name _______________________ Phone # ___________________
o Speak with your nurse or social worker if you have any questions.
DAY 2 AFTER SURGERY
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will start a clear liquid diet for breakfast.
· Your PCA will be discontinued and you will receive crushed pain medications by mouth.
Things To Do Today
Read the “Going Home” section in your information packet. Make sure you read the section on “When to Call the Doctor”.
Write down any questions so you can remember to ask them.
Days:
o Use the incentive spirometer 10 times every hour while awake. How high did you raise the ball? _____ Do coughing and deep breathing exercises every 2 hours.
o Continue to get out of bed and ambulate in the hallwayWhen sitting out of bed, change your position frequently. Try to sit in the chair for 2 hours.
o Take your pain medication as needed to enable you to increase your activity. Remember, the nurse will ask you to rate your pain before and after taking your pain medication.
o You will be discharged tomorrow. Speak with your nurse or social worker if you have any concerns or questions.
Evening/Nights:
o Take your evening walk. Perhaps you can walk to the solarium for a change of scenery.
o If possible, have family members or friends take some of your belongings home today.
o Discharge time is 10 a.m. Confirm transportation home. Ask for your prescriptions.
If you need anything, please ask.
DAY 3 – DAY OF DISCHARGE
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will start a puree diet today.
· Review and sign your discharge plan.
· Your drain will be removed.
· You will be given any needed prescriptions.
· Review the special diet instructions you were given and take the information home.
Things To Do Today
o Shower or wash up.
o Sit in the chair and have breakfast.
o Look at your incision so that you can report any changes to the surgeon.
o Make sure you have any needed prescriptions.
o Find out when you need to return for a follow-up visit.
o Review the discharge plan with your nurse and sign it. Ask any final questions.
o Discharge time is 10 a.m.
· You will be transferred from the Post-Anesthesia Care Unit (PACU) to a room on one of the surgical units.
· Your nurse will take your vital signs (blood pressure, pulse, respiration and temperature) frequently and check the dressing over your incision.
· You will not be allowed to eat or drink today.
· You may have a Sequential Compression Device (SCD) on your legs to prevent inflammation (phlebitis) and the formation of blood clots (thrombus) in your legs while you are in bed. SCDs are like loose blood pressure cuffs that massage your legs.
· You may have a Foley catheter to drain urine from your bladder.
· You will have 1 or 2 surgical drains called Jackson Pratts (JP) draining from your abdomen.
Things To Do Today
Read the section "While in the Hospital." It will explain what to expect during your hospital stay.
o Use the incentive spirometer 10 times every hour while awake. In addition, do the coughing and deep breathing exercise every 2 hours while awake.
o Turn from side to side while you are in bed, and move your legs and feet frequently. You must get out of bed and ambulate at least once. The nursing staff will assist you.
o Take your pain medication to make sure you are comfortable to increase your activity. Do the coughing and deep breathing exercises. The nurse will ask you to rate your pain using the pain scale.
If you need anything, please ask.
DAY 1 AFTER SURGERY
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will have a blood test done in the morning.
· Your Foley catheter will be removed today, if you have one.
· You will be helped to get out of bed and you should increase your activity.
· You will start ice chips today.
· You will be seen by a nutritionist for diet instructions today or tomorrow.
· The doctor and nurse will discuss the discharge plan with you. A social worker is available if needed.
· You will continue to wear the SCD’s while in bed.
Things To Do Today
Review the section “While in the Hospital.”
Days:
o Use the incentive spirometer 10 times every hour while awake. How high did you raise the ball? _____ Do coughing and deep breathing exercises every 2 hours.
o Get out of bed and ambulate (walk) in the hallway at least three times with the nursing staff’s help. When sitting out of bed, change your position frequently. Try to sit in the chair for 2 hours. You can walk to the bathroom.
o Take your pain medication as needed to enable you to increase your activity. Remember, the nurse will ask you to rate your pain before and after taking your pain medication.
o You will be discharged the day after tomorrow. Speak with your nurse or social worker if you have any concerns or questions.
Evening/Nights:
o Sit in the chair for dinner. Take a short walk in the hallway. Have a family member or friend walk with you.
o Use your incentive spirometer 10 times every hour. Do coughing and deep breathing exercises every 2 hours while awake.
o Prepare for discharge the day after tomorrow. Who will accompany you? Name _______________________ Phone # ___________________
o Speak with your nurse or social worker if you have any questions.
DAY 2 AFTER SURGERY
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will start a clear liquid diet for breakfast.
· Your PCA will be discontinued and you will receive crushed pain medications by mouth.
Things To Do Today
Read the “Going Home” section in your information packet. Make sure you read the section on “When to Call the Doctor”.
Write down any questions so you can remember to ask them.
Days:
o Use the incentive spirometer 10 times every hour while awake. How high did you raise the ball? _____ Do coughing and deep breathing exercises every 2 hours.
o Continue to get out of bed and ambulate in the hallwayWhen sitting out of bed, change your position frequently. Try to sit in the chair for 2 hours.
o Take your pain medication as needed to enable you to increase your activity. Remember, the nurse will ask you to rate your pain before and after taking your pain medication.
o You will be discharged tomorrow. Speak with your nurse or social worker if you have any concerns or questions.
Evening/Nights:
o Take your evening walk. Perhaps you can walk to the solarium for a change of scenery.
o If possible, have family members or friends take some of your belongings home today.
o Discharge time is 10 a.m. Confirm transportation home. Ask for your prescriptions.
If you need anything, please ask.
DAY 3 – DAY OF DISCHARGE
Day: ___________ Date: ________________
THINGS TO EXPECT TODAY
· You will start a puree diet today.
· Review and sign your discharge plan.
· Your drain will be removed.
· You will be given any needed prescriptions.
· Review the special diet instructions you were given and take the information home.
Things To Do Today
o Shower or wash up.
o Sit in the chair and have breakfast.
o Look at your incision so that you can report any changes to the surgeon.
o Make sure you have any needed prescriptions.
o Find out when you need to return for a follow-up visit.
o Review the discharge plan with your nurse and sign it. Ask any final questions.
o Discharge time is 10 a.m.
info from the surgeon
A Patient’s Guide
INTRODUCTION
You are scheduled for admission for a Gastric Bypass or a Biliopancreatic Diversion with Duodeneal Switch, also known as Bariatric Surgery. Please read this handout, which discusses what you can expect during your stay in the hospital as well as after you go home. It describes how the members of the health care team – doctors, nurses, and others – will work with you, the most important team member, to ensure a smooth transition to home. Please share this information with your family members and/or friends.
Bring the information packet to the hospital, as staff will be reviewing it with you.
It is anticipated that you will be discharged 3 days after your surgery although this will vary depending on your individual needs. Many people are surprised at how quickly they can return home after surgery. The health care team will be helping you with any concerns you have about discharge. Included in this booklet is a list of questions to help you plan for your discharge. If you have any questions, please speak with your doctor or nurse.
BEFORE SURGERY
MD OFFICE
Once the decision has been made for surgery and insurance approval has been granted, you will be given a pre-admission packet in your doctor’s office containing information necessary to complete the admission process. This packet includes the following forms:
· Personal and insurance information for the admitting office
· Health care proxy
· Health history that you will need to complete and bring with you to Pre-Admission Testing
By this point you may have already had an endoscopy by a gastroenterologist (including H. Pylori), as well as a psychology and a nutrition consult.
PRE-ADMISSION TESTING
Several days to a week before your surgery, you will be scheduled for an appointment at Pre-Admission Testing. At this appointment you will:
· Have an interview and an assessment with a nurse and a resident/nurse practitioner from the Bariatric Service.
· Meet with an anesthesiologist who will explain the type of anesthesia you will have.
· Have blood tests and in some cases a chest x-ray and EKG. If you have had a chest x-ray in the last six months you can avoid another one by bringing the reports with you.
SPECIAL CONSIDERATIONS
It is expected that you will follow a high protein, low calorie/low fat liquid diet for 2 weeks before your surgery. One of the common side effects of obesity is fatty infiltration of the liver. This fatty liver makes surgery more difficult and may mean the difference between the surgery being performed through a laparoscope or done by a laparotomy approach (an incision that extends from the breastbone to the navel). The liver fat will be burned up quickly by this prescribed diet. Shrinkage of the liver makes the operation significantly easier.
Please refer to THE NUTRITION GUIDELINES given to you by your nutritionist for a detailed description of this liquid diet.
After 3 PM on the day before surgery:
· You must only consume clear liquids (e.g. diet gingerale, tea, broth, juice, etc.)
· Do not consume anything after 12 midnight.
ADDITIONAL PREPARATION:
· Do not eat or drink anything after midnight the night before your surgery, nor on the morning of your surgery. This includes coffee.
· Avoid aspirin, products containing aspirin and medications from the class known as non-steroidal anti-inflammatory agents (NSAID), such as ibuprofen or Naproxen for two weeks before surgery. However if you are taking aspirin once a day for heart vascular or neurological reasons, check with your doctor for specific instructions.
· If you are taking Coumadin (warfarin) check with your doctor for specific instructions.
· Stop Estrogen supplements 1 week before surgery.
· Stop any oral diabetic medications the day before surgery.
· Shower the night before or morning of surgery.
· Your physician or anesthesiologist will specifically order any medications to be taken the morning of surgery. Take these medications with a sip of water. If you are taking diuretics (water pills) make sure you get specific instructions.
· You only need to bring slippers, toiletries, and a robe to the hospital; your family can bring other items once you are assigned to a room.
· Please do not bring any valuables, such as furs, jewelry, cash or credit cards, to the hospital. Leave rings and good watches at home.
DAY OF SURGERY
Report to the Same Day Admit Unit, 400 East 34th Street, 6th Floor at the time specified. Here you will be admitted and final preparations for surgery will be completed.
· Immediately before you go to the Operating Room. You will need to change into a hospital gown and remove all jewelry, including wedding ring, dentures, etc.
· The surgery will generally take 5 hours (preparation and actual surgery) and about 2 hours in the Post-Anesthesia Care Unit (PACU).
· Your visitors can wait in the Same Day Admit waiting area (maximum of 2 visitors), or in the Stoler Family Waiting Area in the Tisch Hospital lobby. Identify one contact person and let the surgeon’s office know where he/she can be reached after surgery.
Immediately after surgery you will be taken to the PACU on the 6th floor until the effects of the anesthesia wear off. Generally, from the PACU you will be transferred to a room on one of the surgical floors. Visitors are not allowed in the PACU but your family members or friends will be able to visit you soon after you are transferred to your room.
WHILE IN THE HOSPITAL
The following are general guidelines regarding what you can expect during your stay in the hospital. The Patient Pathway included in this packet explains on a daily basis what you can expect and what you can do.
ASSESSMENT:
· Your nurse will closely monitor your condition. Initially after surgery, your blood pressure, pulse, and temperature will be taken frequently.
DIET:
· The night of surgery you will not be allowed to eat or drink anything, but you will have fluids intravenously.
· The next day you will be given ice chips.
· The second day after surgery, you will receive a clear liquid diet.
· If you tolerate liquids you will have a puree diet by the third postoperative day. However, the nutritionist will instruct you on the pureed diet you need to follow after surgery. In addition, all your medications while you are in the hospital will be crushed or in liquid form. Have your family check with the nurse before giving you anything to eat or drink.
· Remember to eat 1-2 tablespoons of food several times a day.
· Sip liquids during the entire day but stop 1/2 hour before meals and restart 1/2 hour after meals. You should drink at least 6-8 cups a day. Liquids should include: Diet Snapple Flat Diet Soda
Water Decaf Tea/Coffee
Gatorade – 3 times a day Skim Milk or Lactaid
Broth
ACTIVITY:
· It is very important to get out of bed and walk around at least once after surgery. The first time you get out of bed the nursing staff will help you. You will progress to walking in the hallway independently the day after surgery.
· You will be encouraged to get out of bed as much as possible and increase your activity level as tolerated. This increase in activity level decreases the risk of blood clots in the legs and an infection in your lungs (pneumonia).
COUGHING/DEEP BREATHING:
· Your nurse will show you how to do some simple deep breathing and coughing exercises. You should do these every 2 hours while awake.
· In addition, you will to use the Incentive Spirometer. You should use it 10 times every hour while you are awake in order to prevent lung problems after surgery.
LEG EXERCISES:
· You will be instructed to perform simple leg exercises in order to maintain adequate circulation when in bed. It is very important that you do these exercises as recommended. An example of leg exercises are ankle pumping (ankle isotonics) where you pull your toes back toward your knees as far as you can and then move them forward as far as you can.
· In addition, a Sequential Compression Device (SCD) may be used while you are in bed. This device helps to improve circulation and minimize inflammation (phlebitis) and the formation of blood clots (thrombus) in your legs. SCDs are like loose blood pressure cuffs that massage your legs.
PAIN MANAGEMENT:
· You need to let the staff know your level of pain/discomfort after surgery so that the nurse can give you the pain medication the surgeon has ordered.
· The most pain will be felt in the left upper incision after a Gastric Bypass and in the right upper incision after a Biliopancreatic Diversion with Duodenal Switch. This is because most of the operation is performed through the incisions, respectively.
· To help the staff assess your pain level you will be asked to rate your pain on a scale of 0-10 with 0 being no pain and 10 being unbearable pain. Taking pain medication before the pain is excessive provides better relief.
· Right after your surgery you may receive pain medications into a vein using a process called Patient Controlled Analgesia (PCA) or into a muscle for pain relief. These options are explained in a separate section.
· Your surgeon will determine the most appropriate medication for your specific needs. As your level of discomfort decreases and you are able to tolerate liquids and food, you will receive crushed pills or liquid medication for pain management.
· In addition, since it is important that you do the coughing and deep breathing exercises and increase your activity, it may be helpful to take pain medications prior to these activities.
BOWEL AND BLADDER FUNCTIONS:
· You may experience some constipation after surgery. Increasing fluids can minimize this. Walking and increasing your activity is the most effective method of relieving gas pain, if it occurs.
· A catheter is usually inserted during surgery to drain urine from the bladder. This catheter will generally be removed the first day after surgery.
CARE OF YOUR INCISIONS:
· Your stitches are absorbable and they are covered with steri-strips. Eventually, the strei-strips will come off by themselves while you are at home.
· The steri-strips over your incisions will not need a dressing.
· Look at your incisions before you go home so that you can report any changes to your surgeon.
· Your nurse will discuss any special instructions regarding caring for you incision.
DRAINS:
· You will have one or two surgical drains coming from your abdominal area. These drains are called Jackson Pratts and are placed during surgery to help remove unnecessary fluid from your body. These drains are not painful while they are in place. You may just experience a “tugging” sensation when you move.
· The drains will be removed before you are discharged. You may feel some “pulling” or “pressure” while the drains are being removed. Your nurse can five you some pain medication prior to the removal of these drains.
DISCHARGE PROCEDURE:
· You will be discharged 3 days after surgery, although this will depend on your specific needs.
· Your nurse and doctor will discuss specific discharge information at this time, as if needed, you will receive prescriptions.
· Your nutritionist will instruct you on the diet that you will need to follow at home.
· Discharge time is 10:00 am.
GENERAL DISCHARGE INSTRUCTIONS
DIET:
· Your diet will continue to be pureed foods and fluids for 3 weeks as instructed by your nutritionist.
· Water may cause gurgling, cramping or nausea. Try adding a little bbit of juice, ice tea, or Gatorade.
· Try not to eat too fast or too much. This may cause nausea or vomiting. Chew all food thoroughly.
· You will be expected to follow up with the nutritionist 3 weeks after discharge on the same day that you see your surgeon. Your next appointment from then will be 3 months after discharge.
· Beware of “Dumping Syndrome” after Gastric Bypass. Dumping Syndrome is when the contents of the stomach empties too rapidly into the small intestine and causes a combination of profuse sweating, nausea, dizziness, and weakness. Therefore, avoid concentrated sweets and follow the nutritionist’s instructions.
ACTIVITY AFTER DISCHARGE:
· You will be encouraged to walk often as tolerated. Do not exert yourself. Allow yourself to increase your activity level slowly. It is expected that you may tire more easily for a while after surgery, but gradually the periods of activity will get longer before you need to rest.
· No heavy lifting (greater than 5-10 lbs.) or housework (vacuuming, etc.) should be done until your doctor grants permission, usually 1-2 weeks. Light housework is permitted.
· Climbing stairs is generally permitted but it is usually recommended that you climb them slowly and pause after every few steps.
· Continue to use your incentive spirometer at home along with coughing and deep breathing exercises.
· You may shower when you get home but no bathing or swimming for 2 weeks after discharge.
· No driving for 1-2 weeks.
· You can start walking on a treadmill 1 week after discharge.
· You can usually resume sexual relations in 2 weeks after discharge. Check with your doctor.
CARE OF YOUR INCISIONS:
· Generally, your steri-strips will come off by themselves. If they do, not come off within 2 weeks after discharge, you may remove them yourself.
· You can expect some pain, bruising, and clear drainage at the incision sites; but if the incisions become red, more painful or swollen, or if the drainage becomes cloudy or foul smelling, call your doctor immediately.
MEDICATIONS:
· You can resume your usual medications 2 days after surgery. The endocrinologist will adjust medication(s). You will be off Diabetic medication within days or weeks after surgery.
· You should see your primary doctor to adjust your other preoperative medications, such as for hypertension or increased cholesterol levels.
· You should continue to take medications in a crushed or liquid form for 3 weeks after surgery. Start Flinstones chewables twice a day and Tums 500 2-3 times a day when you get home. The nutritionist will outline medication specifics.
· At 3 weeks after discharge, start Actigall 300 mg once a day for 6 months to prevent gallstones. This prescription will be given to you at your follow-up appointment.
· At 3 weeks after discharge, change to a multivitamin pill from Flinstones chewables. In addition, begin taking Niferex, a combination of Iron and B vitamins. The nutritionist will outline medication specifics.
BLADDER AND BOWEL FUNCTION:
· You should be able to pass urine without difficulty. Call your doctor if you experience any burning, pain, bleeding, hesitancy, or frequency.
· You may experience some constipation after surgery. You are allowed to take Milk of Magnesia if necessary. If constipation does not resolve in the first week, call your doctor.
· You may experience diarrhea for several days after surgery. If diarrhea persists beyond one week after discharge, call your doctor. This is more common after the Biliopancreatic Diversion with Duodenal Switch.
REST/SLEEP:
· Your recovery will take several weeks depending on your age and general health. Feelings of fatigue are normal, and you should try to rest as needed.
RETURN VISIT TO YOUR DOCTOR:
· You will be expected to see your doctor 3 weeks after discharge. You will also be expected to see the doctor at 3, 6, 9, and 12 months after surgery and then yearly thereafter.
· Call your surgeon’s office to arrange an appointment.
RETURN TO WORK:
· Generally, you can return to work 1 week after surgery.
WHEN SHOULD I CALL ' THE DOCTOR?
Contact your doctor for the following symptoms (possible danger signs):
· Increased pain, swelling, or redness of incision. An infection will require antibiotics.
· Drainage from the incisions sites that is cloudy or foul smelling.
· Fever over 100.8OF on two or more occasions during the first 1-3 weeks after surgery. For a reliable temperature reading, no aspirin, acetaminophen (Tylenol), ibuprofen, should be taken for 3-4 hours before. Hot liquids should not be taken immediately before taking your temperature.
· A fast heart rate, usually greater than 120 beats per minute (Place your index finger over your pulse on the inside of your wrist nearest your thumb; count the number of beats for 15 seconds and multiply by 4).
· Rigors or night sweats.
· Persistent pain, nausea, and/or vomiting after eating.
· Persistent diarrhea beyond the first week after discharge. Diarrhea after eating fatty foods is normal after Biliopancreatic Diversion with Duodenal Switch.
· New onset of upper back, check, or left shoulder pain for more than 2 hours.
· Prolonged or unusual fatigue, disorientation, confusion, and depression.
· Signs of a bladder infection such as burning, pain, bleeding, hesitancy, or frequency in urinating. If a bladder infection is suspected, a urinalysis must be done. A course of antibiotics will generally resolve the problem.
After you have completed reading this handout, please speak to your nurse regarding any additional questions or concerns you may have. Please remember that we would like to make your stay as comfortable as possible.
Thank you.
SURGEON’S NAME: _________________________________________________
SURGEON’S NUMBER: ______________________________________________
YOUR NEXT OFFICE VISIT/APPOINTMENT: __________________________
RESOURCES
ANATOMY OF THE GASTROINTESTINAL SYSTEM
THE GASTROINTESTINAL SYSTEM is composed of the following:
The STOMACH is the food reservoir and the first major site of digestion. It received partially processed food and drink from the mouth and gradually feeds liquefied food into the small intestine. Food must pass through a valve called the pylorus.
The LIVER is the largest gland of the body. Some of the major functions performed by the liver are the production of bile, secretion of glucose, proteins, vitamins, and fats.
The PANCREAS is an elongated gland that stretches horizontally across the abdomen. It secretes various substances such as digestive enzymes, insulin, and glucagons. Through a series of ducts, the pancreas secretes these substances into the duodenum of the small intestine to aid in digestion.
The SMALL INTESTINE is the longest part of the digestive system extending from the bottom of the stomach to the large intestine. It is divided into three areas: (a) the duodenum, (b) the jejunum, and (c) the ileum. It functions in digestion and is the major organ that absorbs prepared food, vitamins, and minerals. It is about 500 cm or 15 feet long.
The LARGE INTESTINE is the lower part of the digestive tract that is responsible for reabsorbing liquids from the small intestine.
GASTRIC BYPASS OR BILIOPANCREATIC DUVERSION SURGERY
The following surgeries are performed using a laproscope, which is inserted through a small incision on your abdomen. You will usually have 6 incisions on your abdomen.
A GASTRIC BYPASS is a restrictive surgery where a small pouch is made at the upper portion of the stomach, which can hold only 1-2 tablespoons in volume. This means you will feel full with only a small amount of food and your intake is restricted. This pouch is connected to a piece of small bowel through a Y-shaped connection, giving it the name Roux-en Y gastric bypass.
A BILIOPANCREATIC DIVERSION with Duodenal Switch is a malabsorptive surgery that causes food to be poorly digested and absorbed. A larger stomach pouch is made that can hold 2-3 cups of volume. The duodenum, which stays connected to the new stomach pouch is cut in half and re-connected to the ileum. Almost 9 feet of small intestine is bypassed. All the enzymes and bile from the liver and pancreas meet ingested food further down in the ileum, at about 100 cm (3 feet) from the large intestine (colon). This means food is digested and absorbed in only 3 feet of intestine before it enters the large intestine.
INTRODUCTION
You are scheduled for admission for a Gastric Bypass or a Biliopancreatic Diversion with Duodeneal Switch, also known as Bariatric Surgery. Please read this handout, which discusses what you can expect during your stay in the hospital as well as after you go home. It describes how the members of the health care team – doctors, nurses, and others – will work with you, the most important team member, to ensure a smooth transition to home. Please share this information with your family members and/or friends.
Bring the information packet to the hospital, as staff will be reviewing it with you.
It is anticipated that you will be discharged 3 days after your surgery although this will vary depending on your individual needs. Many people are surprised at how quickly they can return home after surgery. The health care team will be helping you with any concerns you have about discharge. Included in this booklet is a list of questions to help you plan for your discharge. If you have any questions, please speak with your doctor or nurse.
BEFORE SURGERY
MD OFFICE
Once the decision has been made for surgery and insurance approval has been granted, you will be given a pre-admission packet in your doctor’s office containing information necessary to complete the admission process. This packet includes the following forms:
· Personal and insurance information for the admitting office
· Health care proxy
· Health history that you will need to complete and bring with you to Pre-Admission Testing
By this point you may have already had an endoscopy by a gastroenterologist (including H. Pylori), as well as a psychology and a nutrition consult.
PRE-ADMISSION TESTING
Several days to a week before your surgery, you will be scheduled for an appointment at Pre-Admission Testing. At this appointment you will:
· Have an interview and an assessment with a nurse and a resident/nurse practitioner from the Bariatric Service.
· Meet with an anesthesiologist who will explain the type of anesthesia you will have.
· Have blood tests and in some cases a chest x-ray and EKG. If you have had a chest x-ray in the last six months you can avoid another one by bringing the reports with you.
SPECIAL CONSIDERATIONS
It is expected that you will follow a high protein, low calorie/low fat liquid diet for 2 weeks before your surgery. One of the common side effects of obesity is fatty infiltration of the liver. This fatty liver makes surgery more difficult and may mean the difference between the surgery being performed through a laparoscope or done by a laparotomy approach (an incision that extends from the breastbone to the navel). The liver fat will be burned up quickly by this prescribed diet. Shrinkage of the liver makes the operation significantly easier.
Please refer to THE NUTRITION GUIDELINES given to you by your nutritionist for a detailed description of this liquid diet.
After 3 PM on the day before surgery:
· You must only consume clear liquids (e.g. diet gingerale, tea, broth, juice, etc.)
· Do not consume anything after 12 midnight.
ADDITIONAL PREPARATION:
· Do not eat or drink anything after midnight the night before your surgery, nor on the morning of your surgery. This includes coffee.
· Avoid aspirin, products containing aspirin and medications from the class known as non-steroidal anti-inflammatory agents (NSAID), such as ibuprofen or Naproxen for two weeks before surgery. However if you are taking aspirin once a day for heart vascular or neurological reasons, check with your doctor for specific instructions.
· If you are taking Coumadin (warfarin) check with your doctor for specific instructions.
· Stop Estrogen supplements 1 week before surgery.
· Stop any oral diabetic medications the day before surgery.
· Shower the night before or morning of surgery.
· Your physician or anesthesiologist will specifically order any medications to be taken the morning of surgery. Take these medications with a sip of water. If you are taking diuretics (water pills) make sure you get specific instructions.
· You only need to bring slippers, toiletries, and a robe to the hospital; your family can bring other items once you are assigned to a room.
· Please do not bring any valuables, such as furs, jewelry, cash or credit cards, to the hospital. Leave rings and good watches at home.
DAY OF SURGERY
Report to the Same Day Admit Unit, 400 East 34th Street, 6th Floor at the time specified. Here you will be admitted and final preparations for surgery will be completed.
· Immediately before you go to the Operating Room. You will need to change into a hospital gown and remove all jewelry, including wedding ring, dentures, etc.
· The surgery will generally take 5 hours (preparation and actual surgery) and about 2 hours in the Post-Anesthesia Care Unit (PACU).
· Your visitors can wait in the Same Day Admit waiting area (maximum of 2 visitors), or in the Stoler Family Waiting Area in the Tisch Hospital lobby. Identify one contact person and let the surgeon’s office know where he/she can be reached after surgery.
Immediately after surgery you will be taken to the PACU on the 6th floor until the effects of the anesthesia wear off. Generally, from the PACU you will be transferred to a room on one of the surgical floors. Visitors are not allowed in the PACU but your family members or friends will be able to visit you soon after you are transferred to your room.
WHILE IN THE HOSPITAL
The following are general guidelines regarding what you can expect during your stay in the hospital. The Patient Pathway included in this packet explains on a daily basis what you can expect and what you can do.
ASSESSMENT:
· Your nurse will closely monitor your condition. Initially after surgery, your blood pressure, pulse, and temperature will be taken frequently.
DIET:
· The night of surgery you will not be allowed to eat or drink anything, but you will have fluids intravenously.
· The next day you will be given ice chips.
· The second day after surgery, you will receive a clear liquid diet.
· If you tolerate liquids you will have a puree diet by the third postoperative day. However, the nutritionist will instruct you on the pureed diet you need to follow after surgery. In addition, all your medications while you are in the hospital will be crushed or in liquid form. Have your family check with the nurse before giving you anything to eat or drink.
· Remember to eat 1-2 tablespoons of food several times a day.
· Sip liquids during the entire day but stop 1/2 hour before meals and restart 1/2 hour after meals. You should drink at least 6-8 cups a day. Liquids should include: Diet Snapple Flat Diet Soda
Water Decaf Tea/Coffee
Gatorade – 3 times a day Skim Milk or Lactaid
Broth
ACTIVITY:
· It is very important to get out of bed and walk around at least once after surgery. The first time you get out of bed the nursing staff will help you. You will progress to walking in the hallway independently the day after surgery.
· You will be encouraged to get out of bed as much as possible and increase your activity level as tolerated. This increase in activity level decreases the risk of blood clots in the legs and an infection in your lungs (pneumonia).
COUGHING/DEEP BREATHING:
· Your nurse will show you how to do some simple deep breathing and coughing exercises. You should do these every 2 hours while awake.
· In addition, you will to use the Incentive Spirometer. You should use it 10 times every hour while you are awake in order to prevent lung problems after surgery.
LEG EXERCISES:
· You will be instructed to perform simple leg exercises in order to maintain adequate circulation when in bed. It is very important that you do these exercises as recommended. An example of leg exercises are ankle pumping (ankle isotonics) where you pull your toes back toward your knees as far as you can and then move them forward as far as you can.
· In addition, a Sequential Compression Device (SCD) may be used while you are in bed. This device helps to improve circulation and minimize inflammation (phlebitis) and the formation of blood clots (thrombus) in your legs. SCDs are like loose blood pressure cuffs that massage your legs.
PAIN MANAGEMENT:
· You need to let the staff know your level of pain/discomfort after surgery so that the nurse can give you the pain medication the surgeon has ordered.
· The most pain will be felt in the left upper incision after a Gastric Bypass and in the right upper incision after a Biliopancreatic Diversion with Duodenal Switch. This is because most of the operation is performed through the incisions, respectively.
· To help the staff assess your pain level you will be asked to rate your pain on a scale of 0-10 with 0 being no pain and 10 being unbearable pain. Taking pain medication before the pain is excessive provides better relief.
· Right after your surgery you may receive pain medications into a vein using a process called Patient Controlled Analgesia (PCA) or into a muscle for pain relief. These options are explained in a separate section.
· Your surgeon will determine the most appropriate medication for your specific needs. As your level of discomfort decreases and you are able to tolerate liquids and food, you will receive crushed pills or liquid medication for pain management.
· In addition, since it is important that you do the coughing and deep breathing exercises and increase your activity, it may be helpful to take pain medications prior to these activities.
BOWEL AND BLADDER FUNCTIONS:
· You may experience some constipation after surgery. Increasing fluids can minimize this. Walking and increasing your activity is the most effective method of relieving gas pain, if it occurs.
· A catheter is usually inserted during surgery to drain urine from the bladder. This catheter will generally be removed the first day after surgery.
CARE OF YOUR INCISIONS:
· Your stitches are absorbable and they are covered with steri-strips. Eventually, the strei-strips will come off by themselves while you are at home.
· The steri-strips over your incisions will not need a dressing.
· Look at your incisions before you go home so that you can report any changes to your surgeon.
· Your nurse will discuss any special instructions regarding caring for you incision.
DRAINS:
· You will have one or two surgical drains coming from your abdominal area. These drains are called Jackson Pratts and are placed during surgery to help remove unnecessary fluid from your body. These drains are not painful while they are in place. You may just experience a “tugging” sensation when you move.
· The drains will be removed before you are discharged. You may feel some “pulling” or “pressure” while the drains are being removed. Your nurse can five you some pain medication prior to the removal of these drains.
DISCHARGE PROCEDURE:
· You will be discharged 3 days after surgery, although this will depend on your specific needs.
· Your nurse and doctor will discuss specific discharge information at this time, as if needed, you will receive prescriptions.
· Your nutritionist will instruct you on the diet that you will need to follow at home.
· Discharge time is 10:00 am.
GENERAL DISCHARGE INSTRUCTIONS
DIET:
· Your diet will continue to be pureed foods and fluids for 3 weeks as instructed by your nutritionist.
· Water may cause gurgling, cramping or nausea. Try adding a little bbit of juice, ice tea, or Gatorade.
· Try not to eat too fast or too much. This may cause nausea or vomiting. Chew all food thoroughly.
· You will be expected to follow up with the nutritionist 3 weeks after discharge on the same day that you see your surgeon. Your next appointment from then will be 3 months after discharge.
· Beware of “Dumping Syndrome” after Gastric Bypass. Dumping Syndrome is when the contents of the stomach empties too rapidly into the small intestine and causes a combination of profuse sweating, nausea, dizziness, and weakness. Therefore, avoid concentrated sweets and follow the nutritionist’s instructions.
ACTIVITY AFTER DISCHARGE:
· You will be encouraged to walk often as tolerated. Do not exert yourself. Allow yourself to increase your activity level slowly. It is expected that you may tire more easily for a while after surgery, but gradually the periods of activity will get longer before you need to rest.
· No heavy lifting (greater than 5-10 lbs.) or housework (vacuuming, etc.) should be done until your doctor grants permission, usually 1-2 weeks. Light housework is permitted.
· Climbing stairs is generally permitted but it is usually recommended that you climb them slowly and pause after every few steps.
· Continue to use your incentive spirometer at home along with coughing and deep breathing exercises.
· You may shower when you get home but no bathing or swimming for 2 weeks after discharge.
· No driving for 1-2 weeks.
· You can start walking on a treadmill 1 week after discharge.
· You can usually resume sexual relations in 2 weeks after discharge. Check with your doctor.
CARE OF YOUR INCISIONS:
· Generally, your steri-strips will come off by themselves. If they do, not come off within 2 weeks after discharge, you may remove them yourself.
· You can expect some pain, bruising, and clear drainage at the incision sites; but if the incisions become red, more painful or swollen, or if the drainage becomes cloudy or foul smelling, call your doctor immediately.
MEDICATIONS:
· You can resume your usual medications 2 days after surgery. The endocrinologist will adjust medication(s). You will be off Diabetic medication within days or weeks after surgery.
· You should see your primary doctor to adjust your other preoperative medications, such as for hypertension or increased cholesterol levels.
· You should continue to take medications in a crushed or liquid form for 3 weeks after surgery. Start Flinstones chewables twice a day and Tums 500 2-3 times a day when you get home. The nutritionist will outline medication specifics.
· At 3 weeks after discharge, start Actigall 300 mg once a day for 6 months to prevent gallstones. This prescription will be given to you at your follow-up appointment.
· At 3 weeks after discharge, change to a multivitamin pill from Flinstones chewables. In addition, begin taking Niferex, a combination of Iron and B vitamins. The nutritionist will outline medication specifics.
BLADDER AND BOWEL FUNCTION:
· You should be able to pass urine without difficulty. Call your doctor if you experience any burning, pain, bleeding, hesitancy, or frequency.
· You may experience some constipation after surgery. You are allowed to take Milk of Magnesia if necessary. If constipation does not resolve in the first week, call your doctor.
· You may experience diarrhea for several days after surgery. If diarrhea persists beyond one week after discharge, call your doctor. This is more common after the Biliopancreatic Diversion with Duodenal Switch.
REST/SLEEP:
· Your recovery will take several weeks depending on your age and general health. Feelings of fatigue are normal, and you should try to rest as needed.
RETURN VISIT TO YOUR DOCTOR:
· You will be expected to see your doctor 3 weeks after discharge. You will also be expected to see the doctor at 3, 6, 9, and 12 months after surgery and then yearly thereafter.
· Call your surgeon’s office to arrange an appointment.
RETURN TO WORK:
· Generally, you can return to work 1 week after surgery.
WHEN SHOULD I CALL ' THE DOCTOR?
Contact your doctor for the following symptoms (possible danger signs):
· Increased pain, swelling, or redness of incision. An infection will require antibiotics.
· Drainage from the incisions sites that is cloudy or foul smelling.
· Fever over 100.8OF on two or more occasions during the first 1-3 weeks after surgery. For a reliable temperature reading, no aspirin, acetaminophen (Tylenol), ibuprofen, should be taken for 3-4 hours before. Hot liquids should not be taken immediately before taking your temperature.
· A fast heart rate, usually greater than 120 beats per minute (Place your index finger over your pulse on the inside of your wrist nearest your thumb; count the number of beats for 15 seconds and multiply by 4).
· Rigors or night sweats.
· Persistent pain, nausea, and/or vomiting after eating.
· Persistent diarrhea beyond the first week after discharge. Diarrhea after eating fatty foods is normal after Biliopancreatic Diversion with Duodenal Switch.
· New onset of upper back, check, or left shoulder pain for more than 2 hours.
· Prolonged or unusual fatigue, disorientation, confusion, and depression.
· Signs of a bladder infection such as burning, pain, bleeding, hesitancy, or frequency in urinating. If a bladder infection is suspected, a urinalysis must be done. A course of antibiotics will generally resolve the problem.
After you have completed reading this handout, please speak to your nurse regarding any additional questions or concerns you may have. Please remember that we would like to make your stay as comfortable as possible.
Thank you.
SURGEON’S NAME: _________________________________________________
SURGEON’S NUMBER: ______________________________________________
YOUR NEXT OFFICE VISIT/APPOINTMENT: __________________________
RESOURCES
ANATOMY OF THE GASTROINTESTINAL SYSTEM
THE GASTROINTESTINAL SYSTEM is composed of the following:
The STOMACH is the food reservoir and the first major site of digestion. It received partially processed food and drink from the mouth and gradually feeds liquefied food into the small intestine. Food must pass through a valve called the pylorus.
The LIVER is the largest gland of the body. Some of the major functions performed by the liver are the production of bile, secretion of glucose, proteins, vitamins, and fats.
The PANCREAS is an elongated gland that stretches horizontally across the abdomen. It secretes various substances such as digestive enzymes, insulin, and glucagons. Through a series of ducts, the pancreas secretes these substances into the duodenum of the small intestine to aid in digestion.
The SMALL INTESTINE is the longest part of the digestive system extending from the bottom of the stomach to the large intestine. It is divided into three areas: (a) the duodenum, (b) the jejunum, and (c) the ileum. It functions in digestion and is the major organ that absorbs prepared food, vitamins, and minerals. It is about 500 cm or 15 feet long.
The LARGE INTESTINE is the lower part of the digestive tract that is responsible for reabsorbing liquids from the small intestine.
GASTRIC BYPASS OR BILIOPANCREATIC DUVERSION SURGERY
The following surgeries are performed using a laproscope, which is inserted through a small incision on your abdomen. You will usually have 6 incisions on your abdomen.
A GASTRIC BYPASS is a restrictive surgery where a small pouch is made at the upper portion of the stomach, which can hold only 1-2 tablespoons in volume. This means you will feel full with only a small amount of food and your intake is restricted. This pouch is connected to a piece of small bowel through a Y-shaped connection, giving it the name Roux-en Y gastric bypass.
A BILIOPANCREATIC DIVERSION with Duodenal Switch is a malabsorptive surgery that causes food to be poorly digested and absorbed. A larger stomach pouch is made that can hold 2-3 cups of volume. The duodenum, which stays connected to the new stomach pouch is cut in half and re-connected to the ileum. Almost 9 feet of small intestine is bypassed. All the enzymes and bile from the liver and pancreas meet ingested food further down in the ileum, at about 100 cm (3 feet) from the large intestine (colon). This means food is digested and absorbed in only 3 feet of intestine before it enters the large intestine.
Friday, April 17, 2009
Introduce myself and background
My name is Elayne. I am 30 years old. I live in upper westchester, NY. I have struggled with my weight for a very very long time. I've been married for going on 2 years and my husband and I were looking to have children. My sister has suffered from Polycystic Ovary Syndrome and when we wanted to start to have kids, found out that I had it too. (if you click on the link above it will open a page to Webmd.com describing the syndrome)
My husband and I met with a reproductive endocronologist and worked with fertility medications in order to make myself ovulate. We started slowly with Clomid of varying strengths and moved up to injectable medications, trying both Follistim AQ and Menopur, and daily blood work to check estrogen levels and internal ultrasounds to measure follicles. Neither medication worked and the doctor informed us that it was because of my weight. She suggested weight loss surgery.
So we did some research online and with friends that have had surgery. We located NYU Medical Center in NYC and went for an information seminar in January 2009. We decided that we liked this facility and the surgeon we elected is Dr. Marina Kurian.
According to the insurance company (Aetna) we need 6 months of medically supervised weight loss attempts for coverage. So I've seen the doctor in January and weighed in at 340 lbs. More than I realized, and this just confirmed for me that weight loss surgery was the right decision. After must research I opted for gastric bypass instead of lap band. I know people that have had the bypass that I can lean on for support but no one with the band.
In February I weighed in at 326 lbs and March 318 lbs but I'm not 100% sure of the doctor's scale because I weighed in at 334 lbs in April. I don't think that I gained 16 pounds in a month or it's possible that I didn't lose that much previously. There's really no way to find out.
In March I also met with a psychologist, as a part of the insurance and surgical requirements. In April I met with the surgeon and now I have to do 2 more months of medically supervised diet and then I will get my surgery date.
I am a little frustrated at this point, with the waiting. I did a lot of research and talked to a lot of people and I feel like I am ready to make this commitment to myself and to the surgery so I can have a family and be healthier and live longer.
Hopefully the next 2 months fly by and I will update with more information when I have it!
[url=http://www.TickerFactory.com/weight-loss/wJ2AoWC/]
[img]http://tickers.TickerFactory.com/ezt/t/wJ2AoWC/weight.png[/img]
[/url]
My husband and I met with a reproductive endocronologist and worked with fertility medications in order to make myself ovulate. We started slowly with Clomid of varying strengths and moved up to injectable medications, trying both Follistim AQ and Menopur, and daily blood work to check estrogen levels and internal ultrasounds to measure follicles. Neither medication worked and the doctor informed us that it was because of my weight. She suggested weight loss surgery.
So we did some research online and with friends that have had surgery. We located NYU Medical Center in NYC and went for an information seminar in January 2009. We decided that we liked this facility and the surgeon we elected is Dr. Marina Kurian.
According to the insurance company (Aetna) we need 6 months of medically supervised weight loss attempts for coverage. So I've seen the doctor in January and weighed in at 340 lbs. More than I realized, and this just confirmed for me that weight loss surgery was the right decision. After must research I opted for gastric bypass instead of lap band. I know people that have had the bypass that I can lean on for support but no one with the band.
In February I weighed in at 326 lbs and March 318 lbs but I'm not 100% sure of the doctor's scale because I weighed in at 334 lbs in April. I don't think that I gained 16 pounds in a month or it's possible that I didn't lose that much previously. There's really no way to find out.
In March I also met with a psychologist, as a part of the insurance and surgical requirements. In April I met with the surgeon and now I have to do 2 more months of medically supervised diet and then I will get my surgery date.
I am a little frustrated at this point, with the waiting. I did a lot of research and talked to a lot of people and I feel like I am ready to make this commitment to myself and to the surgery so I can have a family and be healthier and live longer.
Hopefully the next 2 months fly by and I will update with more information when I have it!
[url=http://www.TickerFactory.com/weight-loss/wJ2AoWC/]
[img]http://tickers.TickerFactory.com/ezt/t/wJ2AoWC/weight.png[/img]
[/url]
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