Bariatric Book Pre & Post Operative Information for Patients ST GEORGE OBESITY SURGERY UNIT Phone: 02 9587 8813 Fax: 02 9587 8835 Dr Ken W Loi Consultant Surgeon MBBS, BSc (Med) FRACS Jodie Hicks Accredited Practicing Dietitian BHlthSc(Nutr), MDietSt Leanne McNamara Registered Nurse CNC Bariatrics Dr Qiuye Cheng MBBS, MS, BSci(Med), FRACS
St George Obesity Surgery Unit Our Integrated Team Dr Ken W.K. Loi Upper Gastrointestinal and Bariatric Surgeon Leanne McNamara Registered Nurse CNC Bariatrics / Practice Manager As a registered Nurse and CNC in bariatrics I have taken a very keen interest in Bariatric both surgical and non-surgical procedures. I enjoy the diversity nursing has offered me moving into a clinical and management role of Bariatric nursing in private practice with Dr Ken Loi and his team. Jodie Hicks Accredited Practising Dietitian BHlthSc(Nutr), MDietSt Since 2017, I have specialised in the management of Obesity, having worked alongside leading bariatric surgeons in both private practice and in the acute hospital setting. In 2022, I was fortunate to be awarded the IFSO APC scholarship to attend the world congress. Admin Support Team **Bariatric procedure images supplied by Medtronic The aim of this information book is to assist you prepare for your bariatric surgery and help you with the lifestyle changes you need to make in order to optimise the outcome of your surgery. In preparation for your bariatric surgery, we strongly advise you to read this information book and ask us any questions. However this information is intended as a guide, and does not replace the individual advice provided by your surgeon, physician, nurse or dietitian. If you have questions regarding any of the information presented in this booklet please do not hesitate to contact us. Dr Qiuye Cheng Upper Gastrointestinal and Bariatric Surgeon Dr Cheng is an experienced minimally-invasive upper gastrointestinal surgeon who specialises in metabolic/ weight loss surgery. He is driven by working closely with his patients to control obesity and its related diseases in order for them to live healthier, longer lives.
Dr. Ken Loi of St. George Obesity Surgery in Kogarah, NSW, Australia achieved accreditation as a Master Surgeon in Metabolic and Bariatric Surgery. Dr Ken Loi specialises in upper gastrointestinal and advanced laparoscopic surgery with a focus on bariatric, hernia and minimally invasive oesophagogastric oncology surgery. His current appointments are at St George Private Hospital, Kareena Private Hospital, East Sydney Private Hospital and St George and Sutherland Public Hospitals. Dr Ken Loi has performed more than ten thousand advanced laparoscopic surgeries including primary and revisional bariatric operations. He was instrumental in setting up the first Australian Centre of Excellence in St George Private Hospital and also achieving a Master of Surgery accreditation based on his thousands of bariatric operations with minimal complications. He has been a regular speaker at both international and local conferences (in person and via Zoom) and has published widely in peer reviewed journals regarding bariatric and hernia surgery. During Dr Ken Loi's time as Honorary Treasurer of ANZMOSS (Australian and New Zealand Metabolic and Obesity Surgery Society), he was a key member in setting up a Bariatric Registry in Australia and assisting the Government in funding Medicare for Sleeve Gastrectomy. Currently Dr Ken Loi holds the position of President Elect for IFSO-APC (International Federation of Obesity Society - Asian-Pacific Chapter) until 2023. He steps into the role of President in 2023 until 2025. He has advanced the course of bariatric surgery in Asian countries by his regular teaching and speaking roles internationally. Other major achievements include being the first Asian Chair for RACS-NSW Chapter (2019-2021), and has been an executive member for RACS (Royal Australasian College of Surgeons) for more than ten years. Current passions include advancing diversity within RACS and being part of the Surgical Sustainability Working Party to help shape the next generation of surgery. He has also been invited to assist the Government in their response to Covid Crisis Management via the Community of Surgery Practice. Dr Ken Loi has played a key role in setting up ANZ Hernia Society and currently holds the position of Executive Secretary and has been involved in education and publication of Advanced Minimally Invasive Hernia Surgery. This includes hosting the Journal Club, setting up pilot hernia surgery and being speaker at International Hernia Conferences. Dr Ken W.K. Loi Upper Gi & Bariatric Surgery, Laparoscopy, Hernia Repair, Endoscopy
2 Table Of Contents Bariatric surgery overview 3 Laparoscopic Sleeve Gastrectomy 3 Laparoscopic Gastric Roux-En-Y Bypass 4 One Anastomosis Gastric Bypass 5 Laparoscopic Single Anastomosis Duodenal-Ileal Bypass With Sleeve 5 How Bariatric Surgery Helps You To Lose Weight 6 Weight Loss Plan Before Your Bariatric Surgery 8 Why Do You Need To Lose Weight Before Surgery? 8 What Diet Plan Should You Follow To Guarantee Weight Loss? 8 How Does Optifast® Work? 8 Will You Be Satisfied On This Diet? 9 How Long Do You Need To Be On This Diet? 9 What Else Can You Eat In Addition To Optifast®? 9 What Are The Expected Side Effects On This Diet Plan? 10 What If You Have Diabetes? 10 The Optifast® VLCD Meal Plan 11 What to Expect After Your Bariatric Surgery 12 Day of Surgery 12 Day One After Your Operation 12 Day Two 13 Going Home 13 Medications, Multivitamins and Supplements 13 Post Operative Symptoms 14 Red flags – when you should contact the clinic 16 Nutrition Management Stages After Surgery 17 What to Expect - An Overview 17 Importance of Protein 18 Protein Content Of Common Foods 19 Nutrition Plan After Your Surgery 21 Days 1-5 – Fluid Diet 22 Day 5 - 3 Weeks – Puree Diet 23 Weeks 4-8 – Soft Diet 25 Week 8 and Onwards – Full Solid Diet 28 Daily Nutrient Supplements 31 Fluids and Meals 31 Alcohol 32 Fibre 32 Exercise 32 Long-term Nutrition Management Weight Maintenance 33 Why is maintaining weight loss a challenge? 33 Bariatric Nutrition Pyramid 34 Long-term Eating Plan 35 Weight Maintenance 36 Post Operative Follow Up Appointments 37 Resources 39
3 St George Obesity Surgery Unit | Bariatric Book | Bariatric Surgery Overview Laparoscopic Sleeve Gastrectomy Laparoscopic Sleeve Gastrectomy (LSG) is now the most commonly performed bariatric surgery in the world. It has demonstrated reasonable durability, acceptable risk and complications and hence the increasing number of bariatric procedures over the past 20 years is the LSG. The LSG typically results in 25% to 35% body weight loss (50 to 70% excess weight loss) with most of the weight loss occurring in the first 6 months. This substantial weight loss may lead to dramatic improvement and even complete remission of many of the obesity-related co morbidities, including Type 2 diabetes. LSG is a bariatric operation that removes 80% of the stomach to leave a narrow gastric tube, which restricts food intake. Gastric emptying might change after surgery due to increasing intra-gastric pressure. The few published studies on long term data for LSG have demonstrated some durability. Although weight regain is often seen in LSG and other bariatric procedures. This happens when there is lack of follow up hence, despite being a simple operation, long term success rely on patient compliance and clinic follow up. The advantages of a LSG over gastric bypass surgery are that LSG is simpler and safer. It results in less vitamin and micronutrient deficiencies compared to the gastric bypass procedure. Although there are some reports of dumping syndrome due to rapid gastric emptying, the
4 incidences are less compared to different types of gastric bypass surgery. In the Asian Pacific population or in countries that have a high incidence of gastric cancer, it is deemed to be acceptable surgery compared to gastric bypass surgery, as the excluded stomach from bypass cannot be routinely checked. The disadvantage of a LSG is that the procedure does carry a chance of leakage in both the short term and long term. With the better understanding of LSG over the past 10-15 years and the advances in technology, the leak rate has gone down from 1-2% to 0.5% or less and even 0.1% in institutes that perform a high volume of LSG. LSG leakage is complex and difficult to manage and requires experienced surgeons to deal with the complications. Sleeve leakages are multifactorial relating to a patient’s tissues and surgical technique, and also the fact that LSG has simply higherpressure systems compared to gastric bypass surgery, which results in the highest pressure point on the top of the stomach. Another drawback of the SG is the long-term data on reflux. The current incidence varies from 5% to 20%, but most of it is managed by medical therapy and may not require surgical repair of a hiatus hernia or conversion to bypass surgery. Laparoscopic Roux-en-Y Gastric Bypass Laparoscopic Gastric Roux-en-Y Bypass (RYGB) as a bariatric, weight loss operation has been studied for over 50 years and is often referred to as the “gold standard”. However, it is important to understand that this does not mean it is the best operation for everyone. Every bariatric surgical procedure has its own characteristics; your treating physicians or surgeons should only make the choice of operation after a thorough evaluation of your particular health issues and potential health risks. The operation is done by laparoscopic technique unless the patient has had previous abdominal surgery. The procedure takes around one to two hours and the hospital stay is around two to three days. The RYGB procedure consists of making a small gastric pouch and diverting food past the majority of the stomach and a segment of the small intestine. The stomach pouch is connected to the middle of the intestine. The procedure is reversible, if necessary, as the stomach and intestine are not removed. It can also be achieved by transecting previous sleeve gastrectomy as a revisional procedure. The intention of the small gastric pouch is to give patients a sensation of fullness, but it does allow passage of the food via the anastomosis (joint of the stomach to the small intestine). The food passes more quickly through the intestine and activates specialised cells, L-cells, further along the gut that are important in the regulation of blood glucose and satiety. The hormones produced by theses cells act directly on the pancreas, the liver and the brain. Therefore, the RYGB besides mechanically restricting food intake will also work on complex neuro-hormonal pathways to improve patient’s metabolic disease. The degree of malabsorption is not long lasting since small intestine absorption will adjust with time. There are variations in versions of RYGB in terms of the length of the intestine that is bypassed. The typical recommendation is approximately one metre of biliary pancreas limb and one metre of alimentary limb. These reconstructions are best to be discussed with the surgeon in terms of the decisions of the length of the intestine bypass, based on the patient's small intestine total length and also the roux limb. There are some surgeons who are also advocating the use of a band around the pouch to prevent the pouch from getting stretched. However this is a foreign body and it does have consequences in terms of symptoms like vomiting and erosion of the band (band migrated inside stomach) can be a huge issue. The variation is better to be discussed with your surgeon and it will be on a case-by-case basis.
5 St George Obesity Surgery Unit | Bariatric Book | The results of the RYGB continue to be very good with a durable outcome. The quality of life analysis, longevity and also the resolution of co-morbidities are good. It produces sustainable weight loss, however again this is all dependent on lifestyle and dietary modification. It is especially good at treating metabolic disease such as hypertension, high cholesterol, fatty liver, sleep apnoea and potentially poly cystic ovary syndrome with infertility issues. The latest evidence also showed weight loss would improve and significantly reduce the risk of certain cancers. One Anastomosis Gastric Bypass The One Anastomosis Gastric Bypass (OAGB) was first reported in 2001 and is now the third commonest primary, bariatric procedure worldwide. It involves the creation of a long, narrow gastric pouch, which is then connected to the small intestine bypassing approximately 150 to 200 cm of the upper part of the small intestine. It takes approximately 90-100 minutes to perform and is usually done laparoscopically. Most patients are admitted on the day of surgery and can expect to go home in one or two days after surgery. It is an effective bariatric procedure with weight loss and co-morbidity (such as Type 2 diabetes and high blood pressure) improvement outcomes that are similar, if not better, to the Laparoscopic Gastric Roux-en-Y (RYGB) and slightly better than Laparoscopic Sleeve Gastrectomy (LSG) It works differently compare to RYGB. The difference is, instead of having two anastomosis (joint), it only involves one join. The chance of an internal hernia is reduced compared to RYGB. It does have the drawback of stomal ulceration if patients are heavy smokers or use a fair amount of anti-inflammatory medication. In a limited amount of studies, there is comparable weight loss to RYGB or LSG. Most patients can expect weight loss of 30-40% from baseline. The exact mechanism is more a kin to a RYGB but there are certain hormonal effects that are slightly different and there is still ongoing global research about this operation. It has just been approved/endorsed by ASMBS American Society of Metabolic & Bariatric Surgery as a validated procedure, for insurance claiming. The OAGB procedure can be performed with remarkable safety. The risk of death from early complications of surgery (such as bleeding, leak, pulmonary embolism, etcetera) is approximately 0.1-0.2%. Risk of major complications that may require surgical intervention is approximately 2.03.0% in the early period after surgery. In the long-term, the three commonest complications associated with this procedure are ulcers at the joint between the stomach, malnutrition and acid/bile reflux. The risk of ulcers can be reduced by prophylaxis with acid-reducing medications (PP) and cessation of smoking. Patients also need to adopt a healthy diet and take life-long iron, vitamin D, Calcium, Vitamin B12, Folate and multivitamin-mineral supplements. If there is severe malnutrition and acid/bile reflux, further surgery may be required to correct this. Overall approximately 5.0% of patients need further surgery in the long- term. Like any other bariatric procedure, patients should undergo lifelong, annual follow-up and monitoring for early diagnosis and treatment of any vitamin/mineral deficiency.
6 by an expert bariatric surgeon. Bowel movements frequency depends on food consumption and hence it is important to have adequate dietetic consultation. This technique is, however, complex, and surgical complications can be quite dramatic, especially in the initial postoperative period. Long-term side effects can be vitamin related deficiencies, (especially fat soluble vitamins A, D, K and E), if patients are non compliant with supplementation. Other deficiencies such as calcium and iron deficiency are detailed as part of the risk factors associated with a malabsorption procedure. To reduce these side effects, adequate education and preparation of the patients is mandatory before and after the surgery. These include promoting healthy eating habits, exercise and the prescription of nutritional supplements. How Bariatric Surgery Helps You To Lose Weight Bariatric surgery can be both a restrictive and/or malabsorptive weight loss procedure, which, if used correctly, will assist most patients in achieving their goal for weight loss and health improvements. How a Sleeve Gastrectomy helps you to lose weight A Laparoscopic Sleeve Gastrectomy (LSG) helps you lose weight in two main ways. • Change in anatomy: You’ll have a much smaller volume of stomach (its new volume is about 20% of your original stomach) which only allows you to eat small amounts of solid food • Change in physiology: Changing the gastrointestinal hormones will reduce your overall hunger, as well as increasing satiety after meal. These hormonal effects of surgery however, do become attenuated with time and hence the importance of making good food choices long term. How a gastric bypass helps you to lose weight The Laparoscopic Gastric Roux-en-Y Bypass (RYGB), One Anastomosis Gastric Bypass (OAGB) and Laparoscopic Single Anastomosis Duodenal-Ileal bypass with Sleeve (SADI-S) will help you to lose weight in three main ways. Laparoscopic Single Anastomosis Duodenal-Ileal Bypass With Sleeve Gastrectomy Laparoscopic Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S) is one of the most powerful bariatric techniques to achieve weight loss. It is a good option for patients with severe obesity, either as primary surgery or as a revisional procedure after weight regain from a sleeve gastrectomy. SADI-S is a laparoscopic procedure that can be performed with or without a robotic assistant. It consists of two steps. In the first one, called “sleeve gastrectomy”, the stomach is reduced and narrowed like a tube to reduce the stomach capacity (almost 80% of the stomach is removed). In the second step, a small bowel bypass is performed to reduce the surface for food absorption. Specifically, the middle part of the small bowel is excluded from food transit. After this second step, the first part of the small bowel, called the duodenum, is connected to the distal small bowel (named ileum). After this operation, the food now travels from the small new stomach to the distal intestine bypassing a long segment of the small bowel, which remains in the abdominal cavity, but is excluded from the food circulation. These anatomical changes decrease oral intake and reduce the absorption of the nutrients and calories eaten. Patients who undergo this procedure can lose up to 80-90% of excess weight. It is a procedure that has powerful effect on resolving resolution of Type 2 diabetes and other metabolic related disease. The SADI-S is generally well tolerated if performed
7 St George Obesity Surgery Unit | Bariatric Book | • Change in anatomy: Reducing the size of your stomach and bypassing a section of your intestines. Therefore, you feel full after eating a small meal. • Reducing the stomach hormones that make you feel hungry. Therefore, you feel fuller for longer. • Causes gut symptoms, when you eat high fat and high sugary foods. This works as a negative feedback so you avoid eating these foods. These restrictions in total food volume result in reduction in total energy intake, hence your body is forced to use its own fat stored energy and therefore weight loss occurs. Bariatric surgery is not a quick fix or a magic wand You should think of it as a tool to help you with your weight loss journey. For best results you will still need to make changes to your lifestyle and eating patterns. However, you can facilitate these changes. What is life like after bariatric surgery? Initially the surgery is very restrictive and you need to go through stages of fluid, puree and soft diet. You’ll only eat small volumes and therefore you need to prioritise what you eat to prevent any complications. Drinking adequate fluid, having protein at each meal and your multivitamins are the initial priorities. However, as your smaller stomach heals and recovers from surgery, you will be able to eat 3 very small meals and include all food groups in your diet. Long term, the key point is that a small meal will now satisfy you, hence the experience is different to dieting and therefore sustainable in the long term. However, you still need to make good food choices to ensure good nutrition. For prevention and treatment of nutrition deficiencies; you need to do blood tests to monitor key nutrition markers. Patients who do not make changes to their dietary and lifestyle habits and continue to eat inappropriately after surgery regain some or all of their weight. SURGERY WILL HELP YOU TO EAT LESS FOOD, AND STILL BE SATISFIED LESS FOOD = WEIGHT LOSS
8 Weight Loss Plan Before Your Bariatric Surgery Why Do You Need To Lose Weight Before Surgery? Your weight loss journey starts before the operation. Studies have shown that weight loss on a Very Low Calorie Diet (VLCD) reduces the liver size and the fat surrounding the stomach. This makes the operation easier for the surgeon to perform and therefore safer for you. In addition, weight loss also improves your blood pressure and blood sugar control and these also reduce the risks of surgery. These include reducing the risk of DVT (clots in the legs), which can then travel into the lungs (PE). Therefore, the lighter you are on the day of surgery, the better the overall outcomes for you. Furthermore, any weight loss before the surgery is a step towards the right direction to reach your weight loss and health improvement goals. So start today! What Diet Plan Should You Follow To Guarantee Weight Loss? Your doctor and dietitian have prescribed Optifast® VLCD before, as the studies have proven that it is safe and it works. Optifast® VLCD will totally replace your normal food intake. You need to replace each of your meals with an Optifast® (any of the Optifast® products are suitable). How Does Optifast® Work? Optifast® VLCD is a medically formulated meal replacement program that is nutritionally complete. This very low energy diet provides all your protein, vitamin and mineral requirements; however it gives you a minimum amount of energy. Therefore your body is forced to break down its own fat stores for energy.
9 St George Obesity Surgery Unit | Bariatric Book | Will You Be Satisfied On This Diet? The first 3-4 days on an Optifast® VLCD diet are the hardest as your body uses up all its glycogen stores (stored sugars) for energy. During these first few days your body transitions into ketosis and you may experience side effects like fatigue, hunger, lack of concentration, nausea and/or headaches. If you can persevere and get beyond those first few days, then things do get easier. Most symptoms pass by days 4-6, as the body is forced to go into “fat burning mode”. By breaking down fat stores ketones are produced, these are chemicals in the body which act as appetite suppressants. If you eat foods other than what is recommended, the ketone production is interrupted, your cravings for food will increase and you will not get the desired outcome. In the rare event that patients cannot tolerate Optifast®, please let your dietitian know ASAP so that suitable alternatives can be offered. We would hate you to miss out on your operation or have your operation date deferred because of inadequate weight loss prior to surgery. Product options Optifast® VLCD Shakes, Bars, Soups or a combination of these products. Preparation Add one sachet of Optifast® VLCD to 200 ml of cold or warm water. Stir, shake or use a blender to dissolve. For the milkshakes, adding ice to it and mixing it in the blender will make it taste better. Do not use boiling water because this will affect the nutritional content of the product. You may use more water if desired. This is based on your weight and the overall risks associated with surgery for your particular circumstances. It is usually for 2-6 weeks before surgery, and the goal is to achieve adequate weight loss and reduce the operation risk. How Long Do You Need To Be On This Diet? Some patients based on weight, BMI and medical history, may need a longer Optifast® ® program. This decision is made by your team and discussed with you. What Else Can You Eat In Addition To Optifast®? Fluids Rapid weight loss places a load on your kidneys; therefore you must drink at least 2 Litres of extra fluids a day to flush them. Most of your fluid should be water but you may also include: diet cordial, unflavored mineral water, soda water, herbal tea and limited tea/coffee with no or 30ml skim milk. No sugar, but artificial sweeteners can be added. Foods with no or small amount of energy In addition to the Optifast® you may also eat other foods that have no energy such as: • Konjac noodles (Slendier/Slim Pasta range), • diet jelly, • stock cubes, • vegetable soups made from allowed vegetables, • strained broth, • miso soup, and • diet cordial. You can also include 2 cups of non starchy vegetables from the list below. You may also add vinegar, lemon, lime, herbs and other spices for flavouring.
10 Suitable vegetables Alfalfa sprouts, asparagus, bean sprouts, beetroot (30-40g), Bok Choy, Broccoli, Brussel sprouts, cabbage, capsicum, carrots, cauliflower, celery, cucumber, eggplant, green beans, lettuce, leeks, mushrooms, onions, radish, shallots, silverbeet, snow peas, spinach, squash, tomatoes, watercress, zucchini and Konjac noodles (Slendier/Slim Pasta range). Protein Based on your individual protein requirements, extra protein sources may be recommended, as calculated by your dietitian. This can be added by choosing the Optifast® Protein Plus shakes or through food sources. If using a food, you may add 65-100g meat, 2 eggs or 130g fish. Fats It is advisable to add 1 teaspoon of olive oil (with cooking or salad dressing) in order to reduce the risk of gallstone formation (a common side effect with any weight loss therapy). What Are The Expected Side Effects On This Diet Plan? When you start the Optifast® it is expected to experience headaches, feel hungry, tired, dizzy or even irritable. However, as your body gets used to it and adjusts to the Optifast® plan these symptoms will improve. The ketone production also causes bad breath. You may chew a sugar – free mint or a chewing gum to alleviate this. Optifast® does not have much fibre and it is designed to be absorbed in the small bowel, therefore you may not have regular bowel motions. It is recommended to have 2 cups of your allowed vegetables per day, drink 2 litres of recommended fluids as well as using fibre supplementation such as Benefiber. If any of the symptoms persist, discuss it with your doctor, dietitian or pharmacist. What If You Have Diabetes? The most effective treatment for diabetes is weight loss; therefore it is still suitable for you to be on this meal replacement plan. However, as the carbohydrates in this product are limited, if you are on insulin or medications for your diabetes you need to discuss this with your doctor or endocrinologist before starting this regime. You may need to modify your diabetes treatment to prevent hypoglycemia (low blood sugar). Monitor your blood sugars very closely and if you experience symptoms of hypoglycemia, such as shakiness, sweating, confusion, fast heart rate, lightheadedness etc. Please contact your health professional (GP or Endocrinologist) for advice if you have diabetes. OTHER MEDICATIONS - WARNING To prevent any complications if you are on medications such as: Insulin, Warfarin (or other blood thinning agents) or Lithium, please let your GP know that you are starting the Optifast program so they can monitor your blood test results.
11 St George Obesity Surgery Unit | Bariatric Book | OPTIFAST® VLED MEAL PLAN The Optifast® VLCD Meal Plan is designed to replace your usual daily food intake. The soup, bars, desserts and standard shakes are interchangeable and contain similar amounts of energy and protein. You can choose one option to replace each meal. EXAMPLE MEAL PLAN BREAKFAST 1 OPTIFAST SHAKE & BLACK TEA OR COFFEE (ONLY ADD A DASH OF SKIM MILK) LUNCH 1 OPTIFAST BAR & 1 CUP SALAD WITH LOW JOULE DRESSING DINNER 1 OPTIFAST SOUP & 1 CUP OF STEAMED/STIRFRIED VEGETABLES MID MEALS OR SNACK STRAINED BROTH, LOW JOULE CORDIAL, DIET JELLY OR HERBAL TEA Should you have any food allergies or intolerances, please discuss this with your dietitian for alternative meal replacement options. This diet is challenging but if followed correctly, it works. It reduces your liver volume, improves your blood sugar levels, improves your breathing and reduces the risk of surgery. It will also help you achieve better weight loss long term. So the sooner you start it the better.
12 Day Of Surgery When you wake up, you will be started on oral analgesia for comfort from post-operative related pain. In certain situations, you may also notice a patient controlled analgesia (PSA) pump connected to your IV drip. This can work very well for pain control along side oral analgesia. You will be asked to sit up and mobilise your legs a few hours after the operation provided you are comfortable. Your nurse will assist you and take frequent observations but you will be required to move yourself. You can have ice to suck to keep your mouth moist, together with occasional sips of water. St George Obesity Surgery Unit | Bariatric Book | Day One After Your Operation It is important to focus on deep breathing and mobilisation. This will assist you in your recuperation after surgery. You are expected to mobilise around as tolerated and to go to the toilet either assisted or by yourself. Most patients will NOT have a catheter in their bladder. Exercise your calf muscles as often as possible. Most patients will also have white stockings (TED) and blood thinning injections to prevent clots in the leg veins. Occasionally, some patients with high risk of deep venous thrombosis (DVT) may have a calf compressor machine on their bedside, which assists with the circulation in the legs. What to Expect After Your Bariatric Surgery
13 St George Obesity Surgery Unit | Bariatric Book | Driving is discouraged until one week after surgery or whenever you are comfortable with it. The same applies to grocery shopping, housekeeping and gardening. Medications, Multivitamins And Supplements Resume the medications you were taking before surgery, except if advised otherwise. You should, if possible, liaise with your GP or endocrinologist to ensure that your usual medications are taken according to your new post op blood pressure and blood sugar levels. If you have multiple medical problems it is suggested you visit the GP 3-4 days after discharge. Any concerns, please contact our room ASAP, however your GP is the best person to adjust those medications, not your surgeon. When you leave the hospital you will also have prescriptions for medications to be taken after discharge. If not, please ASK FOR IT. Anticoagulation medications and analgesia pain medications Please take analgesia according to the instructions. They are not compulsory medication, but are there to keep you comfortable. Usage varies depending on the patient, so only take them if you need them. Remember to drink a lot of fluids but avoid all liquids with high calories (juices, commercial milkshakes and soft drinks). Aim for at least 1.5 litre of water per day. Listen to your “New Stomach”. When you feel full, STOP. Meals should be 1/2 cup and protein based and it should take up to 30 minutes to complete it. PLEASE REFER TO THE DIETARY GUIDE PROVIDED BY OUR DIETITIAN FOR HELP. You will start a “free fluid” diet today that includes yoghurt, custard, milk, soup and diet cordial. Remember this is a test meal and you are not expected to eat all the items on your tray. Take VERY SMALL SIPS, start with a teaspoon and STOP WHEN YOU FEEL SATISFIED. Intravenous fluid will be continuing to ensure adequate hydration. If you can drink at least 1 litre of fluid a day, your IV drip will be removed by the end of the day. Appropriate medication is given to treat and prevent any symptoms such as nausea and vomiting. It is important to prevent vomiting to prevent any stress to the staple line. Any patient with a previous tendency to experience severe nausea and vomiting after operation needs to notify our anaesthetic specialists before the surgery. This allows preventative measures to be taken. Day Two If you have achieved the above mentioned goals you may be ready to be discharged this morning. It is recommended to continue on a fluid diet for a few more days following your surgery. Remember, the most important thing is to maintain hydration. i.e. drinking enough fluid. You will know that you are drinking enough if you are passing urine a few times a day. It is normal for your urine to appear “bright yellow” because of your multivitamin. When you sense fullness, STOP! If you experience pain behind the breastbone or in the upper stomach, or like you’re about to vomit or actually do vomit - you’ve had way too much. Going Home It is important to maintain an active life. You will do better and reduce your risk of complications if you are working towards getting back to normal activities quickly. Try to walk at least 30 minutes each and every day. Walking is the best and the only accepted form of exercise that is allowed until your follow up appointment. No other exercises are encouraged at this time.
14 Somac/Nexium/Pariet This helps to reduce the acid secretions in the stomach. The hospital will send you with a script for 1-month supply. You should take this until the script runs out. However, depending on your progress and symptoms, you may need to take these for a longer period of time. This will be discussed at your next follow up appointment. Multivitamins and supplements You will need to pre-order your multivitamins so you are ready to start a few days post-surgery. Please take a bariatric supplement 1-2 times a day or as prescribed by your dietitian. All other supplements can re-start at 4 weeks post op. TO PREVENT ANY COMPLICATIONS, PLEASE DO NOT CHANGE NOR STOP YOUR MEDICATIONS WITHOUT LIAISING WITH YOUR GP OR SPECIALIST Post Operative Symptoms Dizziness Occasionally you may feel light headed. This is because at this stage you are not drinking as much liquid as you were able to before surgery; therefore the blood volume in your body is reduced. When dizziness occurs, do not panic. If you can find a comfortable place to sit or lie down, do so. Your body will adjust and the blood will be redistributed adequately after a short interval. However, if this is occurring too frequently, (more than three times a day) please call us. Also it is important to check with your GP if the dizziness is due to your medication, low blood pressure or other medical conditions. Aim to drink 1.5 litres of fluid per day and monitor your intake. Remember to sip on fluids in between meals. At this stage, you are going through a rapid weight loss phase and your diet is very low in energy and also sodium. Hence we encourage adding 1 sachet of salt per day to your meals per day to improve your sodium intake and this may help with the above-mentioned symptoms. Altered Bowel Habits Bowel habits do change after the surgery, do not expect your bowel movements to be regular until you start eating solid food. Do not be alarmed if you only open your bowels once every few days initially. On discharge from the hospital we recommend that you take 20mls of lactulose 2 times per day to prevent constipation. In the longer term, bowel habits should become regular but usually less in quantity than prior to surgery. Laxatives such as agarol, lactulose and fibre supplements such as Benefiber Original powder may be used. However please contact your bariatric clinic and discuss any concerns with our Nurse. Vomiting Vomiting is NOT an expected side effect of your procedure. However during the first two months after surgery, you may experience episodes of vomiting. It is important to remember your small stomach is, depending on the surgery type, approximately 30ml to between 100-150ml and can be easily overwhelmed. You must eat slowly and stop when you feel satisfied. Meals will take up to 30 minutes to consume. Vomiting can occur due to eating too fast, eating too much, poor/inadequate chewing and eating inappropriate food. Following the dietary advice given by our dietitian will minimise the chance of vomiting. Too much vomiting or retching will cause secondary swelling and possible obstruction of the passageway. If you cannot keep anything down for 24 hours it is IMPORTANT TO notify either the WARD or our OFFICE ASAP. Frequent vomiting can have unwanted side effects of leak, dehydration and hence kidney damage, electrolyte abnormalities and in worst case permanent neurological symptoms: memory impairment, weakness, nerve damage etc.
15 St George Obesity Surgery Unit | Bariatric Book | Nausea In the initial stages after gastric surgery nausea is a potential side effect. This problem may start as early as the first day after the operation and it could last a couple of weeks after discharge from the hospital. However, nausea should subside with time. Ensure drinking and eating slowly, separate your meals from fluids and do not try to over eat. The feeling of nausea is rarely associated with vomiting. If vomiting does occur what comes up is often not what was eaten, but rather white saliva. There are medications that can be prescribed to help alleviate this symptom, but if persistent, it may need further investigation. Gas pain Gas pain is one of the most vexing problems that some patients experience during the first few days post surgery. This pain can be very severe or mild and is relieved by walking and by passing gas. Pain medications may dull the pain but very rarely relieves it. Sometimes the use of antacids such as Mylanta or Gaviscon have been known to provide temporary relief. The administration of a rectal suppository or an enema to stimulate the passage of gas sometimes provides relief. Patients who walk frequently immediately after their operation have less gas pain and when they do, it usually lasts only a couple of hours. Anorexia Anorexia is defined as a lack of appetite or forgetting to eat and it is a problem some patients experience. A desired effect of your surgery is that's the stomach cells producing hunger hormones have been resected, hence reducing your appetite, but try to make an effort to eat at least three meals a day. Dumping syndrome After your gastric bypass surgery, all of the food that you eat is passed straight into your small bowel and this rapid gastric emptying may cause Dumping Syndrome. Although not dangerous, the symptoms of Dumping Syndrome – heart pounding, nausea, diarrhoea, abdominal pain, sweating and weakness – can be very unpleasant. Dumping Syndrome occurs when you are eating too much, eating too fast or eating high-sugar/high fat foods. The episode usually abates within fifteen minutes. If possible, lie down until it passes. You will learn, in time, what causes Dumping Syndrome for you and you can modify your diet accordingly. To prevent Dumping Syndrome it is important to: • Eat very slowly • Eat small meals • Avoid high-sugar-containing foods such as: lollies, soft drinks, ice-cream, fruit drinks with added sugar, high-sugar cereals, jams, chocolates and all sweets in general • Separate fluids from solids, i.e. have fluids 30 minutes before/after meals Hypoglycemia (low blood sugars) Light-headedness, passing out and a fast heartbeat are typical of hypoglycemia. Hypoglycemia can occur when you do not eat at regular intervals as recommended. Do not go for more than six hours without eating during the day. Hair loss At ~ 2-3 months post op you may experience some hair thinning and hair loss. This is due to the rapid weight loss and effect of surgery. It is temporary and should reverse by 4-6 months post op. Poor protein intake and noncompliance with vitamin and mineral supplements can also contribute to this. However, there is no evidence that higher doses of supplements can prevent or treat it. If you are concerned about your hair loss, discuss this with your team.
16 Red Flags – When You Should Contact The Clinic Following your surgery there are certain symptoms that we take seriously. Please call us and let us know about these straight away so we can assess you, start investigating and prevent more severe complications. • Frequent vomiting that lasts for 24 hours or more – despite eating and drinking slowly • Dehydration – not tolerating fluids, over the last 24hr • Pain on eating and/or drinking • Neurological symptoms – weakness, swelling arms/feet, impaired memory • Significant reflux – despite eating and drinking as recommended and compliant with the medications • Recurrent chest infections/pneumonia • Nutritional deficiencies e.g. hair thinning, nails chipping, feeling tired/weak • Insufficient weight loss within the first 6 months post surgery OR regaining weight generally beyond 9 months post surgery; if we intervene early, we can often make a difference Pregnancy For female patients of child-bearing age, following your weight loss, you could be more likely to fall pregnant and therefore you should use contraception. Your GP will give you the best advice on this. It is important to use regular contraception before and for a minimum of 12 months after your bariatric surgery to ensure that you do not get pregnant. Otherwise there could be increased risk to the developing baby. Portal vein thrombosis (PVT) PVT is a rare but real and serious complication following any laparoscopic general surgery. The documented risk associated with surgery is between 1 in 500 and 1 in 1000. The cause is unknown, however it usually occurs 3-4 weeks post op. Presenting symptoms are: Abdominal pain, nausea and vomiting, which occur following ingestion of a meal. Diagnosis: abdominal CT scan and a blood test. Treatment: Anticoagulation (blood thinners) therapy, IV fluids and analgesia (pain medication) but this needs to be done as an inpatient and hence admission to hospital is necessary. Please contact your bariatric clinic if you are experiencing any of the above-mentioned symptoms or have any concerns. Please note that this list is only a guide and obviously cannot cover everything. Therefore, if you are not sure about something you are feeling or experiencing, just ring us for reassurance. It’s always better to err on the side of caution.
17 St George Obesity Surgery Unit | Bariatric Book | What To Expect - An Overview The majority of the weight loss occurs within the 12 months after surgery. Your small stomach needs to heal and adapt and you also need to learn how to eat and drink with it. This will take some time. The following timeline will help you with your progress after surgery. First six months after surgery Initially your small stomach is swollen and needs to heal. The main aim is to prevent unwanted gastrointestinal symptoms (nausea, vomiting, pain), be well hydrated and ensure an appropriate diet is followed, using this nutrition timeline as a guide. The first priority is protein. Adequate protein intake ensures appropriate weight loss, good nutrition status and prevention of nutritional complications. By 2-3 months post op you can start increasing your vegetable and fruit intake, however we still ask you to avoid grains and starches at this stage. These foods tend to expand in your new stomach, are very filling and are not a source of protein. Hence they may cause discomfort and also displace your protein intake. You are also recommended to take Multivitamins daily and possibly Calcium with Vitamin D. Six to twelve months after surgery At this stage your stomach has adapted well and you will be used to its new capacity. You will be on a normal healthy diet, but eating much smaller portions compared to before surgery. You may feel hungry at times, which is normal, and you can also eat more volume of food at a time. Your weight loss slows down at this stage and therefore you need to continue making good food choices, eat each meal slowly over 20- 30 minutes, avoid snacking, and continue your commitment to regular exercise. We recommend that you base your food intake on protein and non starchy vegetables, limiting grains, avoiding grazing, limiting discretionary (junk/ fast/processed) foods and continuing to take the recommended vitamin and mineral supplements. Nutrition Management Stages After Surgery
18 Twelve months and onwards after surgery From what we read in the medical literature and also what we see from our patients, the success post surgery will depend on your life long efforts to change your lifestyle. This includes making changes to your eating and exercise habits as well as taking responsibility for every decision you make that affect your weight and general health. Studies have shown that in order to maintain your weight loss you need to: • Monitor your weight • Eat regular meals – aim for three small meals per day • Avoid mindless snacking and grazing • Eat a higher protein, low glycaemic index carbohydrate balanced diet • Take your multivitamin & mineral supplements daily • Avoid discretionary (junk/fast/processed) food • Use meal replacement as needed • Practice mindful eating – do not watch TV when eating, sit down to eat, chew well and eat slowly • Exercise regularly – aim for at least 10,000 steps daily Remember: What you eat and how often you eat will help you maintain the weight lost. Importance Of Protein You will be going through a rapid weight loss phase, therefore protein is important to prevent muscle loss, improve healing, and immunity. We do not expect you to be able to meet your requirements in the first few weeks as your stomach is healing but we do recommend: • Include protein at every meal and eat it first • Good sources of protein include: meat, fish, chicken, eggs, legumes and dairy foods • Include meal replacements such as Optifast®, as they are high in protein – eat half a serve at a time • Use protein supplements as recommended by your dietitian, eg. whey protein powders or protein waters • Aim for 60-80 grams of protein per day – use your protein counter to estimate serving size. As your stomach heals, you will be encouraged to increase this. Your dietitian will also calculate your individual protein requirement and discuss it with you. Remember to: • Buy lean meat • Remove all visible fat from meats and the skin from chicken before cooking • Avoid processed meats e.g. salami, ham, bacon or sausages • Use low fat cooking methods such as grilling, steaming, microwaving or boiling instead of frying. Protein supplements/meal replacements Meal replacements such as Optifast®, Tony Ferguson, OptiSlim and/or Formulite are a great substitute for meals. They are high in protein, convenient and generally tolerated at this stage after surgery. You may be able to only have half the recommended volume at a time, so remember to finish the rest at your next meal to ensure meeting your protein needs. There are also other commercial supplements available at pharmacies. Your dietitian will recommend these at the time of consultation. OUR SLEEVE WILL HELP YOU TO EAT LESS FOOD, AND STILL BE SATISFIED LESS FOOD = WEIGHT LOSS
19 St George Obesity Surgery Unit | Bariatric Book | Protein Content Of Common Foods Your dietitian will calculate and discuss your individual protein requirements. Initially, we start with a minimum 60g protein per day and over the next few weeks, as your stomach heals you will be encouraged to increase this. Food Group Food Item Portion Protein (grams) Legumes Baked beans, kidney beans, chickpeas, lentils 1/2 cup 8 Egg 1 6 Meat/Seafood Chicken, Beef, Pork, Veal, Fish 50g (cooked) 15 Prawns 5 7 Lobster, Crab 30g 5 Dairy Milk Skim 1 cup 8 Cheese, cottage or ricotta 1/2 cup 14 Cheese, > parmesan 1/4 cup 12 Cheese, > mozzarella 30g 8 Yoghurt, low fat 200ml 8 Yoghurt, high protein (Chobani FIT or YoPRO) 160g 15 Soy Items Soybean 1/2 cup 14 Tofu 1/2 cup 10 Textured soy protein 1/2 cup 11 Soy milk, plain 1 cup 7 Soy beans 1/2 cup 14 Meal Replacements Optifast® 1 sachet 20 Formulite 1 sachet 32 Feel Good 1 sachet 25 Tony Ferguson 1 sachet 18 Kicstart 1 sachet 20 Protein Supplements* Protein Powder Whey Protein: 1 scoop (7g) 6 - Beneprotein 1 serve (30g) 24 - Boomers Protein 1 scoop 30 - Bulk Nutrients WPI BN Pure Pro 1 scoop (30g) 30 Collagen Protein: - Feel Good Protein 1 scoop (15g) 14 - Peptipro 1 scoop (15g) 15 Protein Water: Formulite 1 serve (15g) 15 Whey Protein: - Bodiez 500ml 15-30 Collagen Protein: - Feel Good Protein 2 scoops 15 - Protein Perfection 2 scoops 15 You can order protein supplements from this website: www.costpricesupplements.com.au. Use code Loi15.
20 Food Groups Example Of Serving Size Protein (Grams) Meat & Alternatives 50 g of Meat, Chicken, Fish 1/2 Cup of Lean Mince 1/2 Cup of Cooked or Canned Beans, Lentils, Chick Peas, Split Peas 2 Small Eggs Dairy Products 250 ml of Low Fat Milk - 1 Cup 200 g Yoghurt (1 Small Carton) 40 g Cheese (2 Slices) 250 ml Custard (1 Cup) Remember at this stage we only focus on protein source. As your stomach heals and you can tolerate more food, we will slowly introduce other food groups. Servings: 2/day Cereals: rice, pasta (90g*), breakfast cereals, bread and toast (30g) Legumes: lentils, peas, black and white beans, soybeans (80g*) Tubers: potato, sweet potato (85g*) *cooked weight Servings: 2-3/day of each food group Fruit: Low sugar fresh fruit: (melon, water melon, stawberry, grapefruit, apple, orange, etc) 140g High sugar fresh fruit: (grapes, apricot, banana, cherry, nectarine, medlar, lychee) 70g Vegetable Oil: (preferably olive oil): 1 teaspoon All vegetable types: 85g Servings: 2-6/day Low fat meat: chicken, beef, pork (60g) Fish: blue (60g), white (85g) Low fat or fat free dairy products: hard cheese (50g), soft cheese (80g), milk (140g), yogurt (115g) Legumes: lentils, peas, black and white beans, soybean (80g*) Eggs: 1 large (50g) *cooked weight Daily nutritional supplements Calcium and Vitamin D Iron V&M complex Vitamin B12 Ensure daily water or non-gas non-sugar non-caffeine fluid intake High saturated and trans fats and cholesterol foods High sugar foods Carbonated and/or alcoholic beverages DON’T FORGET EVERY DAY TRY TO AVOID INTAKE CONTROL INTAKE PREFERENT INTAKE PREFERENT INTAKE HEALTHY EATING PLAN & REGULAR EXERCISE EXCELLENT AND LONG = TERM WEIGHT LOSS
21 St George Obesity Surgery Unit | Bariatric Book | Nutrition Plan After Your Surgery DAY 1 TO 5: Immediately Post Op > Diet: Fluid Diet DAY 5 TO 3 WEEKS: At Home > Diet: Puree Diet WEEKS 3 TO 8: Adaptation Phase > Diet: Soft Diet WEEK 8 TO LONG TERM: Healthy Balanced Diet Plus Multivitamins > Diet: Full Diet Progressing through each stage varies between individuals and depends on your tolerance of food. It is important not to rush through the recommended dietary stages, as this may increase risk of complications. As you are progressing through your diet it is important to: • Have small meals • Chew your food well • Eat slowly • Stop when you feel satisfied The long-term goal is to develop a life-long healthy eating pattern in order to reach and maintain a healthy weight. It is important to follow a balanced diet, eat regular meals, avoid snacking and grazing and avoid processed and junk food. In addition it is essential to take your multivitamins on a daily basis for the rest of your life.
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