Your Weight Loss Surgery

Transcription

1 Your Weight Loss Surgery UCSF Bariatric Surgery Center Surgery Faculty Practice 400 Parnassus Ave., Room A- 655 San Francisco, CA (415)

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3 Roux-en-Y Gastric Bypass Proximal Pouch of Stomach Esophagus Bypassed Portion of Stomach Short Intestinal Roux Limb Pylorus Duodenum Adjustable Gastric Band Small Stomach Pouch Gastric Band Larger Stomach Portion 1

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5 You must read this entire pamphlet before you first visit with the surgeon so that you will understand the expected course from pre-op until your transition home. Preparation Before Your Weight Loss Surgery I. Required Clearance Your operation will not be scheduled until the following requirements are met: A. Loss of approximately 10% of your beginning weight. B. Satisfactory completion of all required studies C. Full evaluation by specialists has been satisfactorily completed: 1. Gastroenterologist 2. Cardiologist 3. Psychiatrist/Psychologist Any other screenings or evaluations requested have been completed. D. You have made arrangements to deal with social concerns, such as payment for post-operative prescriptions, care for dependents in the home (during your hospital stay and for 1 2 weeks after), transportation to and from the hospital, and any other situation that may pose a difficulty for you. II. Pre-Op Day Once you have been cleared for the operation, your operation date will be scheduled by your surgeon s office. You will then be notified of the date, and of your pre-op day appointments. Pre-Op day will include the following: 3

6 A. An appointment in the Prepare Program, which involves the anesthesiologists. During that appointment you will have blood drawn, give a urine sample, and be sent for a chest x-ray. You will also be interviewed by a representative from the anesthesia team. Prepare Clinic 505 Parnassus Avenue, room L-170 Phone B. An appointment in the Surgery Faculty Practice, which involves your surgeon s team. You will meet with a member of the surgical team and they will take a health history and go through a physical exam. Surgery Faculty Practice 400 Parnassus Avenue, room A-655 Phone III. General Instructions Following are guidelines for anyone planning to undergo a weight loss operation: 1. Stop taking any nonsteroidal anti-inflammatory drugs (NSAIDs) one week before your scheduled operation date. Plan to never take these medicines ever again because you will now be at an increased risk regarding gastro-intestinal ulcers. Examples of these are the following: Naprosyn Ibuprofen Nuprin/Motrim Bextra Aspirin Celebrex Advil Vioxx *Check with your Primary Care Physician or pharmacist before starting any new medications, including over-thecounter Medications. 4

7 2. You should continue taking most of your usual medicines, unless specifically told otherwise. 3. On the day before your operation you should have nothing to eat or drink after midnight. Your Stay in the Hospital I. General information A. What to bring: You do not need to bring anything from home, and we recommend that you leave all valuables at home. If you have sleep apnea and use a CPAP machine at night you should bring your machine with you. Also, if you have inhalers for asthma you should bring them with you to the hospital. You may wish to bring a light robe and slippers, a toothbrush and any other toiletries that will make you more comfortable. B. Morning of the operation: You will report at the designated time to the Surgery Waiting Area on the first floor of Moffitt Hospital, 505 Parnassus Avenue. You should check in with the receptionist and then take a seat. When told by the operating room staff, a UCSF employee will escort you to the 4th Floor to a gurney in the pre-op area. One person may accompany you to this area. You will then get into a hospital gown and begin the preparations for the operation. C. After the operation: You will spend one or two hours in the post-anesthesia care unit, then be transferred to a room on the surgical ward. If you have sleep apnea or asthma, or any lung condition, it is likely that you will spend one or two nights in the Intensive Care Unit. 5

8 II. Laparoscopic gastric bypass, expected course A. Post operation day #1 1. The nasogastric tube in your nose will be removed. 2. You will have a fluoroscopy study to evaluate the site of the operation. This will involve swallowing liquid contrast and having multiple x-ray pictures taken. 3. If the swallow study shows that everything is as it should be, then you will be allowed sips of water. You may have small cup (about 30ml) of water every one hour. 4. You should be up out of bed and walking three times on this day. 5. You will continue to wear support stockings and sequential compression devices on your legs. 6. You will have a drain from your abdomen that will be attached to a small suction bulb, called a Jackson-Pratt (J.P.). The nurses will empty the bulb periodically and record the amount of drainage. This will stay in until the day you are discharged. B. Post operation days #2 #4 1. Begin unrestricted clear liquid diet. 2. You will be given oral pain medicine. 3. You will be discharged to home. 4. Usually the drainage tube will be removed. 5. The Dietician will see you before you leave the hospital. 6. You will stay on a clear liquid diet for your entire stay in the hospital. 7. You should return to the UCSF Bariatric Surgery Center for follow-up in approximately 2 weeks. 8. You will be given prescriptions to have filled at your local pharmacy. 6

9 III. Open gastric bypass, expected course A. Post operation day #1 1. The nasogastric tube in your nose will be removed. 2. You should be up out of bed to a chair three times on this day. 3. You will continue to wear an abdominal binder at all times, unless lying still in bed. You will wear this for 6 weeks. 4. You will continue to wear support stockings and sequential compression devices on your legs. 5. You will have a drain from your abdomen that will be attached to a small suction bulb, called a Jackson- Pratt (J.P.). The nurses will empty the bulb periodically and record the amount of drainage. This will stay in until the day you are discharged. B. Post operation day #2 1. You will have a fluoroscopy study to evaluate the site of the operation. This will involve swallowing liquid contrast and having multiple x-ray pictures taken. (may also occur on post operation day #1) 2. If the swallow study shows that everything is as it should be, then you will be allowed sips of water. You may have 30ml of water every one hour. 3. You should be up out of bed walking in the hall three or four times today. C. Post operation day #3 1. Begin unrestricted clear liquid diet. 2. You will be given oral pain medicine. 3. You should be up out of bed walking in the hall four times today. D. Post operation days #4 #6 1. You will be discharged to home. 2. Usually the drainage tube will be removed. 7

10 3. The Dietician will see you before you leave the hospital. 4. You will stay on a clear liquid diet for your entire stay in the hospital. 5. You should return to the UCSF Bariatric Surgery Center for follow-up in one to two weeks to have the staples removed. 6. You will be given prescriptions to have filled at your local pharmacy. IV. Laparoscopic Gastric Banding, expected course A. Post operation day #1 1. You should be out of bed and walking in the hallways first thing in the morning. 2. You will have a fluoroscopy study to evaluate the site of the operation. This will involve swallowing liquid contrast and having multiple x-ray pictures taken. 3. If the swallow study shows that everything is as it should be, then you will be allowed to begin a clear liquid diet. You must remain on this diet for two weeks after surgery. 4. You will be given oral pain medicine. 5. The Dietitian will see you before you leave the hospital. 6. You will be discharged to home. 7. You should return to the UCSF Bariatric Clinic for a follow-up visit in about two weeks. 8

11 Post Operation Instructions For Your Care at Home General It is very common to experience nausea and loose stools in the first month. This will go away with time. The phone number for the Surgery Faculty Practice is This number is answered at night and on weekends, as well as during ordinary working hours. If you have any questions regarding your care at home you should use this number to reach your surgeon. Also, if any of the following symptoms occur it is important for you to call your surgeon: Abdominal pain becomes much worse than when you left the hospital. The area around your incisions becomes very red, increasingly tender, or begins to drain pus. Small amounts of blood-tinged fluid or mild redness are common and are no cause for concern. Shortness of breath, or any sudden difficulty in breathing Your temperature goes above 100.0ºF (38º C). Persistent vomiting, constipation, or diarrhea develop. You feel as if you are getting sicker instead of well. Medications & Pain Control When you leave the hospital you will be given prescriptions for medications you need to take for a short time after this operation. These medications must be taken as prescribed and should be started within one to two days of arriving home. Please discuss these with your pharmacist before your operation to confirm that these are covered by your insurance, or be prepared to pay for them yourself. Resume your usual medicines taken for chronic medical conditions. 9

12 You will have a medicine to help with pain control. Gradually you will need less and less of the narcotic medicine, and you should taper yourself down. DO NOT take any form of non-steroidal anti-inflammatory drugs (NSAIDS)! You may take plain Tylenol (acetaminophen) as needed. You may have a medicine called Omeprazole (or equivalent) to decrease the acid in your stomach. This will help to decrease gastro-intestinal ulcers. This should be taken for three months. If you still have a gallbladder, you will have a medicine called Ursodiol (or equivalent) to help prevent the formation of gallstones. This should be taken for 6 months. Activity It is common in the first couple of weeks after surgery to feel a little more tired than expected. It is not a problem, and is no reason to limit yourself. Just get some extra rest. You may return to full activity, including work, when you feel up to it. After a laparoscopic operation this usually occurs within two weeks. If you have a longer abdominal incision this will probably take several weeks. If you have had an open procedure you should avoid lifting anything over 10 pounds and doing any strenuous activity for 6 weeks. You must wear your abdominal binder whenever you are up out of bed for 4 weeks. If you have laparoscopic incisions you may lift as much as you wish and return to more vigorous activities, such as sports, as soon as you feel up to it. You may perform normal activities, such as walking up and down stairs, walking outside the house, doing chores about the house, riding in a car, etc. when you feel up to it. You may drive after one week as long as you are not taking narcotics regularly and you feel as though you will be safe behind the wheel. 10

13 Bowel Movements Your bowel movements may be irregular for several weeks, but they will gradually return to normal. If you go for more than a couple of days without having a bowel movement, try drinking warm prune juice, or using an over-the-counter suppository or enema. Wound Care You may take showers. Let soap and water run over your incisions. If you have staples in, leave them exposed to air and wear cotton clothing under the abdominal binder. Paper tapes should be removed seven days after they were applied. Follow-up Contacts Please call (415) and make a follow-up appointment to see your surgeon after leaving the hospital. If you were discharged with staples you should have an appointment in one to two weeks, otherwise your appointment should be in two weeks after leaving the hospital. It is recommended that you follow-up with an outpatient Dietitian and join a support group to assist in your lifestyle adjustments. You may wish to see a Dietitian at the UCSF Nutrition Counseling Clinic. If so, you will need to ask for a written referral then call for an appointment at There are multiple support groups in various communities. You may also attend our monthly support at UCSF. You can call (415) for a schedule. 11

14 Post Operative Follow-Up Appointments At the UCSF Bariatric Surgery Center Gastric Bypass 1 2 weeks after discharge 3 months post-op 6 months post-op 9 months post-op 12 months post-op every 6 months thereafter Gastric Band 1-2 weeks after discharge every 6 weeks until 6 months post-op (for band adjustments) 9 months post-op 12 months post-op every 6 months thereafter All patients should remain available for periodic phone interviews, and respond readily to mailed questionnaires. Lab Tests Monitoring lab values is important to avoid malnutrition. Labs should be checked every 4 months for the first two years, and then yearly. Arrangements should be made with your Primary Care Provider to have the following labs checked on a regular basis for the rest of your life. CBC Serum Iron Serum Folate Liver Panel Albumin Vitamin B12 Serum calcium Electrolytes Cholesterol panel Fasting Blood Sugar 12

15 Diet After Your Operation You will begin with a clear liquid diet. You may gradually start adding thicker liquids after discharge hand as described for your surgical procedure. Take only two to three bites at a time of any new food and then wait 10 minutes before taking more. This will help you to learn your limits and tolerance. This is important because your stomach is very small ( less than a 1 4 cup or 60cc) and the opening that allows passage of food out of your stomach is very narrow. Liquids will empty faster from your stomach than soft solids. If you overeat you may experience nausea or pain. The diet guidelines are designed to limit calories while providing a balanced meal plan to help prevent nutrient deficiencies and preserve muscle tissue. General Guidelines Eat slowly and chew foods thoroughly. Avoid rice, bread, raw vegetables, and meats that are not easily chewed such as, pork and steak. Ground meats are usually better tolerated. Eat balanced meals with small portions. Keep a daily record of your food portions and calorie intake. Avoid use of straws, carbonated beverages and chewing ice they can introduce too much air into your pouch and cause discomfort. Concentrate on following a diet low in calories, fats and sweets. Follow-up with a dietitian after discharge. 13

16 Fluids Drink extra water and low calorie or calorie-free fluids between meals to avoid dehydration. Sip about one cup of fluid between each small meal, 6 to 8 times a day. At least two liters (64 ounces or 8 cups) of fluid a day is recommended. Protein Preserve muscle tissue by eating foods rich in protein. High protein foods are meats, fish, tuna, poultry, eggs, soy milk, tofu, cottage cheese, yogurt, and other milk products. Vitamins and Minerals A daily multivitamin with minerals supplement is recommended because decreased food intake, changes in food selections and a decrease in total stomach acid can lead to inadequate nutrient intake. A liquid form of multivitamin or chewable vitamins (adult or prenatal) may be better tolerated in the first 8 weeks after surgery. Additional folic acid and iron may be needed. Taking a prenatal multivitamin or a vitamin and mineral supplement designed for bariatric surgery patients instead of a standard multivitamin helps to meet these needs. Vitamin B 12 supplementation may be needed in the future. Your primary care provider should monitor blood levels of vitamin B 12. Calcium deficiency can occur. A supplementation of 1000 mg calcium is suggested. Take 500 mg calcium two times a day to enhance absorption. TUMS may be used as a calcium supplement. 14

17 Diet Progression After Gastric Bypass In the hospital You will receive clear liquids such as diluted juices, jello and broth as your first meal following surgery. These foods are high in sugar content but your portions are very small and allowable at this early stage. Gradually increase the amount you drink at each meal as tolerated. For the first two weeks Begin adding thicker liquids that are low in fat and sugar. (see examples below) The goal is to eat small portions that will empty easily from your pouch. Begin with portion sizes of only 1 tablespoon and increase to 2 tablespoons as tolerated. Begin drinking 1 4 cup of liquids at a time and increase to a 1 2 cup as tolerated. Thicker Liquids: - Nonfat or 1% milk (if you can tolerate milk) - Lactose free or soy based low calorie drinks. - To increase protein add 2 tablespoons nonfat dry milk powder or egg substitute to each half cup of nonfat or low fat milk. - Diet pudding - Sugar-free and nonfat yogurt - Low fat cottage cheese - Blended broth based or low fat soups - Hot cereals (refined cereals low in fiber such as cream of rice or cream of wheat DO NOT use oatmeal) made with increased liquid to a soup-like consistency. - OPTIONAL High protein supplement diet drinks with no sugar added (< 200 calories and> 20 grams of protein in an 8 to 11 ounce serving) 15

18 Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin supplement everyday. For the next two to four weeks Begin adding small portions of pureed and soft foods as tolerated. Recommended Pureed and Soft foods: Applesauce, canned fruits, well cooked pureed vegetables, hot cereals, mashed potatoes, noodles, scrambled egg whites or egg substitute, canned tuna fish, lean fish, ground meats or poultry. Avoid all bread and meats that are not easy chewed. Recommended Meal Plan for weeks 2 through 8 (up to 2 months) At this time intake usually is no more than 500 calories taken in 6 to 8 small meals a day. Recommended portion sizes are a 1 4 cup for solids and a 1 2 cup for liquids. Sample menu Breakfast 1/4 cup hot cereal made with nonfat milk Mid-Morning 1 2 cup nonfat milk Late Morning 1 2 cup tomato juice Lunch 1 2 cup low fat chicken noodle soup 16

19 Mid-Afternoon 1 4 cup low fat cottage cheese Late Afternoon 1 4 cup juice packed canned fruit Dinner 2 ounces ground meat 1 4 cup pureed or well cooked vegetables Bedtime Snack 1 2 cup nonfat milk Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin and mineral supplement everyday. Recommended Meal Plan for 2 to 6 months after surgery calories and at least 65 to 75 grams of protein a day Your daily servings for balanced nutrient intake should include: 3 milk/dairy servings (nonfat and low fat) 3 meat/meat alternate servings (lean and low fat) 3 starch servings (limit bread and rice) 1 fruit serving (avoid dried fruits and fruits with skin) 2 vegetable servings (well cooked only) Recommended portion sizes are 1 4 cup for solids and 1 2 cup for liquids. Discontinue taking high protein diet supplement drinks. 17

20 Sample menu Breakfast 1 egg or 1 4 cup egg substitute 1 2 cup hot cereal Mid-Morning 1 2 cup nonfat milk Late Morning 1 2 cup tomato juice Lunch 1 2 cup low fat chicken noodle soup 2 saltine crackers Mid-Afternoon 1 4 cup low fat cottage cheese 1 4 cup water or juice packed canned fruit Late Afternoon 1 2 cup sugar free nonfat yogurt Dinner 2 ounces lean meat or fish 1 4 cup mashed potatoes 1 4 cup pureed or well cooked vegetables Bedtime Snack 1 2 cup nonfat milk The sample menu offers 8 small meals a day. You may wish to eat more or less often than shown on the sample menu. Be sure to eat at least 6 times each day. Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin and mineal supplement everyday. 18

21 Recommended Meal Plan for after 6 months - Continue the goal of 900 to 1000 calories a day with a decrease to 3 meals and only 1 to 2 snacks each day. - Discontinue taking high protein drinks. - Increase variety of low fat, low sugar and low calorie foods as tolerated. - Avoid raw vegetables, fruits with skins, dried fruits, breads, popcorn, nuts and red meats only if poorly tolerated. Long-term Over time, you will be able to increase the variety and consistency of foods in your diet. Some foods may continue to be poorly tolerated including red meats, breads, high-fiber fruits and vegetables. Focus on low fat, low sugar and low calorie foods and continue to count your calories every day. Diet Progression After Laparoscopic Gastric Banding In the hospital You will receive clear liquids such as diluted juices, jello and broth as your first meal following surgery. These foods are high in sugar content but your portions are very small and this is allowable at this early stage. Gradually increase the amount you drink at each meal as tolerated. For the first two weeks Begin adding thin nutrient dense liquids that are low in fat and sugar. Begin drinking 1 4 cup of liquids at a time with increase to a 1 2 cup as tolerated. Recommended Thin Liquids: - Nonfat or 1% milk 19

22 - Lactose free or soy based low calorie drinks if you do not tolerate milk. - To increase protein add 2 tablespoons nonfat dry milk powder or egg substitute to each half cup of nonfat or low fat milk. - OPTIONAL High protein supplement diet drinks with no sugar added (< 200 calories and > 20 grams of protein in an 8 to 11 ounce serving) Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin supplement everyday. For the next two to four weeks Begin adding thicker liquids that are low in fat and sugar. The goal is to eat small portions that will empty easily from your stomach. Begin with portion sizes of only 1 tablespoon with increase to 2 tablespoons as tolerated. Continue drinking liquids as tolerated. Thicker liquids: - Diet pudding - Sugar-free or nonfat yogurt - Low fat cottage cheese - Blended broth based or low fat soups - Hot cereals (refined cereals low in fiber such as cream of rice or cream of wheat but NOT oatmeal) made with increased liquid to a soup-like consistency. Diet after first band adjustment Continue thick liquids as tolerated but you will need to reduce portions taken. Start with 1 4 cup for solids and 1 2 cup for liquids. Other changes will be made in consultation with your doctor according to your tolerance. 20

23 Diet for weeks four through six Begin adding small portions of pureed and soft foods as tolerated. Recommended Pureed and Soft foods: applesauce, canned fruits, well cooked pureed vegetables, hot cereals, mashed potatoes, noodles, scrambled egg whites or egg substitute, canned tuna fish, lean fish, ground meats or ground poultry. Avoid all bread, rice and red meats. Recommended Meal Plan for 2 to 6 months after surgery calories and at least 65 to 75 grams of protein a day Your daily servings for balanced nutrient intake should include: 3 milk/dairy servings (nonfat and low fat) 3 meat/meat alternate servings (lean and low fat) 3 starch servings (limit bread and rice) 1 fruit serving (avoid dried fruits and fruits with skin) 2 vegetable servings (well cooked only) Recommended portion sizes are 1 4 cup for solids and 1 2 cup for liquids. Discontinue taking high protein diet supplement drinks. Sample menu BREAKFAST 1 egg or 1 4 cup egg substitute 1 2 cup hot cereal MID-MORNING 1 2 cup nonfat milk 21

24 LUNCH 1 2 cup low fat chicken noodle soup 2 saltine crackers 1 4 cup sugar free nonfat yogurt AFTERNOON 1 4 cup low fat cottage cheese 1 4 cup water or juice packed canned fruit 1 2 cup tomato juice DINNER 2 ounces lean meat or fish 1 4 cup mashed potatoes 1 4 cup pureed or well cooked vegetables BEDTIME SNACK 1 2 cup nonfat milk The sample menu offers 6 small meals a day. You may wish to eat less often than shown on the sample menu. Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin supplement everyday. Recommended Meal Plan for after 6 months - Continue the goal of 900 to 1000 calories a day with a decrease to 3 meals and only 1 to 2 snacks each day. - Discontinue taking high protein drinks. - Increase variety of low fat, low sugar and low calorie foods as tolerated. - Avoid raw vegetables, fruits with skins, dried fruits, breads, popcorn, nuts and red meats only if poorly tolerated. 22

25 Long-term Over time, you will be able to increase the variety and consistency of foods in your diet. Some foods may continue to be poorly tolerated including red meats, breads, high-fiber fruits and vegetables. Focus on low fat, low sugar and low calorie foods and continue to count your calories every day. 23

26 The Body Mass Index is calculated by dividing the patient s weight in kilograms by height in meters squared. If you know your patient s height and weight you can calculate the BMI using the Body Mass Index Quick Reference Guide above. 24

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28 Written by: Robin M. Andersen, MSN, CRNP Nurse Practitioner Andrew M. Posselt MD, PhD Assistant Professor of Surgery Nutrition Recommendations by: Viveca Ross, RD, CNSD Clinical Nutritionist Third Edition SDSUR0220 Rev. 9/04