Laparoscopic Gastric Bypass/Vertical Sleeve. Patient Manual. Dr. William Richards One Medical Park Drive Mobile, AL (251)

Transcription

1 Laparoscopic Gastric Bypass/Vertical Sleeve Patient Manual Dr. William Richards One Medical Park Drive Mobile, AL (251) USA Medical Center 2451 Fillingim Mobile, AL 36617

2 The Bariatric Surgery Team Dr. William Richards Surgeon Valerie Heinl, RN, BSN Unit Educator 3 rd /4 th Floors USAMC Angela Duffy, RN, BSN, CCRN Nurse Manager 3 rd /4 th /Burn Center/Wound Center USAMC Willamener Gales, RN Clinic Nurse Tammy O Haver, RD Clinical Dietitian USAMC Third Floor Nurses USAMC

3 Gastric Bypass: Bariatric surgery is a tool to assist patients in losing weight. Your food choices and behavior will directly result in the amount of weight loss that occurs. Gastric Bypass will assist in eating smaller meals, decreasing hunger and snacking less. To be successful, you need to avoid snacking and high calorie meals/liquids. To be successful, you should also avoid foods that flow through your pouch easily. Avoid drinking fluids with meals and for 45 minutes after meals. You will need to eat high protein meals, increase activity, and exercise. By making the necessary psychological adjustments, you will be successful. Pre Op/Preparing for Surgery: Primary Care Physician (PCP): Take this opportunity to become acquainted with your PCP. Your physician will play a large role in your post operative care. After surgery, your medical conditions will improve significantly. Your medication requirements will change as you lose weight. Also, your lab values will need to be monitored by your physician. University of South Alabama Medical Center: All surgeries are performed at the University of South Alabama Medical Center. The address is 2451 Fillingim St. Mobile, AL You will receive directions to the hospital in this packet. USA has a care team that will assist your surgeon to ensure that you receive the highest quality of

4 care. All rooms on the bariatric surgery floor are private so a family member or friend may stay with you. If you are transferred to the Surgical Intensive Care Unit, no family members are allowed to stay in the room with you. USA Preoperative Clinic: About 1 3 weeks prior to surgery, you will have a pre anesthesia clinic visit. In this interview, the anesthesia course will be explained. Detailed instructions will be given regarding medications to stop and which ones to take the morning of surgery. Medications: Stop taking all aspirin products (Aleve, Ibuprofen, and NSAIDS) and Vitamin E seven days prior to surgery. You may take Tylenol for aches and pains. Some diabetes medications may also need to be stopped. Support Groups: Prior to surgery, we request that you attend a support group. Support groups are available in our community. USA plans to start a support group in the future. Please ask your surgeon or nurse for information regarding these support groups. Personal Care: If possible, begin walking every day to increase your lung capacity and increase circulation. Start taking one to two showers per day three days prior to your admission. You should shower with an antibacterial soap. Pay close attention to skin folds and areas that are difficult to reach. Proper hygiene is necessary and may help in preventing skin irritation. Bowel Preparation Before Surgery: You will be placed on a preoperative liquid diet prior to surgery. Your dietitian will go over this diet with you in detail to make sure you understand every aspect of this diet. You must increase your water intake during this time to avoid

5 dehydration. Do not have anything to eat or drink after midnight the night before surgery. Your stomach must be empty at the time of surgery to avoid aspiration. Hospital Necessities: The following are some suggestions on things to bring with you when you come to the hospital. This list is not comprehensive. Be sure to check your patient information for any additional items you may need to bring. CPAP or BiPAP machine (with settings) and mask if you have sleep apnea Knee length bathrobe Non skid pair of slippers Hand lotion Comb or brush Lip balm Toothbrush and toothpaste Deodorant Magazines Personal pillow it may be more comfortable Phone card or cell phone to make long distance calls Medications in their original packaging Women Feminine hygiene products Eye glasses or contacts and supplies Wear loose comfortable clothing to the hospital that you can also wear home from the hospital Please leave valuables (such as jewelry) at home Cafeteria: The cafeteria at USAMC is located on the 2 nd floor of the hospital and is available for your family and friends. Breakfast is served

6 from 6:30 8:30 am. Lunch is served from 11:00 am 1:30 pm. Dinner is served from 6:00 7:00 pm Monday through Friday. The USAMC cafeteria does not open on Saturday and Sunday for dinner. Patient Floors: Most patients will go to the third floor from the recovery room. These rooms are all private and you may have one family member spend the night. The USAMC phone number is The third floor nursing station phone number is Morning of Surgery Please take a shower the morning of your surgery. Remove all jewelry and do not wear nail polish. Please pull long hair back into an elastic band. Contacts may not be worn, so bring glasses instead. If you wear dentures, you will be asked to remove them before surgery. Be sure that you arrive at the appropriate time. You will be checked in and asked to put on a hospital gown. You will wait in the holding area until time for your surgery. Your family will be directed to the waiting area. The Holding Area While awaiting surgery, your surgeon will see you so you may ask any last minute questions. Your anesthesiologist, nurse anesthetist, and the nurse that will take care of you in the operating room will ask you many questions. An IV will be placed in your arm.

7 The Operating Room Dr. Richards works with a trained operating room staff. The operating room team will work together to provide you with high quality care. After transfer to the operating room, you will be moved from the stretcher to the operating room table. The anesthesia provider will place a mask over your nose and you will go to sleep. The anesthesia provider will place an endotracheal tube in your airway to assist your breathing during the operation. Once the procedure is over, you will be transferred to the recovery room and your surgeon will give an update to your family. Pain Control You will be kept as comfortable as possible. You will be given IV pain medication at first, as most patients experience soreness at the operative sites. As soon as you are able to tolerate liquids, we will change your pain medication to oral medicines. Be sure to tell the nurse if you are experiencing any pain. The Hospital Stay The typical hospital stay is 2 4 days after surgery. The time in the hospital will increase if there are any complications or if you are not taking liquids well. You will be asked to get out of bed and walk the

8 night of surgery. The first time out of bed is usually the most difficult, so the nurse will need to assist you. We find that patients who walk at least four times per day recover faster. Walking will decrease the chance of blood clots and pneumonia. You will also be asked to take deep breaths and cough. The respiratory therapist will educate you on how to use an incentive spirometer. This will assist you in expanding your lungs, thereby decreasing the risk of pneumonia You will be required to wear a compression device on your legs while you are sleeping or resting in bed or sitting in the chair. The only time you are allowed to take the device off is while walking or while in the bathroom. You should also move your legs frequently while in bed to decrease the risk of blood clots. Discharge While in the hospital you will see a dietitian to reinforce the gastric bypass diet. It is important to address any issues before surgery so that you may rest and heal after surgery. We prefer that you have someone stay with you for the first few days. Your first clinic appointment will be approximately one week after surgery. The Drive Home Upon discharge, if you live more than 30 minutes from the hospital, we expect you to get out of the car every 30 minutes and walk around the car 3 4 times. You are still at risk for developing a blood clot. You will need to repeat this every 30 minutes.

9 Common Problems After Surgery Understanding the normal process of recovery can decrease many problems and concerns. The following are common symptoms of recovery and how to deal with these occurrences. Nausea: Nausea is a common side effect of this surgery. Occasionally, this is due to postnasal sinus drainage. Nausea will usually subside within eight weeks after surgery. Often patients will vomit clear, frothy mucus. Warm tea first thing in the morning will usually alleviate this problem. Tea will assist in clearing the drainage from your pouch. However, if you continue to vomit mucus, notify us. Another cause of nausea after surgery is the increased sensitivity to odors, eating and drinking too quickly, and increased acid in the stomach. Sometimes herbal tea (chamomile) will assist in easing the nausea. Sensitivity to odors will improve with time. Vomiting: Vomiting is usually caused by eating too quickly, taking too large of a bite, not chewing food adequately, or by over eating. You will feel full quickly after gastric bypass surgery. Take your time, take small bites and chew your food well. Please call the office if you vomit for more than one day. Call the office if you experience vomiting with PAIN. Vomiting can lead to dehydration. This can be a serious issue and will need to be resolved. Make sure that you drink at least ounces of fluid a day. You must not drink with meals. Take water with you everywhere you go. You should sip water all day long which will prevent dehydration. Monitor your urine and if it is dark yellow, increase your fluids.

10 Diarrhea/Constipation: Diarrhea is normal for up to 6 8 weeks after surgery. The day before surgery, you only had clear liquids to eat, and for the next 7 10 days you are only allowed a full liquid diet. Once your diet is advanced to softer foods, your bowel movements will become more consistent. Constipation may occur due to the fact that you are not taking in as much food as your body is used to, so you may not have as many bowel movements. You need to make sure you are taking in at least ounces of water everyday to maintain hydration and help with constipation. Numbness: Nerves to the skin are sometimes cut with surgery. It is normal to experience numbness at the incision site. Sensation at those areas will gradually return with time. Numbness in Legs: Some patients will occasionally experience upper, lateral thigh numbness and tingling within the first 2 months after surgery. This is a sensation called neuralgia parasthetica. It occurs due to the extensive pressure that has been placed on the nerve endings from the excess weight. The sensation will correct itself over time. Decreased Energy: It is normal to feel tired after surgery. You must keep in mind that you have just undergone major surgery. Decreased energy can last for 2 months so you must work at rebuilding your stamina. Be sure to stay hydrated. If you are on blood pressure medication or diabetic medication, make a follow up appointment with your physician as you will frequently need an adjustment on those medicines. Bruising/Swelling: Moderate bruising and swelling are expected after surgery. If the condition becomes severe, please call the office.

11 Your Scar: It is normal for the scar to be red or dark pink. Scars are red due to the fact that blood vessels are still working in the healing process. It takes the scar about one year to heal completely. You should keep the scar covered while tanning. You may also rub the scar with vitamin E or an over the counter cream that reduces the appearance of the scar. Hair Loss: Hair loss is common with rapid weight loss. The hair loss is temporary and reversible. It usually begins around three months after surgery and lasts until around nine months. Make sure you are taking in adequate amounts of protein. You may take an over the counter hair supplement. Lactose Intolerance: Many patients who tolerated milk products before surgery find that after gastric bypass surgery, milk products may cause abdominal cramping, nausea, and diarrhea. This occurs due to stress to the bowel created by the surgery itself. The intolerance to lactose can be treated with Lactaid, an over the counter tablet that patients may take prior to eating milk products. The bowel will adapt over time and most patients can resume having milk products within six months. Returning to Daily Activities Restrictions: You may not lift anything heavier than 10 pounds for four weeks. Your incision needs time to heal. Lifting before the two weeks can increase the risk of hernia so following the weight restrictions will decrease the likelihood. We cannot guarantee that this will prevent a hernia. Climbing stairs is acceptable. If you have an open procedure you may not drive for two weeks.

12 Primary Care Physician Follow Up: Please make a follow up appointment with your primary care physician within 1 2 weeks of surgery for management of your medications. Returning to Work Patients are usually ready to return to work 2 weeks after surgery. This may vary for some patients. If you have an open procedure it will be longer. Exercise/Activity: The only exercises that are allowed for the first two weeks are walking and riding a stationary bike. Walking can be done as soon as you return home. We ask that you walk as much as you can tolerate. Do not sit or stand in the same position for long periods of time. Sexual Activity: You may resume sexual activity when you feel physically able. For women of childbearing age, please remember to use two reliable methods of birth control to prevent pregnancy for the first 18 months after surgery. Most women choose some form of injectable birth control. Wound Care: Your incision will vary according to the surgical approach. For laparoscopic surgery you will have small incisions that will be covered with small adherent dressings. The open approach for the lap band is rare. The incision depends on the body mass index and your previous surgery history. For open surgery, you will have a midline incision that begins at the sternum and extends downward. The incision is closed with staples. Despite careful handling of the incision, it can become infected. Signs and symptoms to watch fore are: increased redness, temperature above 101, red streaks, swelling of the area, cloudy drainage from the incision, and increased tenderness. If you experience any of these, you should call the office immediately.

13 Medications/Supplements You will need to crush your pills for the first six weeks. Ask your pharmacist or doctor if your medications are available in liquid form. Be sure to discuss this with your PCP and your surgeon, along with any other medications that you are taking prior to surgery. As you lose weight, you may be able to come off of or decrease the amount of medication you are currently taking. The following is a list of medications that you may take if necessary: Lortab (hydrocodone/acetaminophen) a narcotic pain relieving medication. Liquid or tablets (crushed). Phenergan for nausea (crush the tablets). Tylenol may be taken in place of Lortab if your pain is mild. Prevacid or Pepcid acid reducing medications that should be taken for three months (chewable tablet or tablet that can be crushed). The following is a list of supplements you must take daily for the rest of your life: Multivitamin with minerals buy an over the counter multivitamin with minerals (liquid or chewable for the first six weeks) and take twice a day. Calcium Citrate with Vitamin D take 500mg three times a day for a total of 1500mg/day (liquid or chewable for the first six weeks). Vitamin B 12 take µg once a day (crystalline or

14 sublingual) OR get a B 12 shot once a month. There may be additional supplements recommended based on your nutritional lab work. Deficiencies: Vitamin deficiencies with the gastric bypass are not common, but that does not mean that you will never develop a deficiency. Deficiencies can occur because of the decreased amount of food you will be eating or noncompliance with vitamins and/or diet. A good multivitamin and following the post op diet are the foundation of health and nutrition. Calcium: Calcium is essential for building and maintaining healthy bones, muscle contraction, blood clotting, and healthy teeth. Calcium deficiency symptoms include: muscle aches and pains, muscle twitching and spasm, muscle cramps, and reduced bone density. Vitamin D is essential for proper calcium absorption and utilization. A lack of calcium can cause osteoporosis in adults. This condition will cause softening and weakening of the bones and can result in increased fractures. Iron: Iron deficiency anemia is a form of anemia caused by a lack of iron. The body needs iron to make hemoglobin, a substance in red blood cells that carries oxygen from the lungs to body tissues. When you have iron deficiency anemia, you will likely have fatigue, dizziness, irritability, headaches, difficulty concentrating, shortness of breath during exercise, a pale appearance, brittle nails, and cracked lips. Vitamin B 12: Vitamin B 12 s primary functions are in the formation of red blood cells and the maintenance of a healthy nervous system. B 12 is also important in maintaining the nervous system. When you have a B 12 deficiency, you will likely have muscle weakness, loss of balance, fatigue, and mental confusion or forgetfulness.

15 Other issues to Remember When Taking Your Vitamins: Calcium is best absorbed when taken in doses no larger than 500mg at a time, so you will need to take at least three separate doses per day to get the recommended 1500mg/day. Calcium and iron interfere with one another s absorption. Try not to take iron or a multivitamin that contains iron at the same time as your calcium. Try to take them at least two hours apart if possible. Expected Weight Loss After Surgery The laparoscopic gastric bypass procedure can procedure can help patients decrease their weight, but surgery alone will not ensure longterm success. Surgery is a tool, something to help patients with their weight loss efforts. In order to get to a healthy weight, patients must adjust their eating habits and exercise patterns. Most patients lose nearly half of their excess weight in the first year and continue to lose weight after this point. There is no amount of weight loss that is guaranteed. Weight control is the personal responsibility of the patient. Successful habits include eating three small, well balanced meals, and NO SNACKS!! Carbonated, caffeinated, sugary beverages and alcohol should be avoided. Patients tend to gain back weight if they start eating larger portions, snack or graze, consume high fat or junk foods or drink high calorie beverages. A program of regular exercise is also very important for promoting and maintaining weight loss. Studies have shown that patients who exercise

16 at least 45 minutes, three times a week, lose an average of 18% more excess weight than patients who do not exercise regularly. The first post operative year is a critical time that must be dedicated to changing old behaviors and forming new, lifelong habits. The success of weight loss surgery is most commonly defined by the total weight loss during the initial weight loss phase. However, foremost in the minds of patients undergoing surgery for morbid obesity are the questions: 1. Will this be a long term permanent solution? 2. What can I do to ensure my lifelong success? In other words, how can I maintain at least 60% of my initial excess weight loss after a successful gastric bypass? Patients should take responsibility for staying in control. Patients who are most successful have a general feeling that maintaining their weight is indeed their own responsibility and that surgery is a tool they use to reach and maintain a healthy weight.

17 Nutritional Expectations After the, you will need to make changes in your eating patterns. The diet after surgery progresses from a liquid diet to a pureed diet to a soft diet and then a modified regular diet. The diet progression is designed to allow your body to heal. Initially, it will help you meet your protein and liquid requirements, and later to assist you in meeting your nutritional needs. It is imperative that you follow the diet s progression and adhere to this regimen to maximize healing and minimize the risk for unnecessary complications. At first your stomach capacity will be limited, so be patient. You may find that two to three teaspoons of food fills you up and this is expected. You may also find that you are able to eat more of one type of food than another. That is okay because overtime your stomach pouch will stretch. By six months after surgery, it may stretch to 8 ounces. Long term, the size of your pouch is likely to be 8 to 12 ounces or 1 to 1.5 cups. This size will always limit the amount of food you can eat at one time. One of the changes that patients often comment about is the concept of wasting food. After surgery, your eyes and head will still work the same way they did before surgery. However, because of the new stomach pouch, you will be satisfied with much less food. It is critical that you listen to your body s new signals of fullness. You may also be surprised at how the surgery changes your wants and desires for certain food. Foods you may have previously loved may no longer be appetizing to you.

18 Gastric Bypass/Sleeve Post Op Diet Guidelines Phase 1: Clear Liquids (hospital stay) Phase 2: Full Liquid (10 days) Phase 3: Pureed Diet (2 weeks) Phase 4: Soft Diet (1 month) Phase 5: Regular Diet

19 Remember to refer to your diet packet for specific guidelines for each stage and sample menus.only advance if you are tolerating your current diet Do not advance early

20 Pre Operative Liquid Diet Purpose: To cause weight loss prior to surgery in order to improve obesity related comorbidities (ex: high blood pressure, elevated blood lipids, insulin resistance), reduce surgical complications, and help shrink the liver to make your surgery easier to perform. Instructions: You will need to purchase unflavored UNJURY. You will need 3 containers. You will mix 1 scoop of UNJURY with 1 cup low potassium juice (e.g. regular apple, grape or cranberry juice). Drink 4 servings daily for days prior to surgery Additional calorie free beverages (e.g. crystal lite, flavored water, decaf coffee) can be added up to patient fluid restriction goal cups. Add 1 or 1.5 cup (8 12 oz) of bouillon daily This will provide: total of 800 calories/80 gm protein/ 124 gm carbohydrate daily approximately 31 gram at each meal/ ~ 1530 to 2240 mg sodium/ meq K daily.

21 Limit caffeinated beverages to 2 cup (16 ounces) because they will make it more difficult to stay hydrated. You can use artificial sweeteners. You may experience hunger, headaches, and/or dizziness due to low calories. This usually improves by the 3 rd to 4 th day. Contact your physician if does not improve. You will be asked to follow up at the clinic for check up in middle of pre op liquid diet. Other Guidelines: Weight Loss during this pre op diet phase may result in decreased requirements for medications, especially those used to treat diabetes. Discuss your current meds with your Primary Care Physician. Compliance with this pre op liquid diet is mandatory. Noncompliance with this diet will cause us to question your ability to comply with the lifelong diet guidelines. DO NOT TAKE MULTIVITAMIN OR CALCIUM DURING THIS PHASE

22 EXERCISE Making exercise a priority in your life can be done if you properly understand its importance and relationship in helping to lose and maintain your weight. The following tips might be helpful in making your exercise program fun and exciting in the days ahead. Select an activity that is both practical and enjoyable. Set long range as well as short range goals for yourself. (examples: distance walked, pounds lost, miles biked, resistance on treadmill/elliptical machines) Exercise with family or friends as often as possible. Set aside specific times and days of the week for your exercise program. Remember that the ability to perform exercise varies from day to day, some days will be better than others. Be positive, a day missed is no reason to despair. Realize that success of your exercise program is ultimately in your hands. REMEMBER: DO NOT BEGIN ANY EXERCISE PROGRAM UNTIL YOU HAVE PERMISSION FROM YOUR SURGEON AND PRIMARY CARE PHYSICIAN.

23 Vitamin Flowsheet Name Allergies Date Vitamin Dosage/Direction/Amount AM noon PM bedtime Multivitamin: 2 tablets daily Calcium Citrate + D mg daily Take 500 mg, 3 times/day (do not take with multivitamin) Vitamin B µg/day or 1 B-12 shot/month Other supplements as needed Multivitamin: 2 tablets daily Calcium Citrate + D mg daily Take 500 mg, 3 times/day (do not take with multivitamin) Vitamin B µg/day or 1 B-12 shot/month Other supplements as needed Multivitamin: 2 tablets daily

24 Calcium Citrate + D mg daily Take 500 mg, 3 times/day (do not take with multivitamin) Vitamin B µg/day or 1 B-12 shot/month Other supplements as needed Multivitamin: 2 tablets daily Calcium Citrate + D mg daily Take 500 mg, 3 times/day (do not take with multivitamin) Vitamin B µg/day or 1 B-12 shot/month Other supplements as needed

25 Medicine Flowsheet Name Allergies Date Medicine Refills Dosage/Direction/Amount AM noon PM bedtime

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27 WEEKLY WEIGHT LOG Starting Weight: Starting BMI: Weeks Post Op: Date: BMI: Weight Total Weight Lost:

28 Weeks Post Op: Date: BMI: Weight Total Weight Lost:

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30 POST OPERATIVE FOLLOW UP SCHEDULE Follow up appointments after gastric bypass surgery are very important to your overall health and weight loss outcomes. We must see you back in our office for the first year. If you live out of town and have trouble getting to Mobile for the remainder of your visitis, we would be glad to arrange your visits through your primary care physician, as long as we talk with you via the phone or to answer a few simple questions, and receive the necessary lab work from your doctor. Appointment Date Weight BMI Draw Labs 1-2 week No 3 month Yes 6 month Yes 1 year Yes 2 year Yes 3 year Yes 4 year Yes 5 year Yes 6 year Yes 7 year Yes 8 year Yes 9 year Yes 10 year Yes

31 My Food Diary Date: Mon Tues Wed Thurs Fri Sat Sun Weight: Time Food/Beverage Amount Calorie Protein Goal > 75 gm

32 Total Check # of 8 oz glasses of water Physical Activity Minutes Intensity Low/Moderate/High Calories Burned Overall Evaluation of the day: Fantastic Great Okay Help! Notes:

33 USA Medical Center: (Directions from South Mobile County ) Take I-10 East to I-65 North. Take Springhill Avenue Exit and turn right onto Springhill Avenue. Go approximately 2 miles and turn left onto Mobile Street (traffic signal). Go approximately 1 ½ miles and after the road curves, the USA Medical Center is the 2nd building on the right after the bridge. USA Medical Center: (Directions From North Mobile County ) Take I-65 South to the Springhill Avenue Exit and turn right onto Springhill Avenue. Go approximately 2 miles and turn left onto Mobile Street (traffic signal). Go approximately 1 ½ miles and after the road curves, the USA Medical Center is the 2nd building on the right past the bridge. USA Medical Center: (Directions From Semmes/Lucedale) Take Highway 98 to Springhill Avenue. Take a left onto Springhill Avenue and go approximately ½ mile to Mobile Street. Take a left onto Mobile Street and go approximately 1 ½ miles and after the road curves the USA Medical Center is the 2nd building on the right past the bridge. USA Medical Center: (Directions From Baldwin County ) Take I-10 West to US Highway 98. Take Highway 98 to Springhill Avenue. Go approximately 4 miles to Mobile Street. Take a right onto Mobile Street and go approximately 1 ½ miles. After the curve in the road, the USA Medical Center will be the 2 nd building on the right past the bridge. For more information about healthcare services available at USA Medical Center, contact Bob Lowry, Office of Public Relations.