Post Operative Guidelines For Gastric Bypass Surgery

Liquid Protein Diet. 4 Weeks

There are three reasons for the post-op liquid protein diet:

• The surgical construct is not stretched by solid food while it is healing.
• The patient is provided with a balanced diet which sustains weight loss while preventing dangerous out-right starvation.
• The liquid protein diet is a means to changing food preferences. It separates the patient in time from her previous eating behaviors. Because it is monotonous, it can make a future transition to a low fat diet seem tasty in contrast. The theory is that the low fat diet will then become a preference.

Soft Transitional Diet. 7 Days:

The 4 week liquid protein diet is followed by a 7 day soft transitional diet. In going from liquids to solids, a puree diet is helpful in preventing unnecessary vomiting

The soft diet consists of:

Hot cereals, non-fat cottage cheese, non-fat yogurt, baby food and nearly anything that the patient is willing to put through a blender and can swallow without chewing. .

Following 7 days, the patient can resume eating small quantities of non-fat, sugar free, high protein food. Patients should avoiding obvious high calorie type foods including:

Cheese, nuts, butter, mayonnaise, most crackers and foods cooked in oil like fries and chips.

Most patients are well aware of which foods are high in fats and therefore to be avoided but the above list is worth mentioning If in doubt, they should look at the labels on the packages. This information is also available on our website.

Vitamin, Mineral Supplementation:

We believe multivitamin/mineral supplementation is desirable. If the patient has diarrhea, extra fat-soluble vitamins are recommended. As a general rule our patients mal absorb iron, B-12 and calcium. We therefore usually prescribe 1 mg B-12 weekly and Iron in combination form called Trinsicon (or it’s generic) along with 1.5 gm calcium supplement daily. If Trinsicon is not available, 120 mg of iron each week is adequate. Pre operative patients are provided an order form for their convenience. They can also order these products on line @ www.coastalobesity.com,

Cautionary considerations:

Steroids are sometimes useful and necessary medications however, it should be remembered that they are powerful appetite stimulants and do cause muscle breakdown. Some but not all antidepressants (e.g. Elavil) are appetite stimulants as well.

As a result of surgery, our patients will not tolerate uncrushed pills thereby making sustained release medications impractical.

Repeated vomiting in the first twelve weeks is most often due to a failure to chew adequately such that a food bolus sticks at the anastomosis. However, when the problem is with all solids and sounds progressive it is likely due to an anastomotic stricture. This is best seen on gastrograffin UGI and becomes symptomatic when the opening is 7 mm or less. The normal anastomotic size is 12 mm and lesser diameters are usually not treated as the long-term tendency is for the anastomosis to enlarge slightly. Symptomatic stricture is usually remedied by one or two balloon dilatations to not more than 15-mm diameter. I would prefer to talk to the endoscopist prior to any intervention as over dilatation can impair the effectiveness of the surgery. Other causes for vomiting include medications, depression, hypokalemia, and obstruction distal to the gastrojejeunostomy and pregnancy. In this regard, we have noted that most patients are more or less anorectic following surgery and that some, for a time, are downright nauseated. Nearly all are more easily and persistently nauseated following the usual stimuli than most of us. Patients who are nauseated may stop eating entirely and then become even more nauseated presumably from ketosis or the effects of starvation and iv hyperalimentation may be required before the patient can start eating again.

Redness and induration or purulent drainage around a wound suggests infection and I would be happy to discuss management over the telephone if you desire. Although purulent drainage in small amounts around a drain tube is common, actual infections are rare simply because the drain provides appropriate treatment for localized infection should it occur.

Hernias are fairly common complications and, if not particularly symptomatic, can be tolerated until such time as an abdominoplasty can also be done, usually around 12-18 months post-operative.

Hypertension is variably responsive to weight loss and the need for medication should be re-evaluated frequently. Diabetes and sleep apnea usually improve very rapidly with the onset of weight loss.

Gallstones affect patients losing weight and should be suspected if right upper quadrant pain or odd digestive symptoms occur.

Except for patients who have had mal-absorptive procedures, constipation is more common than diarrhea and the latter should be evaluated as in any other patient: smear for wbc’s and qualitative fat, and fungal elements, culture, O & P, C. Difficile toxins and begin empiric metronidazole. We treat constipation by advising the patient to take time for a bowel movement at the time of the gastro-colic reflex, which usually occurs after breakfast. Then, in escalating fashion, increase vitamin intake as an excess of virtually any vitamin will cause diarrhea, add unprocessed bran (Miller’s in the cereal section) and, lastly, use an electrolyte type laxative.

Severe abdominal pain and nausea should always occasion a call to us as it suggests an obstruction and it is a difficult problem to evaluate because part of the surgical construct is not readily available to x-ray evaluation.

In-patients who take their vitamin supplements, deficiency problems are rare but it is useful to check albumin, ferritin, B-12 and parathyroid hormone levels six-month intervals (secondary hyperparathyroidism seems to be the best early indictor of calcium deficiency).

Our patients are committed to a lifetime of regular scheduled exercise (minimum of 3 times a week) and dietary discipline, which includes three-five high protein, low fat meals a day and no snacking.