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
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 itís 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 @
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 wbcís 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 (Millerís 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.