Concerns: Laparoscopic Gastric Bypass Roux Y

The patient will receive the appropriate dietary education and a book that is designed to act as an instruction manual for this bariatric procedure.

 

The general guidelines are as follows:

 

·        Hydration:

 

In the early post-op period (first few months), the emphasis is on the patient’s fluid intake. Patients are instructed to sip small amounts of calorie-free fluids (water, diet ice tea, Crystal LightTM, etc.) on an almost-constant basis. Indicators of inadequate hydration are dry mouth and dark, concentrated urine. Post-operative constipation is usually due to inadequate fluid intake. The patient should increase their hydration before using Colaceä or other stool softeners. Drinking or staying hydrated, however, is essential and all patients must drink at least 1 liter per day.

 

 

·        Appetite Loss: 

 

Studies have shown that the Laparoscopic Gastric-Bypass with Roux-en-Y Limb generates a massive decrease of a serum hormone named “Ghrelin”. This hormone is responsible for appetite generation. A decreased level of Ghrelin promotes a lack of appetite. This is a beneficial effect that will only last 3 to 6-months. This effect (the impact on hormonal secretion of Ghrelin), which is particular to the Laparoscopic Gastric-Bypass with Roux-en-Y Limb, is one of reasons why it is by far the most superior of the restrictive bariatric procedures.

 

o        For the first 2-weeks after surgery, do not be too concerned about a partial or total lack of appetite.Patients should consume small meals, but should not eat frequently. The patient should not be "force" eating.

 

o       Within a few weeks of surgery, a 3-meals-per-day schedule is optimal. This “classic European eating” behavior has been shown to be the ideal eating habit that post-bypass patients can develop. Patients are warned to avoid eating 6 to 8 meals per day.  This behavior, called "grazing," may promote a long-term failure of the procedure.

If a patient feels the need to snack, a minimal and healthy snack should be introduced between lunch and dinner.

 

 

·        Diet: 

 

The post-operative diet varies greatly. Although immediately after the surgery the diet consists of “full liquids,” the long-term goal is to be able to eat normal meals and food. All patients will encounter some type of food, which they do not tolerate well. Early on, the most frequent offenders are fresh breads, red meats, and starches (simple carbohydrates). Each patient is unique, however, and foods-to-avoid will vary.

 

o       Sweet carbonated beverages: should be avoided. Recent studies have shown consumption of sweetened carbonated drinks in western society is one of the factors responsible for the extraordinary increase in obesity rate. Some authors have even identified these drinks as “liquid candy”. Interestingly, the use of diet carbonated drinks promoted obesity as they have the tendency to make people feel they can consume more.

 

o       Sugar and Fat: Foods with high fat content, fried foods, and sugar added foods, should always be avoided. Foods high in protein are encouraged.

 

o       Supplements: The patient must take two multi-vitamins with supplemental iron daily. In addition, the patient should take calcium supplements.

 

o       Alcohol: Moderate alcohol consumption is acceptable, as long as the patient remembers it is a significant calorie source.

 

·        Nausea and Vomiting: 

 

Early post-operative nausea and vomiting are a common problem. In the early post-operative period, the new gastric pouch and the outlet of the gastric pouch into the small bowel will not function well together. Eating small meals slowly can decrease these problems. When these symptoms do occur, patients should follow a clear liquid only diet. The problem will usually subside in 12-24-hours. If the vomiting continues or if the patient becomes dehydrated, they should be seen in the office or in the local emergency room. Arrangements will be made for intravenous fluid hydration.

 

 

·        Pain: 

 

Usually, most incision pain is resolved by the time the patient is discharged from the hospital. If the laparoscopic approach is used, patients may experience some shoulder pain (from diaphragmatic irritation) and an inability to expand their lungs painlessly. It is critical that patients maintain an exertive walking regimen and use the Incentive Spirometer (blowing machine) they are given upon discharge.

 

·        Rate of Weight Loss: 

 

All post-operative patients are anxious to know if they are losing weight at an appropriate rate. The answer is almost always, “yes,” as there is a very broad range of acceptable weight loss.

In general, the weight-loss will be rapid in the first 3- months, will continue steadily for 6-months, and will usually stabilize around 12-months. (Generally, the higher the patient’s initial weight, the longer the weight-loss continues.) The patient should be aware that weight-loss is uneven, and that "plateaus" (weight remains steady for up to 2-weeks) commonly occur. Average weight loss during the first few months after surgery is 7 – 14 pounds per month.

 

If the patient’s weight-loss stops during the first 3 to 6- months post-surgery, or if they begin to regain significantamounts of weight at any point after surgery, they should be evaluated by their surgeons. However, most often, the problem of persistent weight or weight regain is a behavioral problem rather than a surgical one.

Post gastric-bypass patients should contact their surgeon or physician for any weight gain over 5 pounds. Recent studies are demonstrating that such weight gain should be immediately addressed and corrective measures put in place.

 

 

·        Management of Medications: 

 

Eventually, almost any medication can be taken *after the Gastric-Bypass with Roux- en-Y Limb. During the first month after surgery, only small pills should be taken or swallowed intact. Larger pills should be crushed. Afterward (assuming the patient is tolerating their diet well), the patient can take pills of any size (if unsure about a medication, check with surgeon).

o       Oral hypoglycemic agents and insulin: should be significantly reduced or eliminated after gastric-bypass. This will be a physician-supervised withdrawal.

o       Diuretics: should be stopped immediately after the procedure. A patient generally experiences a substantial diuresis due to ketosis, making the diuretics less necessary. Furthermore, the potassium-wasting effects of most diuretics can cause serious hypokalemia (low potassium levels) in these patients who have dramatically restricted oral intake.

o       NSAIDS: (Ibuprofenä, Naproxenä, and other drugs in this class) may cause gastritis or ulcers in the newlycreated gastric pouch. Tylenol is safe.  If the patient needs anti-inflammatory medications, some options are available but this should be discussed with the surgeon.

o       Pain Medication: By the time patients are discharged from the hospital, they will only need occasional pain medication. Any increase in pain level should be reported. 

Patients can drive after surgery once they stop taking pain or narcotic-type pain medication. It is illegal to drive under the influence of narcotics.

 

 

·        Frequent Stools/Diarrhea: 

 

During the first month after surgery, approximately 10% of patients will report loose and frequent bowel movements. The frequency may range from 2 to 6-bowel movements per day. This is normal. malodorous stools are also frequent.

 

·        Constipation: 

 

Early in their post-operative course, some patients may be constipated. This is usually due to dehydration. The patient should immediately increase their fluid intake.  If the constipation persists after a few months, we recommend Metamucilä -diet formula- one pack (daily dose) per day in divided doses. 

 

 

·        Early Post-Operative Exercise: 

 

Once discharged, a patient can resume all physical activities. Common sense should be used. Patients have been returning to their gyms as early as 1- week post procedure. Our recommendations are as follows:

1.    While in the hospital, walk at least 1-mile per day.

2.    After discharge, walk at least 1 to 2-miles per day [routine walking is not included].

3.    After 2-weeks, you may start an exercise program.

4.    Post-bypass patients must exercise routinely, at least 1-hour per day, 5 times a week with their heart rate at recommended exercise level for their age.

Exercise is essential for long term sustained weight- loss. The more aggressively the patient exercises, the better the outcome.

 

 

·        Persistent Upper Abdominal Pain and Discomfort: 

 

Post- gastric-bypass patients can experience persistent upper abdominal discomfort at any time after their procedure. Statistically, this chronic pain or discomfort is due to either gallstones [if the patient still has their gallbladder], or ulcers in the gastric pouch. If you develop such symptoms, contact your surgeon.

 

 

·        Severe Abdominal Pain:

 

Post-gastric-bypass patients who develop severe abdominal pain should immediately call their surgeon or go to the nearest emergency room.