All patients considering surgical treatment of clinically severe obesity will be evaluated by the surgical team, clinical dietitian and a psychologist, each of whom must individually agree that the patient is a good candidate for surgery. A series of preoperative blood tests and x-rays are performed following the initial evaluations usually one week before surgery.
If you are a smoker, you MUST quit smoking at least one month and preferably two months before your surgery. This is important because smoking greatly increases you risk of pneumonia and other lung problems after surgery. Call your primary care physician if you need medicated patches or gum to help you quit. Smoking is the number one cause of preventable death in the US.
Day of Surgery
If you have heart problems or if the surgeon wants special monitoring, you may be admitted one day before your Gastric Bypass. However, this is extremely rare. A nurse will get you ready to go to the operating room when you arrive. You will wait on a stretcher or chair in the pre-operative area. Nurses, physicians, and anesthesiologists will ask you questions and will tell you what to expect in the operating room. An IV will be started. An epidural catheter may be placed for pain management, depending on you and your surgeon's preference.
Surgery lasts less than 3 hours; however, it may be 4 or 5 hours before your family and friends see the surgeon. The surgeon will speak with them after the surgery is completed.
When you wake up from surgery, you will either be in the recovery room or you will go there shortly. Once your breathing is normal and vital signs are stable, which usually takes several hours, you will be taken to a monitored hospital room. If all goes well and the oxygen levels in your blood are okay, you will move to a regular hospital room the next day.
After Surgery: Tubes and Drains
When you are asleep in the operating room, two other tubes will be placed while you are under anesthesia: a tube to breathe for you while you are asleep and a catheter in your bladder to collect urine. The catheter will stay in until the day after your surgery or possibly longer. You may have a sore throat from the tube in your nose and the breathing tube used during surgery. This soreness will usually go away in a day or two.
Occasionally, a tube may be placed through the nose into the stomach at the end of surgery. This nasogastric tube will remain in place postoperatively until it is determined that your stomach is healing well. The tube removes secretions from the upper portion of the stomach and helps prevent distention of the upper pouch. In our program, a nasogastric tube is rarely used and is reserved for only complicated situations.
Rarely, your surgeon may also choose to place a tube through your skin into the bottom part of your stomach. This tube is called a Gastrostomy tube or G-tube. G-tubes are not routinely placed, but may be necessary to keep the bottom part of your stomach from getting too bloated. If you have had stomach surgery in the past, you are more likely to need a G-tube. G-tubes are often used for patients who are having revisional surgery.
Patient Controlled Analgesia (PCA) is the method of pain management used for Gastric Bypass patients. Medication such as Demerol or Morphine will be given through an IV or an epidural, and the dosage is controlled by the patient within pre-set limits. PCA allows you to receive small doses of pain medicine frequently, which provides steady pain relief. After surgery, a nurse in the recovery room will set up your PCA and instruct you on how to use it. When you want to administer a dose of medication, you just push a button. PCA will not let you take too much medication. PCA does an excellent job of controlling your pain, although it does not take away all of your pain. You will be very sore for the first couple of days, with your soreness rapidly decreasing over the next few days. We also use Toradol which is an injectable non-steroidal anti-inflammatory drug. Tylenol is also frequently used to decrease the amount of narcotic needed.
Activity and Circulation After Surgery
Activity is a very important part of your recovery and weight loss. Activity helps to prevent pneumonia, blood clots, and constipation, and it increases weight loss. For these reasons, your exercise program will start while you are in the hospital. You will get out of bed and walk the evening of your surgery. Most patients will be assisted out of bed on the evening of surgery. You will start walking in the hall the day after surgery.
Compression hose are plastic sleeves that will be wrapped around your legs during surgery and while you are in bed after surgery. They gently squeeze your legs and help blood circulate in your legs and feet. These hose will help prevent blood clots from forming in the veins of your legs. You will wear the compression hose for the first 2-3 days while in bed. Your nurse can send cool air through the hose if your legs become hot.
Breathing Exercises After Surgery
You will be provided with an "Incentive Spirometer" after surgery. It is very important to take about ten deep breaths into the spirometer every hour to help prevent pneumonia, lung collapse and other breathing problems. Coughing and deep breathing will also help to prevent breathing problems. Holding a pillow over your incision will help with discomfort during coughing. If you have asthma, you will need to bring your asthma inhalers with you to the hospital.
If you have been diagnosed with sleep apnea through a sleep study, you will remain on breathing monitors in a monitored bed overnight or until you are breathing well on your own. If you use a C-PAP machine at home, you will need to bring it with you to use in the hospital.
Tests After Surgery
You will receive nothing by mouth following surgery. This allows time for return of GI function and helps reduce the possibility of leaks.
Patients who have received a banded gastric bypass operation will have an upper gastrointestinal X-ray test, also known as an "upper GI." For this procedure, you will drink special liquids and X-rays will be taken. This test lets us know that a leak has not developed from the small stomach pouch. To relieve discomfort, ask your nurse for pain medication or push your PCA button before your upper GI.
Gastric banding patients are taken for an upper GI the morning after their surgery if they stay overnight in the hospital. If they go home the day of surgery, they must go for an upper GI before an adjustment will be done.
The need for an upper GI in patients who have received gastric sleeve or duodenal switch procedures varies, and is determined by the surgeon.
Nutrition After Surgery
Every patient will receive thorough nutrition counseling by the clinical dietician. Patients will need to learn to take small bites and swallow slowly.
During your hospital stay, your diet will be as follows:
Gastric Bypass/Sleeve Gastrectomy/Duodenal Switch
- Day 1 after surgery: No food or drink
- Day 2 after surgery and for rest of the hospital stay: May be progressed to clear liquids and water if no signs of a leak and after approval from surgeon. Then 1-2 ounces every 20 minutes while awake.
- First week after discharge: Full liquids including 2 high protein drinks daily. Sugar-free pudding and fat free/light yogurt may be consumed during this diet stage. Drink/eat one to two ounces no more frequently than every 20 minutes while awake.
- Second and third week after discharge: Pureed food with an emphasis on those high in protein plus one high protein drink daily. Eat one to two ounces of a pureed food every three hours. Stop drinking 15 minutes before eating and do not drink for 30 minutes after you have finished eating. Try to drink four ounces every 30 minutes between your meals.
- The next stage of your diet will be discussed at your first follow-up appointment with your dietitian.
- Day of surgery and for rest of hospital stay: Clear liquids and water after approval from surgeon. Then 1-2 ounces every 20 minutes while awake.
- If you go home the day of surgery, stay on clear liquids for the rest of the day and progress to full liquids the day after your surgery. Follow the above instructions starting with the first week after discharge.
Post-Operative Discharge Instructions & Follow-Up
You should be ready to go home on the second or third day after surgery unless your surgeon tells you that he/she plans to extend your hospital stay. If you are having a gastric banding procedure, you may go home the same day of surgery. If you have any questions or concerns once you are home, call your surgeon or the nurse practitioner.
It is fairly common to feel weak and tired immediately after discharge from the hospital. The body is recovering from the stress of a major operation and because weight loss is occurring during this time, the feeling of weakness may be somewhat prolonged.
Follow up after surgery is extremely important. The operation is only one part of the course to a good result. Success is not determined at the time of discharge. Weight loss will occur for 12 to 24 months following the operation. Participation in the behavior modification program is VITAL to the long term maintenance of weight loss. Counseling by the dietician is important in making the transition from pureed to solid foods. This will help emphasize the importance of appropriate food choices to maintain a balanced diet and avoid high calorie liquids and soft foods, which can defeat the purpose of the operation.
CONSUMING TOO MANY CALORIES CAN DEFEAT ALL GASTRIC REDUCTION OPERATIONS. The follow up visits permit early recognition of vitamin and iron deficiencies or other problems so appropriate treatment can be given.
Gastric Bypass, Duodenal Switch and Sleeve Gastrectomy patients should schedule their first postoperative visit 2-3 weeks after discharge. Visits will then be at 5-6 weeks, 3 months and 6 months after the operation. Follow-up visits are scheduled every 6 months for the first two years after surgery, and then yearly for life, although duodenal switch patients continue with follow-up appointments every six months for life. Follow-up after this surgery is forever, and will need to be arranged with another practitioner if you leave the area.
For gastric banding patients, the first postoperative visit will be 2-3 weeks after discharge and the second will be 5-6 weeks after discharge. We consider your first band adjustment at the 5-6 week follow-up appointment. Visits are scheduled every 2-4 weeks until the band is adjusted appropriately for you. We then recommend monthly follow-up visits for the first year, every 3 months for the second year, and yearly starting the third year after surgery.