Bariatric surgery is an advanced surgical procedure designed to promote weight loss and reduce the complications associated with morbid obesity. This procedure will transect (cut) your stomach, dividing the stomach into two parts. The surgically created small stomach pouch will receive the food you eat. The remaining segment of your stomach continues to produce stomach acid and digestive juices, but does not receive any food. The surgeon creates a new connection from your stomach pouch to your small intestine, and bypasses a segment that is equivalent to about one-third of your small bowel.
The surgery is performed through six, small, half-inch incisions (laparoscopic surgery). Laparoscopic surgical instruments, including a small camera, are placed through tubes inside these incisions, called ports. In rare occasions, an "open" gastric bypass or laparatomy may be necessary.
It refers to the ‘Y’ shape of the small bowel connection. During the operation, the small bowel is cut and then reconnected at one end to the newly created pouch (the new stomach) where it will now receive food that has been chewed and swallowed. None of the bowel is removed during the surgery. The new connection between the stomach pouch and the small bowel is called an anastomosis. This narrow opening helps restrict the passage of food moving from the pouch into this piece of small bowel, called the Roux limb. The Roux limb is the right arm of the “Y.” The left arm of the “Y” is the part of the bowel still connected to the excluded stomach. It carries the acids produced in the remnant stomach, the digestive juices produced by the liver and pancreas, including insulin, and some juices produced by the small bowel itself. The two arms of the “Y” are connected again.
Your surgeon will evaluate you on an individual basis. It is possible to have a laparoscopic gastric bypass after having open abdominal surgery or other laparoscopic abdominal procedures. Our surgeons believe that every patient has the right to be given the opportunity to choose minimally invasive surgery as an option.
Yes, you can have laparoscopic gastric bypass surgery if your surgeons are experienced and have good success rate. We exclude no one as a laparoscopic surgical candidate based on BMI alone. Your surgeon will evaluate you on an individual basis.
- You will be prepared for your surgery making sure that you did not eat or drink anything after midnight.
- You will be greeted by your nurses and Anesthesiologist. An IV will be started there, and relaxation medicine will be given to you, as well as one ounce of an antacid that you will drink.
- You will be brought to the operating room where a team of surgeons will be waiting for you. Before you know it, surgery will be done; you will be awoken from the procedure and brought to the post-anesthesia care unit (PACU.)
- You will be groggy as you awaken from anesthesia. You may have an oxygen mask over your face or oxygen delivered through your nostrils. IV fluids will be running, and you may have a catheter in your bladder draining your urine into a bag. You will have compression boots on your feet or compression sleeves on your lower legs, giving you a gentle massage: they are there to help prevent blood clots in your legs.
- You will stay in PACU for one to two hours. Most patients will be transfered to the surgical nursing unit that receives all of our patients. You will travel in your bed.
- You will get out of bed and sit in a chair on the day of your surgery, if you have had the laparoscopic gastric bypass. You will walk with assistance as soon as you are able. You are required to walk every two hours while awake, while you are in the hospital. This helps you to recover faster and restore your bowel activity. It helps fully expand your lungs, aids in preventing pneumonia, and in preventing blood clots. Oddly enough, the more you walk, the more your abdominal wall relaxes, whether you have had an open or a laparoscopic procedure. You will find that you have better pain control if you get up and walk. Patients are always amazed to find out how well this works!
- You may feel nauseated. This is part of the surgical process itself. Again, walking and sitting upright will help relieve some of this early nausea.
- You will feel sleepy most of the time and need frequent naps. You have had major surgery!
Most patients stay two after laparoscopic gastric bypass and up to four days after open gastric bypass.
- The Bariatric Team will assist you with the bariatric prerequisits to gain insurance approval.
- You will need to stop smoking completely. Smoking greatly increases the risk of ulcers at your anastomosis sites.
- Increase your physical activity to the best of your ability. This will make your post-operative recovery easier.
- Stop taking any aspirin or aspirin type medication (for example: Motrin, Ibuprophen, Advil, Anaprox, and Lodine) at least 7 -10 days before your surgery date. If you are unsure of what medication you are taking, ask your doctor.
- Herbal medications that start with the letter “G” (garlic, glucosamine, ginko biloba, ginseng) and Vitamin E have been know to increase bleeding in the immediate post-operative period. These medicines tend to thin the blood. You may wish to stop taking these common over the counter remedies, too, one week before your surgery.
- After midnight, the day of your surgery, do not eat or drink anything. Do not eat or drink anything the morning of your surgery. (Your surgery may need to be postponed or cancelled if you do eat or drink.) Your surgeon will tell you which of your prescription medications to take the morning of surgery and which to hold.
- Take a shower to wash your entire body the morning of or the night before surgery.
- Consider having your hair braided to keep it groomed and in control while you are in the hospital. Avoid hairspray, which will just get hard and sticky and make it hard to comb.
- Slippers which are easy to put on and take off and have a good non-slip tread on the bottom for walking.
- A robe to slip over your shoulders or pajama bottoms or sweat shorts. We will provide you with gowns that will fit. A second gown can be placed over your shoulders to cover you modestly while you are walking.
- You might want to bring a few personal toiletries, like toothpaste, your own hair items, moisturizing creams.
- Your Sleep Apnea machine (CPAP/BiPAP) if you use one at home
You will need to purchase high protein drinks and bariatric vitamins before your surgery so you are well prepared. You are going to experience some things unique to gastric bypass patients. One of the most important things to remember is that you will have a stomach pouch smaller than your mouth. This can prove a challenge in your early post-op life.
You may be used to taking large bites or gulps or in not chewing your foods thoroughly. Give yourself time to heal and to become familiar with the volume capacity of your pouch. Do not rush your meals. Sip your fluids and chew everything to the consistency of applesauce. If you have trouble chewing, you might want to consider using a blender, potato masher, or food processor to bring the foods to a manageable consistency.Supplies to purchase before surgery:
- Children’s Chewable Vitamins with Iron (for example: Flintstones Complete, One-A-Day Kids Complete): you will start taking these two weeks post op, two multivitamins once a day.
- Chewable Calcium Citrate: Calcium carbonate is not absorbed after gastric bypass. One 500mg - 600 mg tablet three times a day.
- B-12 Supplement: This needs to be sublingual (under the tongue). You will be taking 1000 mcg once per week.
- Measuring Cups and Spoons: These will help you better understand your pouch capacity, until you are more familiar with your physical limitations. Your pouch will hold 3 - 5 ounces. A cup equals eight ounces, a quarter cup equals two ounces, and an eighth of a cup is one ounce. One ounce is 30 ml, which equals two tablespoons. It takes a little time and practice until that concept becomes a part of your daily life and your eating habits are automatic.
The remnant (or remaining) stomach gets smaller over time since it is no longer getting stretched with food and drink, but still serves an essential purpose in producing stomach acid and enzymes to help us digest our food.
Certain vitamins and minerals will not be absorbed well enough for you to meet the recommended daily requirements. This is especially true of Vitamins B6, B12, Folate, calcium and the mineral iron. For this reason, we strongly recommend that you take two multivitamins with minerals and calcium citrate daily, and a dose of Vitamin B12 under your tongue weekly for the rest of your life.
Dumping is caused by rapid passage of food from the pouch into the small intestine. Before surgery, the stomach has a valve at the top and bottom, and serves as an acid-filled storage tank, breaking food intake down into small pieces and passing it to the small bowel in increments. After surgery, food passes directly into the small bowel, mixed only with saliva and amylase from the mouth, but no stomach acid. The molecules of food remain fairly intact and therefore, large. The small bowel responds by diluting what we eat through a process of ‘water recruitment’ into the bowel space. The ‘richer’ the food, in terms of molecule size or sugar content, the more water will rush into the small bowel to dilute it. This is referred to as ‘early dumping.’ Suddenly, the heart will pound and beat rapidly; you may feel dizzy, and overwhelmingly tired. The bowels may gurgle and churn, and will feel bloated and gassy. This might be followed by loose stools and even vomiting. It is not dangerous, but it can be frightening to the uneducated patient. ‘Late dumping’ is caused by an insulin response to the ingested food. One might feel flushed, sweaty, fatigued, and experience all the signs of hypoglycemia (low blood sugar).
You can avoid early and late dumping by avoiding the foods that cause dumping. In other words: sugars, starches, fried foods, fats, and high glycemic foods. The glycemic index refers to how swiftly the sugars from the food enter the bloodstream after eating. Each person has a different tolerance, and you will discover what your personal safe foods might be throughout your post-operative life. Person A might have no problem with bananas, Person B might dump every time one is eaten, and Person C might be able to do a rare banana, only if it is a little bit green. You will learn what your own trigger foods might be. Be aware that these may change over time, as your surgical tool matures. What you tolerate in your early post-operative course you might not tolerate later, and vice versa. Every body and everybody is different!
Diarrhea can occur immediately after surgery but usually subsides in the first week. Any time the bowel is touched, third spacing can occur. Third spacing means that water will fill the bowel space, and may pass as loose stool. Sometimes, this extra water may be reabsorbed without causing diarrhea. Chronic diarrhea that does not get better is not a common side effect of this procedure. Examine what you are eating (see dumping, as listed above.) Fruit juices, potatoes, high sugar and high starch foods will provoke diarrhea. Read your labels! If the diarrhea persists, and you have eliminated any offending foods, call your surgeon.
You can expect to see some blood in your stool for the first few bowel movements after surgery because the procedures to the stomach and intestine will have caused some trauma to the tissues and oozing of a small amount of blood is not unusual. If this persists, or if the toilet water is not merely tinged with blood (looking like cranberry juice) but in fact appears to be purely blood (looking like tomato juice) call your surgeon. If you feel weak or dizzy, proceed to the nearest emergency room. Be sure to report to them that you have just had a gastric bypass, give the date of surgery and the name of the surgeon.
Some hair loss is unavoidable, usually starting in the third month after surgery, but is only temporary and fully resolved by the sixth to ninth month post-op. With proper nutrition, it is rare for a patient to have thinner hair a year after surgery than the amount they had before surgery. Some patients have fuller and healthier hair because the body’s hormone balance has improved with weight loss. The medical term for hair loss is trichatrophia. It occurs partly in response to having had a major surgery and exposure to anesthesia, as well as the sudden calorie and protein deprivation experienced just after surgery. Hair follicles have a three month life cycle. The hair follicles that were born on the day of your surgery inside your scalp, working their way outwards over three months, were born unhealthy and will fall out, leaving an empty socket until the next hair follicle emerges in the same spot.
Do not over eat protein calories thinking this will prevent hair loss. It will not work, and you will be setting a bad precedent for yourself. As pouch capacity increases, calorie intake increases. At first, the capacity of the pouch is so small that a patient can lose weight no matter how often they eat during the day. By eating often and in ever increasing amounts, you may unwittingly increase your total calorie intake to the point where you exceed the number of calories you require for weight maintenance, let alone weight loss. Your long term weight loss might not proceed as far as it could have if you train yourself to eat frequently. Hair loss is only temporary. Bad eating habits can become permanent.
You can minimize hair loss by taking biotin (a vitamin supplement) or primrose and flaxseed oil capsules; using a mild, protein based shampoo; reducing the number of times you wash your hair per week to prevent drying your scalp, styling the hair to reduce tension and strain at the roots (perhaps going shorter to ease pulling); and having a short suspension of hair-coloring, braiding, weaving, and chemical processing to give the hair a rest. Consider this as an opportunity to try something new! By this point, given your weight loss at three months, it is a great time to try a new style that you might never have tried before when your face was fuller and your neck was heavier. A whole new you can emerge!
While the incidence of infection is low, any time an incision is made into the skin and through the gastrointestinal tract, the risk of infection exists. Shower daily with a good antibacterial soap to reduce surface bacteria, and always wash your incision first. Wash your hands well and then apply soap and water to your incisions gently. Please consider installing a hand-held shower in your bathroom to help you reach difficult places. Your ability to twist and turn will be altered immediately after surgery. Do not take a bath or swim until all your incisions are well-healed, without drainage and have formed closed scabs.
You are expected to lose a percentage of your excess weight, but only a few patients lose 100% of their excess weight and reach a number established on a weight chart, most of which have been developed by an Actuary (a statistics specialist) employed by a life insurance company. That ideal weight might have little to do with your best weight, where you feel and function at peak health. When you have been carrying excess weight for a long time, your bone frame and muscle mass will have needed to increase, too, in order to support your excess weight. The standard weight charts do not reflect this. Most patients lose 60-70% of their excess weight in the first year after surgery.
If you are a woman of child-bearing age, it is strongly advised that you do not get pregnant for at least a year and a half after your surgery. By delaying a post-operative pregnancy until this time, you are better assured that you will be able to get the proper nutrition for the health of your baby and yourself. Your hormone levels are going to change as you lose weight, and you may find yourself more fertile, with an increased chance of pregnancy. Consult your Gynecologist to develop a contraceptive plan. If you do find yourself pregnant, please notify your Bariatric surgeon immediately, so that the team might help you modify your eating plan for the best possible outcome for yourself and your baby from the earliest stages of your pregnancy.
Much depends on the demands of your daily life. For example, you must avoid lifting more than 15-20 pounds for one month after your surgery. If you have small children, this might require childcare assistance. You will have no restriction on walking or climbing stairs. You will avoid driving for one week. You will avoid vigorous physical activity. If you need to go back to work or to drive immediately, consult your doctor.
You will be given a comprehensive list of appropriate and acceptable food and drink at the time of your surgical consult. Everyone has different tastes and tolerances, so you might notice that there is no cookbook detailing exactly what you should eat, at exactly what time, and in exactly which amount. This is not a diet in the traditional sense of the word. You must develop a new relationship to food and to eating that suits your tastes and cultural heritage, obeying just a few simple guidelines.
- Rule Number One: Read all your labels for SUGAR CONTENT. The magic number is 16 grams of sugar, or sweet sixteen. In other words, everything must have LESS THAN 16 grams of sugar per serving, as labeled. Be careful to read the label of No Sugar Added Products-there might still be enough sugar to trigger dumping in your system, depending on your sensitivity. Items sweetened with ‘sugar alcohol’ (maltilol, sorbitol, anything with an ‘-ol’ ending) can have a laxative effect. In fact, maltilol is used as a baby laxative.
- Rule Number Two: Do not be concerned about fat content. In exchange for fat, the manufacturers add sugar. You are not absorbing fats well and you need some to absorb your fat-soluble vitamins: A, D, E, and K, which are essential antioxidants, to name one of their gifts.
- Rule Number Three: Your taste tolerances are going to change rapidly. This has a lot to do with your zinc levels, which drop after surgery and change your perception of sweet and sour. Resist the urge to buy things you like today in mass quantities, for tomorrow they might get scratched off your list. Another thing that will change in the early post-operative period is your sense of smell. You might not tolerate heavy perfumes or certain scents easily. This is a temporary stage.
Eat at least 600 per day, which will be a struggle in the early days when you have no appetite and limited tolerance for food. This number of calories might seem terribly low to you now, but you will discover that it is an effort to reach it on some days in your early post-operative life.
This can be the most challenging aspect of early recovery. Pay attention to your body’s signals of fullness and keep yourself hydrated. Your pouch will instinctively protect itself when over-stimulated or over-dry by producing a white mucous liquid (referred to as Frothing) which may make you feel quite nauseated. The pouch is lubricating itself, sometimes in preparation to cause vomiting and release of whatever food is offending the pouch or stuck in the Roux limb. You might find that your nose feels full after you eat. This is also part of the frothing process. Some people combat frothing with a mildly acid liquid, sipped slowly, like milky tea or tea with lemon, lemon water, drops of apple cider vinegar in water, or even a few drops of pickle juice or sauerkraut juice. The common feature in all of these is the acidity of the remedies.
Pay attention to your body’s signals of fullness. One extra bite may cause pain and discomfort. Your pouch and Roux limb, the two parts of the gastric bypass tool, work like a slow moving sink drain. There is no stopper at the bottom of the sink, but the narrowness of the connection between the pouch and the Roux limb restricts the passage of food out of the pouch and into the Roux limb. The passage of food is greatly affected by the texture or consistency of the food: heavy, fibrous or dense food exits slowly; soups or liquids pass quickly. Sometimes if a food gets stuck and will not pass into the Roux limb, the only solution is to cough out the offending food to release it from the pouch. Vomiting is best avoided; it is rough on your tender pouch. If you do vomit, go easy on the next meal or next few meals. Consider going to a full liquid diet for the next meals to rest your pouch.Ask yourself the following:
- Am I eating too fast?
- Am I chewing my food?
- Am I eating too much?
- Am I drinking with meals or too soon after eating?
- Am I lying down too soon after eating?
- Are the foods I'm trying to eat too advanced for my pouch and roux?
This surgery changes your food tolerances and capacity and will lead to behavioral changes, but only if you listen to your new anatomy, not your old habits. The surgery does not fix you. You must consciously and mindfully choose to live a healthier life, with healthier eating habits, that will lead to improved health overall. Is it not automatic. You can choose to not change your relationship to food and to eating. You can ‘out eat’ any surgery. The moment the last instrument is removed and the last stitch is placed, you are responsible for your body's upkeep and maintenance.
The first 12 to 14 month time period is what surgeons call the ‘window of opportunity,’ during which time you have the highest degree of pouch restriction and malabsorption working together to your greatest advantage. Do not squander this gift. It is when your surgical tool is working at its maximum level of function. The relative ease with which weight loss occurs in the first few months after surgery can lead some patients to the mistaken belief that their bowel has been made impervious to calories. Even sloppy eating habits can lead to weight loss in the early post-operative course. This stage does not last long. Your pouch will soften, your bowel will adapt, and the behavioral changes you make or fail to make in your early post-operative life will determine how well you succeed in the long-term with gastric bypass surgery. Losing weight early on is a given, maintaining that loss takes work.