How does weight loss surgery work?

The Gastrointestinal tract (gut) is a complex system of hormones, enzymes and feedback-systems that control the absorption of food, the bodies response to and desire for more food (Satiety). Surgery alters the gut to achieve both weight loss and better metabolic control of the absorbed calories/glucose. This is achieved by RESTRICTIVE, MALABSORPTIVE (or a COMBINATION OF RESTRICTIVE/MALABSORPTIVE) types of surgery.

Most absorption of food (Calories, elements and vitamins) occurs in the small bowel. The large bowel is almost mostly solely for fluid absorption. Various parts of the small bowel are more designed to absorb different parts of your diet (i.e. Calcium in Duodenum, vitamin K in Terminal ileum) and secrete a number of hormones to control digestion and feed-back to the brain.

RESTRICTIVE

The Stomach is a reservoir that can hold over 1000ml, this enables us to comfortably have large meals (i.e. three square meals a day). Weight loss surgery creates a smaller gastric ‘pouch’ or ‘sleeve’. This is typically 50-100ml in volume and significantly decreases the volume one can consume at once. When this new stomach is filled up at low volumes, it signals through nerves and hormones to the brain to stop eating and the body and brain feel satisfied and “full”. Patients do not desire to eat more (Satiety) due to the brains response to Ghrelin. Ghrelin is known as the “hunger hormone”.

MALABSORPTIVE

Weight loss surgery re-arranges the internal plumbing of the small bowel to delay the mixing of eaten food with the bile and enzymes required for its digestion. This delay in mixing means that there is less time in the small bowel for this digestion to occur and less calories absorbed. Typically this mixing is delayed by 100-150cm (the typical small bowel length ranges from 300cm – 600cm).

METABOLIC AND OTHER CHANGES

Weight loss surgery causes alteration in various hormones that result in the body behaving differently to ingested food/calories. This is not completely understood, but the most commonly described immediate change is the loss of peripheral insulin resistance seen in type 2 Diabetics. Within days of surgery a large number of Diabetic patients have better control of their blood sugar levels as a result of the body responding to insulin more effectively and lowering blood sugar levels. Other metabolic benefits seen are improved blood pressure and lipid profile through complex feed-back loops.

Roux en Y Gastric Bypass

A Gastric Bypass is a major operation to create a small stomach pouch and rearrange the small bowel to partially “bypass/ delay” the food eaten from being in mixed with the digestive enzymes. This results in both malabsorptive and restrictive changes that results in weight loss and generally improvement in various comorbidities (such as diabetes and hypertension)

A Roux-en-Y Gastric Bypass is a major laparoscopic operation, and requires lifestyle changes to maximise its results

How does a Roux en Y Gastric Bypass work?

Restrictive

The majority of the stomach is disconnected forming a small pouch at the top of the stomach. This measures approximately 50ml . This results in less food eaten and ‘early satiety’, which is the sensation of feeling full and satisfied after eating smaller volumes and thus less calories consumed.

Malabsorptive

This pouch is reconnected to a segment of small bowel in a “Roux en Y” configuration, resulting in the nutrients eaten not being in contact with the enzymes required for breakdown and digestion until further down the gastrointestinal tract (The “gut”). Therefore the body has less time to absorb these calories before passage into the large bowel/ colon

Other changes

Metabolic and Hormonal changes occur after the operation. These are changes in the hormones and signals sent from the remaining stomach to the body. These signals cause the body to secrete less hormones, that in turn ‘turn down’ your appetite. Your body responds by controlling glucose and fats better within the blood stream. Through a complex system, more Insulin is secreted and reduction in ‘peripheral insulin resistance’, which is the hallmark of Type 2 Diabetes

Lifestyle

Only with lifestyle changes can any Bariatric surgery be effective. These include regular exercise, healthy eating, stopping smoking and avoiding high calorie foods.

Who Benefits from a Roux en Y gastric bypass?

People who are committed to lifestyle changes and psychologically prepared with a;

  • BMI >40
    or
  • BMI >35 with comorbidites (Diabetes/ Obstructive Sleep Apnoea/ Joint disease)
  • (International guidelines include BMI >30 and recent-onset type 2 Diabetes)
  • BMI 30-35 will be assessed on a case by case basis
  • Who has attempted several months of weight loss without desired results and no contraindication to surgery (liver/kidney failure, critical heart disease)

What are the benefits?

  • Weight loss of between 65-75% excess body weight (sometimes higher)
  • Resolution of comorbidities
  • Diabetes (approx 50-70%)
  • High blood pressure
  • Obstructive sleep apnoea
  • Halt deterioration of weight-related conditions
  • 40% reduction in all-cause mortality (mostly due to the improvement of Diabetes, Cardiovascular risk factor and Cancer reduction)
  • A BMI >40 is equivalent to smoking in shortening one’s life expectancy

What are the contraindications?

  • Not psychologically prepared for lifestyle changes
  • Non-compliance to follow-up/ medications
  • Certain medical conditions

Preoperative care

  • Continued weight loss/ lifestyle changes.
  • Stop smoking.
  • Reduce Alcohol intake. Postoperatively it is recommended to avoid alcohol completely for 6 months
  • Stabilisation/optimisation of co-morbidities (Diabetes/ High blood pressure)
  • 2-3 weeks before surgery you commence OPTIFAST diet, a very low-calorie diet (VLCD) that is <800kcal per day that completely replaces your meals/ diet (Nutritionally complete)

This achieves further weight loss and deceases the size of your liver improving surgical access and safer surgery with less complications

Dietician Review

All patients will be assessed by our Dietician

This is to:  

  • Optimise preoperative weight loss
  • Education surrounding a healthy diet
  • Prepare yourself for the dietary changes necessary after surgery to improve weight loss and longevity of effect

Psychologist Review

All patients will be assessed by our psychologist. This is routine and been shown to improve one’s understanding around the operation and the post-operative effects on your life

 

Risks of surgery

  • Death – <1 in 400 patients
  • Bleeding – 3% chance of blood transfusion. May require a return to surgery
  • Conversion – <2% risk of a large scar
  • Injury to bowel – <1%. From the insertion of the laparoscopic ports
  • Leak – 1%. From the staple lines and anastomosis (Bowel ‘joins’). This is a serious complication. That may result in further surgery and prolonged hospital stay. This is the complication that increases the risk of death.
  • Vomiting/dehydration – <5%. Due to small stomach volume
  • Medical complications – DVT (clots), Heart attack, Skin infection, Stroke, Pancreatitis

Long term concerns

  • Dehydration – Due to smaller volume fluid drunk, and fluid shifts in the bowel.
  • Excessive weight loss – slow sustained weight loss best.
  • Nutritional Deficiencies – Multi vitamins and Vit B12 injections required. Calcium, Iron and Vitamin B12 are most common deficiencies.
  • Psychological – Depression, anxiety and adjustment disorders can occur in the longer term.
  • Gallstones – Not infrequently stones develop following Bariatric surgery. management is dictated by symptoms.
  • Abdominal bloat/ vomiting – Due to various causes. Can be due to “dumping” of food into the small intestine, internal scars, or angulation of the sleeve. The latter may require intervention (Surgery or Endoscopic dilation).
  • “Dumping Syndrome” – A constellation of symptoms (usually sweating/pain/feeling faint) following the rapid transit of food into the small bowel. Due to either loss of fluid into the small bowel (Early) or low blood sugar (Late). Managed by avoiding sweet foods/ dietary modification and increasing fluid intake.
  • Hernia – Through surgical scars. “Port site” hernia or “Internal Hernia” through small openings created during bypass

Postoperative cares

  • Hospital Stay – 2 nights
  • Dressings – Stay on 4-5 days
  • Clinic review – 1-week post-op, 4 weeks post-op, 3 months post-op
  • Diet – Liquid diet 3 days, Optifast diet for 3 weeks, Soft diet from weeks 3-6 weeks, Light diet from 6 weeks
  • Dietician and Nurse Specialist input

Sleeve Gastrectomy

Sleeve gastrectomy is the removal of a large part of your stomach. This results in both metabolic and restrictive changes that result in weight loss and generally improvement in various comorbidities (such as Diabetes and Hypertension).

A Sleeve Gastrectomy is a major laparoscopic operation and requires lifestyle changes to maximise the results for you.

How does the Sleeve Gastrectomy work?

Restrictive

The majority of the stomach is removed. Approximately 100ml ‘sleeve’ of the stomach remains (<15% of the stomach). This then results in less food being consumed and with ‘early satiety’, this is the sensation of feeling full and satisfied after eating smaller volumes and thus less calories consumed.

Other factors 

Metabolic and hormonal changes occur after the operation. There are changes in the amount of hormones and signals sent from the remaining stomach to the body, that ‘turn down’ your appetite and also creates “early satiety”. Your body also responds by controlling glucose and fats better within the bloodstream (less insulin resistance- which is the hallmark of type 2 Diabetes.

Lifestyle

Only with lifestyle changes can any Bariatric surgery be effective. These include regular exercise, healthy eating, stopping smoking and avoiding high-calorie foods.

Who benefits from a Sleeve Gastrectomy

People who are committed to lifestyle changes and psychologically prepared with a;

  • BMI >40
  • BMI >35 with comorbidites (Diabetes/ Obstructive Sleep Apnoea/ Joint disease)

Who has attempted several months of weight loss without desired results and no contraindication to surgery (liver/kidney failure, critical heart disease

The benefits of weight surgery are greatest in people under 65yrs. This is due to the reversibility of the comorbidities and risks of surgery. Patients with lower BMI (30-35) can be discussed on a case by case basis.

Any Bariatric operation is a partnership between the Surgeon and the Patient

What are the benefits of the Sleeve Gastrectomy?

  • Weight loss of between 50-70% excess body weight
  • Resolution of comorbidities
  • Diabetes (approx 70-80%)
  • High blood pressure
  • Obstructive sleep apnoea
  • Halt deterioration of weight related conditions
  • A BMI >40 is equivalent to smoking in shortening ones life expectancy

What are the contra-indications to a Sleeve Gastrectomy?

  • Moderate/Severe acid reflux (“Heartburn”)
  • If not prepared to undergo lifestyle and dietary changes
  • Significant medical comorbidities (Cirrhosis of liver/ Heart failure etc…)

Preoperative cares

  • Continued dietary and lifestyle changes.
  • Strongly recommended to stop smoking and reduce alcohol intake. Post operatively it is recommended to avoid alcohol completely for 6 months
  • Stabilisation/optimisation of co-morbidities (Diabetes/ High blood pressure)
    2-3 weeks before surgery you commence the OPTIFAST diet, a very low-calorie diet (VLCD) that is <800kcal per day that completely replaces your meals/ diet (Nutritionally complete).

This achieves further weight loss and decreases the size of your liver improving surgical access, safer surgery and fewer complications

Dietician Review

All patients will be assessed by our Dietician

This is to:

  • Optimise preoperative weight loss
  • Education surrounding a healthy diet
  • Prepare yourself for the dietary changes necessary after surgery

Psychologist Review

All patients will be assessed by our psychologist. This is routine and been shown to improve one’s understanding around the operation and the post-operative effects on your life.

Risks of surgery

  • Death – very low; between 1-2/1000 patients
  • Bleeding – 3% chance of blood transfusion
  • Conversion – <2% risk of a large scar
  • Injury to bowel – <1%. From the insertion of the laparoscopic ports
  • Leak – 1%. From staple line. This is a serious complication. That may result in further surgery and prolonged hospital stay.
  • Vomiting – <5%. This occasionally occurs from kinking/twisting of the stomach tube. Generally resolves within 4 weeks
  • Medical complications – DVT (clots in leg veins), Heart attacks, Skin infections, Stroke, Pancreatitis – all unlikely

Long term concerns

  • Increased acid reflux symptoms – Association of increased reflux symptoms after Sleeve surgery (Approx 20%). Unclear cause
  • Smaller meals – Smaller stomach volume after surgery
  • Dehydration – Due to smaller volume fluid drunk
  • Excessive weight loss – slow sustained weight loss best
  • Nutritional Deficiencies – Multivitamins taken postoperatively may be required. Calcium and Iron are the most common deficiencies resulting in osteoporosis and anaemia respectively. These are generally mild.
  • Psychological – Depression, anxiety and adjustment disorders can occur in the longer term
  • Gallstones – Not infrequently stones develop following Sleeve surgery. Management is dictated by symptoms
  • Abdominal bloat/ vomiting – Due to various causes. Can be due to “dumping” of food into the small intestine, internal scars, or angulation of the sleeve. The Latter may require intervention (Surgery or Endoscopic dilation)
  • Hernia – Through surgical scars = “Port site” hernia. Internal hernias not seen in Sleeve Gastrectomy

Sleeve Gastrectomy summary

Advantages

  • Rapid weight loss as hunger and satiety control well tolerated. Most near target weight by 1 year with maximal weight loss at 18 months
  • The continuity of the gastrointestinal tract is preserved so that many of the nutritional complications seen with Bypasses are avoided.
  • Recovery time is rapid with most patients returning to work in a week or two. No heavy lifting 4-6weeks

Disadvantages

  • Leaks from staple line can occur (2%), which would require hospitalisation and re-intervention.
  • Possibly 10% of patients may require revisional surgery due to weight regain (at 5-10+ years).
  • Long-term data is lacking so its longevity is not tested

THE OMEGA LOOP GASTRIC BYPASS (mini-loop gastric bypass)

The Omega Loop is the reduction in the size of your stomach and re-arrangement of your small bowel such that the mixing of digestive enzymes/ bile (required for the breakdown of calories/vitamins) with swallowed food is delayed (bypassed) to decrease absorption. This results in respective restrictive and malabsorptive changes that results in weight loss and generally improvement in various comorbidities (such as diabetes and hypertension).

An Omega loop Bypass is a major laparoscopic operation, and requires lifestyle changes to maximise its results.

How does an Omega Loop Gastric Bypass work?

Restrictive

The majority of the stomach is removed. Approximately 100- 150ml ‘sleeve’ of stomach remains (<10% of stomach). This results in ‘early satiety’, this is the sensation of feeling full and satisfied after eating smaller volumes and thus less calories eaten through regulation of hormones (“Ghrelin”).

Malabsorptive

This pouch is reconnected to a segment of small bowel in a “loop” configuration resulting in the nutrients eaten not being in contact with the enzymes required for breakdown and digestion until further down the gastrointestinal tract (The “gut”) than normal. Therefore the body has less time to absorb these calories before passage into the large bowel/ colon

Other Changes

Metabolic changes occur after the operation. These are changes in the hormones and signals sent from the remaining stomach to the body. These signals cause the body to secrete less hormones, that in turn ‘turn down’ your appetite. Your body responds by controlling glucose and fats better within the blood stream. Through a complex system, more Insulin is secreted and reduction in ‘peripheral insulin resistance’, which is the hallmark of Type 2 Diabetes

Lifestyle

Only with lifestyle changes can any Bariatric surgery be effective. These include regular exercise, healthy eating, stopping smoking and avoiding high calorie foods.

Who benefits from an Omega loop Gastric Bypass?

People who are committed to lifestyle changes and psychologically prepared with a;

  • BMI >40
    or
  • BMI >35 with comorbidites (Diabetes/ Obstructive Sleep Apnoea/ Joint disease)
  • (Certain international Guidelines include BMI >30 and recent-onset type 2 Diabetes)

Lower BMI’s considered in case-by-case basis

People who have attempted several months of weight loss without desired results and no contraindication to surgery (liver/kidney failure, critical heart disease)

What are the benefits of an Omega loop Gastric Bypass?

  • Weight loss of between 65-75% excess body weight (sometimes higher)
  • Potential resolution of comorbidities
  • Type 2 Diabetes (approx 90%)
  • High blood pressure
  • Obstructive sleep apnoea
  • Halt deterioration of weight related conditions
  • 40% reduction in all cause mortality (mostly due to improvement of Diabetes, Cardiovascular risk factor and Cancer reduction)
  • A BMI >40 is equivalent to smoking in shortening ones life expectancy

Contraindications to an Omega loop Gastric Bypass

  • Not psychologically prepared for lifestyle changes
  • Non-compliance to follow-up/ medications
  • Certain medical conditions

Preoperative Cares

  • Continued weight loss/ lifestyle changes.
  • Stop smoking.
  • Reduce Alcohol intake. Postoperatively it is recommended to avoid alcohol completely for 6 months.
  • Stabilisation/optimisation of co-morbidities (Diabetes/ High blood pressure)
  • 2-3weeks before surgery you commence OPTIFAST diet, a very low-calorie diet (VLCD) that is <800kcal per day that completely replaces your meals/ diet (Nutritionally complete)

This achieves further weight loss, and deceases the size of your liver improving surgical access and safer surgery with less complications

Dietician Review

All patients will be assessed by our Dietician

This is to:

  • Optimise preoperative weight loss
  • Education surrounding a healthy diet
  • Prepare yourself for the dietary changes necessary after surgery

Psychologist Review

All patients will be assessed by our psychologist. This is routine and been shown to improve one’s understanding around the operation and the post-operative effects on your life

Risks of surgery

  • Death – < 1 in 400 patients
  • Bleeding – 3% chance of blood transfusion
  • Conversion – <2% risk of a large scar
  • Injury to bowel – <1%. From the insertion of the laparoscopic ports
  • Leak – 2%. From staple line. This is serious complication. That may result infurther surgery and prolonged hospital stay. A leak is the most common surgical causes for death
  • Medical complications – DVT (clots), Heart attacks, Skin infections, Stroke, Pancreatitis

Long term concerns

  • Bile reflux symptoms – 10-20% patients experience reflux symptoms due to the increased presence of bile within the stomach pouch refluxing up the oesophagus
  • Smaller meals – Smaller stomach volume after surgery
  • Dehydration – Due to smaller volume fluid drunk
  • Excessive weight loss – Slow sustained weight loss best
  • Nutritional Deficiencies – Multi vitamins and Vit B12 injections required. Calcium, Iron and Vitamin B12 are most common deficiencies. Malnutrition from vitamin deficiencies are more common then after Roux-en-Y gastric Bypass
  • Psychological – Depression, anxiety and adjustment disorders can occur in the longer term
  • Gallstones – Not infrequently stones develop following Bariatric surgery. Management is dictated by symptoms
  • Abdominal bloat/ vomiting – Due to various causes. Can be due to “dumping” of food into small intestine, internal scars, or angulation of the sleeve. The Latter may require intervention (Surgery or Endoscopic dilation)
  • Hernia – Through surgical scars (“port site” hernia) or through defects created by forming the “Bypass”
  • Conversion to Roux en Y gastric bypass – Study’s have shown that 7-10% of patients have a further operation to convert an Omega loop bypass to a Roux-en-Y bypass within 5 years. This is generally due to reflux of bile into oesophagus (“Heartburn”)

Postoperative Cares

  • Hospital Stay – 2 nights
  • Clinic review – 1-week post-op, 4 weeks post-op, 3 months post-op
  • Diet – Optifast for 3 weeks, Soft diet from weeks 3-6 weeks, Lite diet from 6 weeks
  • Dietician and Nurse Specialist input

Choosing the right operation for you

Once you have decided that weight loss surgery is for you, the next major step is which operation is best for you. This can sometimes be straight forward but commonly requires deciding between the “pros and cons” of each. For instance, smoking and acid reflux would generally mean that a Gastric Sleeve and Gastric Bypass respectively would be best for you.

The operation that you choose should take into account your motivating factors. If comorbidity resolution (such as diabetes), solely weight loss or combination are your reasons for choosing surgery then this may reflect which operation is best for you.

In broad terms the operations are either RESTRICTIVE (Sleeve gastrectomy), MALABSORPTIVE (Duodenal switch) or combination of the two (Roux en Y and Omega-loop Gastric bypass). A restrictive operation reduces the size of your stomach (by 75-85%) and limits the volume you can physically eat at any one time. A malabsorptive operation delays the mixing of eaten food with the enzymes required for digestion to further down the gastrointestinal tract (‘the gut” or small bowel) and thus less calories absorbed by the body. After an operation that has a malabsorptive component, one must strictly adhere to the post-operative prescribed multivitamins to avoid nutritional and mineral deficiencies. Each operation has excellent weight loss results however weight regains and ability to ‘eat around’ the surgery is higher in some.

Any weight loss surgery is a major operation but generally considered safe. Major complications are seen in <4%. The Duodenal switch operation is not commonly performed in New Zealand (<1%), and if you are interested I will refer you to the surgeon who performs them.

A BMI >40 is equivalent to smoking in shortening one’s life expectancy.

Prior to Very Low Calorie Diet (i.e. OptiFast)

Guidelines may vary from person to person, but may include the following: 

  • Eliminate or decrease saturated fats, including whole milk products, fatty meat, and fried food
  • Eliminate or decrease foods that are high in carbohydrates, such as sugary desserts, pasta, potatoes, bread, and bread products
  • Eliminate high-sugar beverages, such as juice and sodas
  • Exercise portion control
  • Avoid binge eating
  • Don’t smoke cigarettes
  • Avoid alcoholic beverages and recreational drugs
  • Don’t drink beverages with your meals
  • You may take protein supplements as protein shakes or powder

Very Low Calorie Diet (i.e. Optifast)

  • You will be given instructions to take this preop by dietician. Generally 2-3 weeks pre operatively. You will be best to have at least 1 week available post operative as you will be on a liquid diet for at least 1 week

Blood thining medications

  • You will be given advice as to when to discontinue your medictaion. If you have any questions, please ask

CPAP breathing machines

  • If you use a CPAP machine at night for Obstructive Sleep Apnoea you will be required to bring to Grace Hospital during your stay

Birth Control

  • It is best to have thought about alternative birth control options prior to surgery. Your usual oral contraceptive medication will no longer be reliable (due to unpreductable absorption)
  • These are be discussed with your Surgeon or General Pracitioner
  • It is best that you do not become pregant in first 12months

Post operative multivitamin

  • These are best started upon discharge. A chewable form is recommended for the initial 2 weeks.
  • Celebrate Bariatric chewable Multivitamin can be ordered through amsnutrition.co.nz
  • Berocca can also be commenced post-operativly (you will need to bring this to the Hospital)

Post operative diet

  • You will be on a liquid diet for 1 week, then progressing through pureed diet to soft and finally solid over 4-5 weeks period. It is best to prepare for this by pre-buying appropriate foods and ensuring you have access to a good Kitchen blender

Fitness/ Wellbeing

  • Before any major surgery it is best to stay as fit as posible and to seek medical attention if unwell iprior to your surgery date

Work

  • Most people will require at least 2 weeks off work. Total 6 weeks off heavy lifting (>5kg lifting)

Optifast Diet Instructions

You will have told you how long you need to follow this diet before surgery. This depends on your personal treatment plan.

How do I take Optifast?

Make sure you have 4 Optifast packets each day. Do not drink less than 4 Optifast a day as this can result in muscle loss and poor healing after surgery. Mix 1 packet with at least 300 ml (11⁄4 cups) of cold water. You can add ice cubes if you like. Shake well or blend in a blender. Drink at least 2 litres (8 cups) of fluid each day including the Optifast amounts.

What else can I take with Optifast?

Drink sugar-free, calorie-free beverages that are non-carbonated, including:

  • Water
  • Decaf coffee or decaf tea (no milk or sugar added), artificial sweetener is okay
  • Low-fat broth (up to 20 calories per serving is allowed)
  • Sugar-free jelly

You can also eat up to a total of 500 ml (2 cups) a day of the following vegetables while taking Optifast. These are the ONLY vegetables you can eat:

  • Green peppers
  • Broccoli
  • Cauliflower
  • Lettuce
  • Spinach
  • Celery
  • Cabbage
  • Cucumber

You can use a small amount (1 tablespoon or 15 ml) of calorie-free dressing with your vegetables if you like. You cannot eat any other solid foods while you are taking Optifast.

Optifast Diet Instructions

Can I add anything to change the flavour?
You may add any of the following to your Optifast to change the flavour:

  • Decaf coffee (brewed or instant coffee crystals)
  • Sugar-free syrups or flavour extracts such as mint, berry, maple or banana
  • Zero-calorie drinks such as Crystal Light or Mio

What do I do if I have diabetes?
If may need help adjusting your diabetes medications while on Optifast

What if I have constipation or diarrhoea while taking Optifast?

Sometimes, people have constipation or diarrhoea while taking Optifast. This is mostly related to the low amount of fibre found in the product.

If you have constipation, try increasing your liquids up to 3 litres (12 cups) each day. You can also try using a fibre supplement such as Benefibre or Metamucil capsules. Use the sugar-free versions of these products. Start with the lowest dose and follow the instructions on the label, up to the maximum daily dose. If you still have constipation, you can also use medications for constipation such as Colace, Senekot or milk of magnesia.

If you have diarrhoea, it is still important to drink at least 2 litres (8 cups) of fluids daily. Using a fibre supplement such as Benefibre or Metamucil capsules can also help with diarrhoea. Use the sugar-free versions of these products. Start with the lowest dose and follow the instructions on the label, up to the maximum daily
dose.

POSTOPERATIVE VITAMIN AND ELEMENT REPLACEMENT

After a Gastric Bypass you are more likely to develop vitamin and elemental deficiencies. The duodenum and first part of the small bowel is on longer in contact with your ingested food. It is here that some vitamins and elements are absorbed into the blood stream. This is generally less following a Sleeve Gastrectomy, as there is no mal-absorptive component (the gut continuity is ‘normal’). 

Common deficiencies are calcium (if low can thin bones), iron (if low results in anaemia) and vitamin B12 (if low can result in abnormal red blood cells). To account for this you will be required to take regular daily chewable multi-vitamin tablets and Vitamin D supplementation. Vitamin B12 will require a 6-12monthly injection at your GP. This will generally be adequate however we recommend annual blood test. A bone density scan is recommended at 2 and 5 years to assess any premature thinning of your bones.

Common examples of chewable multivitamin tablets are;

  • Centrum
  • Celebtrate

It is important that these multivitamins and injections are continued lifelong.

Post operative multivitamin

  • These are best started upon discharge. A chewable form is recommended for the initial 2 weeks or Berocca.
    • Celebrate Bariatric chewable Multivitamin can be ordered through amsnutrition.co.nz
    • Centrium Advance 50+ or Centrium Woman’s multi (x2 per day) once on pureed diet (2-3 weeks post procedure)
    • Berocca can also be commenced post postoperativley (you will need to bring this to the Hospital)
  • Calcium Citrate is recommended 500mg daily
    • Do not take with meals
  • Vitamin D orally 5000IU weekly
  • Vitamin B12 6-12 monthly injections 
    • possible oral solutions available through amsnutrition.co.nz

POST OP PROTOCOL   

Day 0 (day of surgery)

• May have sips of water up to 30mls per hour

• Encourage mobilisation

• IV Omeprazole as charted

STOP all diabetic medication

• Regular anti-emetic as charted

• Strict fluid balance – show patient how to record this themselves

• Sub-cut Clexane as charted

• TEDS should still be in place from admission

Day 1 post op

• Start sips of water 30ml/hr. – if well tolerated increase to 60ml/hr. by mid-day

• Stop IV fluids once tolerating 60ml per hour

• Strict fluid balance – patient to record fluids themselves

• Can change to oral medication – these must be crushed or capsule opened

IV Omeprazole change to oral Pantoprazole 20mg daily

Contents swallowed only, capsule to be discarded

• If tolerating 60mls per hour later in the day then progress to dilute Optifast (or similar) into 400mls of fluid)

• Remind patient to re-read the dietitian information

Day 2 post op (if not discharged day 1)

• Increase oral fluids to 100mls per hour if tolerated and introduce dilute Optifast as above

• Can begin Berocca performance (dilute) once daily or wait until discharge – Optifast is more important at this stage

• Aim for discharge

Discharge plan

• Paracetamol (dissolvable or suspension) Q4-6H for at least 48hrs

• Pantoprazole 20mg PO daily for the next 12 months due to risk of developing a gastric ulcer. Crush until 3-4 weeks post procedure

• Centrium Advance 50+ (x2 per day) once on pureed diet (2-3 weeks post procedure) or Celebrate Bariatric Multivitamin (chewable, one per day) on discharge

• Crush all usual medications (or open capsules) for at least 3 weeks

• Dietitian sheets and vitamin supplement sheets given to patient with contact details if any problems arise

• Bowel management (preventative promoted) e.g. alpine tea or Phloe tablets

Strictly no NSAIDs after Gastric Bypass

Clinic review approx. 1 week post op

 

Week 1 = Liquids

For the first day after surgery, you’ll only be allowed to drink clear liquids.

Once you’re handling clear liquids, you can start having other liquids, such as

  • Optifast (or similar)
  • Broth
  • Unsweetened juice
  • Decaffeinated tea or coffee
  • Milk (skim)
  • Sugar-free gelatin or popsicles

Aim for 1.5 – 2.0 litres per day

All drinks should be low in sugar

Weeks 2-3 = Pureed foods

After 1 week of tolerating liquids, you can begin to eat strained and pureed (mashed up) foods. The foods should have the consistency of a smooth paste, pudding or a thick liquid, without any solid pieces of food in the mixture. V-8 juice and first-stage baby foods, which do not contain solids, are also convenient options.

As you start to include purees into your diet, it’s important not to drink fluids while you eat. 

You can eat three to six small meals a day. Each meal should consist of 4 to 6 tablespoons of food.

  • Eat slowly — about 30 minutes for each meal

Choose foods that will puree well, such as:

  • Lean ground meat, poultry or fish, cottage cheese, soft scrambled eggs , yogurt, white fish, cottage cheese, ricotta, cooked cereal, soft fruits and cooked vegetables (applesauce, bananas, canned fruits , peaches, apricots, pears, pineapples, melons), strained cream soups

Blend solid foods with a liquid, such as:

  • Water, Skim milk, Juice with no sugar added, Broth

Practical tips to help meet Nutritional Requirements at Pureed Stage:

  • Each meal should include a high protein food item
  • Protein shakes should be included to help ensure an adequate protein intake and protein powder can be added to meals to increase the protein content

Spicy seasonings may irritate the stomach, so avoid these completely or try them one at a time.

Avoid fruits that have lots of seeds, such as strawberries or kiwifruit. You should also stay away from foods that are too fibrous to liquefy, such as broccoli and cauliflower. 

Weeks 4-5 = Soft foods

After a few weeks of pureed foods you can start soft diet (generally week 4). They should be small, tender and easily chewed pieces of food.

You can eat three to five small meals a day. Each meal should consist of one-third to one-half cup of food. Chew each bite until the food is pureed consistency before swallowing.

Soft foods include:

  • Ground lean meat or poultry, Flaked fish, eggs, Cottage cheese, cooked or dried cereal, rice, canned or soft fresh fruit, without seeds or skin, cooked vegetables, without skin

Include 1 protein shake per day as part of fluid intake

  • Optifast® shakes / soups / desserts (Pharmacies, PharmacyDirect.co.nz)
  • Red8 Protein Plus, Whey or Soy Protein (Health 2000 stores, PharmacyDirect.co.nz)
  • Balance, 100% Whey Protein (Health 2000 stores, PharmacyDirect.co.nz)
  • Clean Lean Protein Pea (Health 2000 stores, Hardys, PharmacyDirect.co.nz)

>6 Weeks = Solid foods

After about 6 weeks on the gastric bypass diet, you can gradually return to eating firmer foods. Start with eating three meals a day, with each meal consisting of 1 to 1-1/2 cups of food. It’s important to stop eating before you feel completely full.

Depending on how you tolerate solid food, you may be able to vary the number of meals and amount of food at each meal. Talk to your dietitian about what’s best for you.

Try new foods one at a time. Certain foods may cause pain, nausea or vomiting after gastric bypass surgery.

Foods that can cause problems at this stage include:

  • Breads, carbonated drinks, raw vegetables, cooked fibrous vegetables, such as celery, broccoli, corn or cabbage, tough meats or meats with gristle, red meat, fried foods, highly seasoned or spicy foods, nuts and seeds and popcorn

Avoid

  • Avoid alcohol 6 months, fizzy drink 3 months, chewing gum 1-3 months
  • limit caffeine to 1 Café coffee per day (so long as you are drinking >1.5l/day)

Post Operative Follow-up

Surgical review

  • Week 1-2
  • Week 3
  • 12 months following surgery

Stop Omeprazole at 6 months
DEXA (bone density scan) at 1 and 5 Years

Dietician post op

  • Week 3
  • 3 months
  • 8 months
  • 12 months
  • 18 months
  • 2 years

Psychologist/ Group Sessions

  • As required/desired

Long Term Considerations

Eat Slowly

  • Chew your food 20 times before swallowing

Ensure you eat enough protein

  • Eat your protein before your carbohydrates

Avoid liquids with meals (do not drink within 30 mins before or after meals)

Exercise at least 30mins 5 times per week

Avoid alcohol 6 months

  • Your tolerance to alcohol may be significantly lower postoperatively

Try to limit caffeine in taking to 1-2 cups per day

Avoid pregnancy for 12 months post surgery

  • Use contraception during this waiting period (oral contraception may be less effective)
  • Get regular blood tests to look for nutritional deficiencies. You may need additional supplements
  • See a Dietician to help regulate weight gain during pregnancy

Always carry drink bottle on your person

  • To sip clear fluids over the course of the day

Try to carry/ have handy a protein bar (or similar) to eat if feeling fatigued/ low blood sugar
We strongly recommend that you NEVER smoke postoperatively

  • Smoking is the main contributor to Gastric pouch ulceration

Avoid Non-Steroidal Anti Inflammatory pain relief (NSAID’s)

  • Increase Gastric pouch ulceration

Continue Multivitamin/ Calcium/ Vitamin D tablets lifelong

Monitor vitamin B12 with 6 monthly blood tests

  • You may require a vitamin B12 injection if low

Dumping syndrome can occur after eating a high sugar meal/sweets

  • Can make you feel unwell (Dizziness/pain/flushes/cramps/diarrhoea).
  • This is self limiting/ Not harmful
  • Immediately after eating, or delayed by 2-3 hours
  • Managed by avoiding sweet/ high sugar foods and increasing fluid intake

Constipation can be an issue. Laxatives may be required as oral fibre intake may be low.

  • Best to avoid Lactulose

If at any stage you feel unwell postoperatively it is important to contact us (especially in the first week postoperatively)

Such as;

  • FEVERS/ SWEATS/ DEHYDRATION/ SEVERE ABDOMINAL PAIN/ SIGNS OF INFECTION

 

Mr Barnaby Smith
Ph 571 5548
Mob 021988961

Email info@barnabysmithsurgical.co.nz

POST OP PROTOCOL   

Day 0 (day of surgery)

• May have sips of water up to 30mls per hour

• Encourage mobilisation

• IV Omeprazole as charted

STOP all diabetic medication

• Regular anti-emetic as charted

• Strict fluid balance – show patient how to record this themselves

• Sub-cut Clexane as charted

• TEDS should still be in place from admission

Day 1 post op

• Start sips of water 30ml/hr. – if well tolerated increase to 60ml/hr. by mid-day

• Stop IV fluids once tolerating 60ml per hour

• Strict fluid balance – patient to record fluids themselves

• Can change to oral medication – these must be crushed or capsule opened

IV Omeprazole change to oral Pantoprazole 20mg daily

Contents swallowed only, capsule to be discarded

• If tolerating 60mls per hour later in the day then progress to dilute Optifast (or similar) into 400mls of fluid)

• Remind patient to re-read the dietitian information

Day 2 post op (if not discharged day 1)

• Increase oral fluids to 100mls per hour if tolerated and introduce dilute Optifast as above

• Can begin Berocca performance (dilute) once daily or wait until discharge – Optifast is more important at this stage

• Aim for discharge

Discharge plan

• Paracetamol (dissolvable or suspension) Q4-6H for at least 48hrs

• Pantoprazole 20mg PO daily for the next 12 months due to risk of developing a gastric ulcer. Crush until 3-4 weeks post procedure

• Centrium Advance 50+ (x2 per day) once on pureed diet (2-3 weeks post procedure) or Celebrate Bariatric Multivitamin (chewable, one per day) on discharge

• Crush all usual medications (or open capsules) for at least 3 weeks

• Dietitian sheets and vitamin supplement sheets given to patient with contact details if any problems arise

• Bowel management (preventative promoted) e.g. alpine tea or Phloe tablets

Strictly no NSAIDs after Gastric Bypass

Clinic review approx. 1 week post op

 

Week 1 = Liquids

For the first day after surgery, you’ll only be allowed to drink clear liquids.

Once you’re handling clear liquids, you can start having other liquids, such as

  • Optifast (or similar)
  • Broth
  • Unsweetened juice
  • Decaffeinated tea or coffee
  • Milk (skim)
  • Sugar-free gelatin or popsicles

Aim for 1.5 – 2.0 litres per day

All drinks should be low in sugar

Weeks 2-3 = Pureed foods

After 1 week of tolerating liquids, you can begin to eat strained and pureed (mashed up) foods. The foods should have the consistency of a smooth paste, pudding or a thick liquid, without any solid pieces of food in the mixture. V-8 juice and first-stage baby foods, which do not contain solids, are also convenient options.

As you start to include purees into your diet, it’s important not to drink fluids while you eat. 

You can eat three to six small meals a day. Each meal should consist of 4 to 6 tablespoons of food.

  • Eat slowly — about 30 minutes for each meal

Choose foods that will puree well, such as:

  • Lean ground meat, poultry or fish, cottage cheese, soft scrambled eggs , yogurt, white fish, cottage cheese, ricotta, cooked cereal, soft fruits and cooked vegetables (applesauce, bananas, canned fruits , peaches, apricots, pears, pineapples, melons), strained cream soups

Blend solid foods with a liquid, such as:

  • Water, Skim milk, Juice with no sugar added, Broth

Practical tips to help meet Nutritional Requirements at Pureed Stage:

  • Each meal should include a high protein food item
  • Protein shakes should be included to help ensure an adequate protein intake and protein powder can be added to meals to increase the protein content

Spicy seasonings may irritate the stomach, so avoid these completely or try them one at a time.

Avoid fruits that have lots of seeds, such as strawberries or kiwifruit. You should also stay away from foods that are too fibrous to liquefy, such as broccoli and cauliflower. 

Weeks 4-5 = Soft foods

After a few weeks of pureed foods you can start soft diet (generally week 4). They should be small, tender and easily chewed pieces of food.

You can eat three to five small meals a day. Each meal should consist of one-third to one-half cup of food. Chew each bite until the food is pureed consistency before swallowing.

Soft foods include:

  • Ground lean meat or poultry, Flaked fish, eggs, Cottage cheese, cooked or dried cereal, rice, canned or soft fresh fruit, without seeds or skin, cooked vegetables, without skin

Include 1 protein shake per day as part of fluid intake

  • Optifast® shakes / soups / desserts (Pharmacies, PharmacyDirect.co.nz)
  • Red8 Protein Plus, Whey or Soy Protein (Health 2000 stores, PharmacyDirect.co.nz)
  • Balance, 100% Whey Protein (Health 2000 stores, PharmacyDirect.co.nz)
  • Clean Lean Protein Pea (Health 2000 stores, Hardys, PharmacyDirect.co.nz)

>6 Weeks = Solid foods

After about 6 weeks on the gastric bypass diet, you can gradually return to eating firmer foods. Start with eating three meals a day, with each meal consisting of 1 to 1-1/2 cups of food. It’s important to stop eating before you feel completely full.

Depending on how you tolerate solid food, you may be able to vary the number of meals and amount of food at each meal. Talk to your dietitian about what’s best for you.

Try new foods one at a time. Certain foods may cause pain, nausea or vomiting after gastric bypass surgery.

Foods that can cause problems at this stage include:

  • Breads, carbonated drinks, raw vegetables, cooked fibrous vegetables, such as celery, broccoli, corn or cabbage, tough meats or meats with gristle, red meat, fried foods, highly seasoned or spicy foods, nuts and seeds and popcorn

Avoid

  • Avoid alcohol 6 months, fizzy drink 3 months, chewing gum 1-3 months
  • limit caffeine to 1 Café coffee per day (so long as you are drinking >1.5l/day)

Post Operative Follow-up

Surgical review

  • Week 1-2
  • Week 3
  • 12 months following surgery

Stop Omeprazole at 6 months
DEXA (bone density scan) at 1 and 5 Years

Dietician post op

  • Week 3
  • 3 months
  • 8 months
  • 12 months
  • 18 months
  • 2 years

Psychologist/ Group Sessions

  • As required/desired

Long Term Considerations

Eat Slowly

  • Chew your food 20 times before swallowing

Ensure you eat enough protein

  • Eat your protein before your carbohydrates

Avoid liquids with meals (do not drink within 30 mins before or after meals)

Exercise at least 30mins 5 times per week

Avoid alcohol 6 months

  • Your tolerance to alcohol may be significantly lower postoperatively

Try to limit caffeine in taking to 1-2 cups per day

Avoid pregnancy for 12 months post surgery

  • Use contraception during this waiting period (oral contraception may be less effective)
  • Get regular blood tests to look for nutritional deficiencies. You may need additional supplements
  • See a Dietician to help regulate weight gain during pregnancy

Always carry drink bottle on your person

  • To sip clear fluids over the course of the day

Try to carry/ have handy a protein bar (or similar) to eat if feeling fatigued/ low blood sugar
We strongly recommend that you NEVER smoke postoperatively

  • Smoking is the main contributor to Gastric pouch ulceration

Avoid Non-Steroidal Anti Inflammatory pain relief (NSAID’s)

  • Increase Gastric pouch ulceration

Continue Multivitamin/ Calcium/ Vitamin D tablets lifelong

Monitor vitamin B12 with 6 monthly blood tests

  • You may require a vitamin B12 injection if low

Dumping syndrome can occur after eating a high sugar meal/sweets

  • Can make you feel unwell (Dizziness/pain/flushes/cramps/diarrhoea).
  • This is self limiting/ Not harmful
  • Immediately after eating, or delayed by 2-3 hours
  • Managed by avoiding sweet/ high sugar foods and increasing fluid intake

Constipation can be an issue. Laxatives may be required as oral fibre intake may be low.

  • Best to avoid Lactulose

If at any stage you feel unwell postoperatively it is important to contact us (especially in the first week postoperatively)

Such as;

  • FEVERS/ SWEATS/ DEHYDRATION/ SEVERE ABDOMINAL PAIN/ SIGNS OF INFECTION

 

Mr Barnaby Smith
Ph 571 5548
Mob 021988961

Email info@barnabysmithsurgical.co.nz

Before your Surgery

What is Optifast?

Optifast is a meal replacement which is very low in calories and high in protein. It is available in shakes, soups, bars, and as a dessert.

Why do I need to take Optifast?

  • To reduce the size of your liver so that surgery is safer and easier.
  • To improve your recovery after surgery.
  • To kick start your weight loss.

How do I take Optifast?

You need to be on the Optifast diet for 2-3 weeks before your surgery as advised by your dietician

You should take:

  • Optifast products (as advised by dietician) per day.
  • Two cups of low starch vegetables per day. (see examples on the next page)
  • One serve of fruit per day (optional. See examples on the next page).
  • At least two litres of calorie-free fluids per day (see examples on the next page).

 

If you eat foods that are not permitted, it may reduce the effect of Optifast and your liver may not shrink. This can make the surgery more difficult and may result in your operation being cancelled.

 

What do I do if I have Diabetes?

  • You should not need to make any changes to your diabetes management whilst you are on Optifast if:
    • Your diabetes is diet controlled or
    • You take metformin
  • Please contact the Diabetes team, your GP or Diabetes specialist to discuss any changes when using Optifast if:
    • You take any other medication such as gliclazide or insulin

Where can I buy Optifast?

Most pharmacies stock Optifast.

How will I feel while taking Optifast?

The first four days are the most difficult. Keep going – it will get easier! You may feel hungry, tired and emotional. Doing more exercise may help you to get through these first few days because it provides distraction and releases ‘feel good’ endorphins.

Constipation can be a problem for some people. To help, make sure you are eating two cups of the allowed vegetables and drinking at least two litres of calorie-free fluid every day. You may find drinking alpine tea, adding Benefibre to liquids, or Phloe helps. These are all available in most supermarkets.

Additional foods allowed while on Optifast

                    Allowed

        Avoid

Vegetables

2 cups /day

alfalfa sprouts

asparagus

beans

beetroot

bok choy

broccoli

brussel sprouts

celery

cabbage

capsicum

cauliflower

carrot

courgette

cucumber

eggplant

kale

lettuce

leeks

mung beans

mushrooms

onions

radishes

shallots

silverbeet

snow peas

spinach

tomato

watercress /puha

avocado

corn

green banana

green peas

kumara

legumes e.g. baked beans /chickpeas

lentils

parsnip

potato

pumpkin

taro

yams

Fruit

1 serve /day

(Optional)

1 small apple

2 apricots

¼ cup blueberries

½ cup canned fruit in juice- drained

10 cherries

1 kiwifruit

1 small orange / mandarin

I small nectarine

2 passion fruit

1 small peach

1 small pear

2 small slices pineapple

2 plums

3 prunes

1 cup cooked rhubarb

5-10 strawberries

all other fruit

NO BANANA

Herbs and

Spices

All

Sauces and condiments

lemon juice, balsamic vinegar,  soy sauce, chilli, mustard, tomato paste

2 tsp canola /olive oil

mayonnaise (all types)

butter/margarine

Soups

stock cubes, miso soup, broth

vegetable soups using allowed vegetables

Weight watchers zero point soup

Drinks

water

herbal & fruit teas

tea and coffee – no milk & no sugar

diet / low calorie cordial diet soft drink

alcohol

fruit juice

milk

Other

unsweetened gum / lollies artificial sweetener

diet jelly

essence – banana, mint, orange, vanilla, strawberry

Eating after Weight Loss Surgery

How it works

  • Weight loss surgery reduces the size of your stomach.
  • This restricts the size of the portions you can eat.
  • Your stomach size is smaller than it was.
  • To begin with, there will be a lot of swelling and your stomach will only hold about 30 ml.
  • During the year, this will gradually increase to about 150-200 ml.

General recommendations:

  • Eat slowly and eat until you feel full.
  • Chew your food well.
  • Allow 20 – 30 minutes to eat each meal.
  • Use a teaspoon, as this will help control the amount you eat.
  • You may only be able to eat one to two teaspoons at each meal. This will increase slowly over the next few weeks.
  • Avoid chewing gum, lollies and mints, even if they are sugar free.
  • Flavour your food. You can use all types of herbs and spices.

Protein

Having enough protein is vital for your surgery wounds to heal properly. Protein will help preserve your muscle and encourage your fat stores to be used as energy.

  • Include two protein shakes (Optifast) per day.
  • Have one shake as a meal and one shake as part of your fluid.

Fluid

  • Drink at least 1,500ml of calorie-free fluid per day.
  • Most of your fluid intake should be water.
  • Stop drinking 30 minutes before and 30 minutes after meals.
  • Sip your liquids, do not gulp as you may regurgitate or vomit.
  • Avoid straws as this takes in air that may bloat your small stomach.
  • Avoid fizzy drinks, they will make you feel bloated and can cause heartburn.

Constipation

  • Because you are eating less, constipation may be a problem. These strategies may help;
    • Ensure you are drinking sufficient fluid.
    • Regular physical activity.
    • Alpine tea (Red Seal brand).
    • Phloe
    • Benefibre – this will only help if you are drinking at least 1,500 ml fluid.

Multivitamin

  • When you start eating you will need to start a multi-vitamin in the first month post surgery it should be a chewable multi-vitamin (either BN chewable multi or Nutri-chew, take 2 per day) Four weeks after your surgery you can either continue on the chewable multi-vitamin or change to the BN capsule (2/day) or Centrum Women’s Multi-Vitamin (1/day)
  • You will need to take a multivitamin daily for the rest of your life
  • You will have your blood biochemistry checked routinely in the first year after surgery and then annually to monitor your nutritional status

Bariatric Dietary Progression

Puree Diet – Start 1 week after surgery

General recommendations:

  • Eat three meals per day and don’t have any snacks.
  • Stop drinking 30 minutes before and after your meals.
  • All food must be a smooth puree Use a blender or food processor to puree food to a thick soup consistency, with no lumps.
  • Avoid all solid foods.
  • Remember to drink at least 1,500ml of low-calorie fluids per day.

The majority of your pureed food should be focused on protein:

  • Meat, chicken, fish and seafood are the best sources of protein. Include meat, chicken, fish, seafood, eggs, lentils, legumes, tofu and low fat dairy products with every meal.
  • Have two protein shakes per day.
  • You can add protein powder to your meals to increase the protein content of your food.
  • If you are vegetarian, you will need to add protein powder to your meals.

How to puree:

  • Put chopped cooked meat, chicken or fish into a blender.
  • Then slowly add liquid until it is pureed.

Possible liquids to add:

  • Soup (homemade, dried packet soup, canned soup, ‘pouch’ soup)
  • Stock
  • Water from vegetables
  • Gravy (low-fat homemade gravy, Bisto, or a Weight Watchers packet)
  • Natural juices from a stew or slow cooker meal
  • Tomato pasta sauce
  • Light ‘Chicken Tonight’ sauce
  • Cottage Cheese
  • Tofu

Add flavour:

  • Use  flavoured liquids rather than water.
  • Any seasoning / herbs/ spices/ garlic / onions/ balsamic vinegar / sweet chilli sauce.

Commercial Pre-prepared Options

  • The Pure Food Company provide a variety of ready to eat high protein pureed foods
  • These can be purchased online and delivered directly to your home www.thepurefoodco.co.nz

 

What to eat

Meal

Food Options

Amount

Breakfast

  • Porridge made with calci‐trim milk (make according to directions, and add a bit more milk to make thinner).Weetbix with calci-trim milk
  • Plain smooth unsweetened yoghurt
  • Egg – loosely scrambled
  • Egg – lightly poached
  • Optifast or Protein Shake*

To start with you will only be able to eat very small amounts.

Gradually over the first few weeks your portion sizes will increase.

It is normal to be able to eat as little as 1-2 teaspoons or as much as ¼ cup of food.

You may be able to eat more of some foods and less of others.

Stop eating as soon as you feel full.

Lunch

  • Protein-based soup
  • Egg – loosely scrambled
  • Egg lightly poached
  • Tuna/salmon/egg/ ChopChop Chicken whizzed with cottage cheese or extra low fat cream cheese (<10g fat per 100g) until smooth pureed consistency
  • Dinner type meal as below
  • Optifast or Protein Shake*

Dinner

Your meal should be mostly protein with a small amount of sauce to keep it quite moist. Puree all food before eating.

  • Mince (any) with Weight Watchers gravy or low fat bolognaise sauce
  • Chicken with Light Chicken Tonight sauce
  • Casserole with any meat (crock pot meals are usually good)
  • Fish with low fat white sauce
  • Vegetarian protein alternative, pureed smooth with reduced fat sauce. Add unflavoured protein powder to vegetarian meals increase the protein content.

*Optifast or Protein Shake

  • After bariatric surgery, you may use other protein shakes, instead of Optifast.
  • Look for a protein shake which is low in fat and carbohydrate and has at least 20g of protein per serve.
  • Have two Optifast or Protein Shakes per day
  • Include one Optifast or Protein shake as a meal, and the other as part of your fluids.
  • If you add fruit, add no more than an egg-sized amount of fruit per shake.

Soft Diet – Start 4 weeks after surgery

The soft diet is the transition between the puree diet and a solid diet.  A soft diet includes foods that are easy to eat and can be mashed with a fork.  You may also be able to manage some crispy foods, such as Cruskits. You should stay on a soft diet for two weeks before gradually introducing more solid foods. Everyone progresses at a different rate – you may need to stay on your puree or soft diet longer.

General recommendations:

  • Remember to stop drinking 30 minutes before and after your meals.
  • Eat three meals per day and no snacks.
  • Remember the majority of your intake should be focused on protein.
  • You can add protein powder to your meals to increase the protein content of your food.
  • A sauce such as tomato pasta sauce, salsa, hummus, cottage cheese, or ricotta may help you to manage meat more easily.
  • Remember to drink at least 1,500ml of low-calorie fluids per day.

What to eat:

Food Group

Suitable Foods

Meat, chicken and Fish

  • Tender chicken, fish and meat in

bite-sized pieces or minced

  • Shaved ham, turkey or chicken
  • Tinned salmon, tuna in spring water
  • ‘Chop Chop’ chicken

Milk and

milk products

  • Low fat milk, cottage/ricotta cheese
  • Low fat yoghurt (less than 2g fat per 100g)

Vegetables

  • Cooked vegetables – mashed, stir fries, grilled or boiled
  • Introduce salads slowly

Fruit

  • Soft fruits – peeled pears, apples, stone fruit, melon, berries

Fluids

  • Most of the fluid you drink should be water.
  • Try to limit the number of cups of coffee you have per day.
    • You may have a maximum of 4 coffees per day (no more than 1 milky café coffee), or 6 cups of tea
  • If you have milk in your tea or coffee, always use trim milk.
    • Trim milk contains more calcium and protein.

Multivitamin:

  • Start taking a multivitamin every day.
  • We recommend the Centrum Womens or Centrum Advance 50+ or Celebrate Bariatric Multivitamin.
  • If you find this difficult to swallow try cutting it in half or having with a teaspoon of yoghurt.

Meal ideas

Meal

Food Options

Amount

Breakfast

  • Weetbix /porridge/cereal with calci-trim milk
  • Low fat yoghurt with a small amount of fruit
  • Eggs – scrambled or poached

Over the next few months your portion sizes will gradually increase.

It is normal to be able to eat as between 1-2 eggs size portions of food or up to about ½ a cup per meal.

You may be able to eat more of some foods and less of others.

Use your stomach as a guide and eat until you feel full.

Stop eating as soon as you feel full.

Lunch

  • Cruskits with;
    • tinned fish 
    • chop chop chicken
    • smoked chicken
    • shaved ham or lean thinly sliced deli meat
    • You may also include some hummus / cottage cheese / tomato/ cucumber or other soft vegetables.
  • Thick meat-based soups (avoid cream based ones), for example
  • Left overs from dinner  with small amounts of soft cooked vegetables
  • Rice paper spring rolls filled with soft meat
  • Thinly sliced deli meat rolled and filled with mashed egg, hummus or cottage cheese
  • Sashimi (raw fish)
  • Baked beans

Dinner

Aim to eat an egg-sized portion of protein and include soft vegetables for the remainder of the meal.

  • Lean mince (any) with Weight Watchers gravy
  • Mince with bolognaise sauce/chilli con carne sauce/taco sauce (or similar)
  • Chicken with Light Chicken Tonight sauce Casserole with any tender meat or chicken  and vegetables (crock pot meals are usually good)
  • Fish with low fat white sauce
  • Fish that flakes apart easily
  • Prawns
  • Scallops
  • Tofu

Optifast or Protein Shake

Try to have 1 protein shake per day as part of your fluid intake for the next 3 weeks

Fluid – After surgery

Why is fluid important?

After surgery  you will be eating much less food, therefore you need to drink even more fluid to maintain your levels of hydration. The feeling of hunger and thirst are similar and sometimes you may think you are hungry, but you may in fact need a drink. Being even slightly dehydrated will also decrease your energy.

Drink Frequently

Take small, slow, frequent sips throughout the day. You won’t be able to drink fluids quickly. Always have a drink bottle with you.  Try and drink 500ml by lunch time, 500ml by dinner and 500ml by bedtime.

Your aim after surgery is to drink at least 1.5L of calorie-free fluid per day. You may need even more on hot days, or if you are exercising.

Some people mention that water doesn’t taste right or it feels heavy in the stomach after their surgery. If this is the case try experimenting with different temperatures of water. Some people find that ice-cold, room temperature or hot water is better tolerated. Try flavouring water – see overleaf for low calorie fluid ideas.

Tea and Coffee

It’s fine to drink tea and coffee after the surgery. Try to limit the number of coffees you have per day. You may have a maximum of 4 coffees per day of which only one is a milk-based café coffee, or 6 cups of tea per day. Always use trim milk – trim milk also contains more calcium and protein.

Fizzy Drinks

Drinking carbonated fluid after surgery isn’t recommended.  Sometimes people can’t burp very well and having excess gas could put pressure on your area of surgery. This may cause heartburn and make you feel bloated. Over time, you should be able to manage carbonated beverages if you would like them. Sparkling water is the best choice.

Alcohol

Alcohol is not recommended in the first six months after surgery. It is high in energy and can increase appetite. Drinking alcohol can slow your weight loss and lead to weight regain.

You will absorb alcohol more quickly after your surgery and reach a higher peak blood alcohol.  A little alcohol will have a significant effect. Please be mindful of this, if you intend to drive.

Tempt your taste buds! -Suitable fluid ideas

  • Slices of ginger in hot water and then pour over ice.
  • Add a stick of lemon grass in water for a few hours
  • Hot or cold Herbal Tea – tea bags work just as well in cold water – keepfor a bit longer than normal
  • Some cubes of honeydew melon and cucumber
  • Water with a twist of lemon or lime
  • Water with slices of cucumber
  • Angostura bitters
  • Water with a cube of fruit in it
  • A drop of peppermint essence
  • Water with mint (crush the leaves a little to release the flavour)
  • A teaspoon of vegemite or marmite in hot water
  • Miso soup
  • Soup Stock
  • Chicken Broth
  • Vitalzing Water Drops Water Enhancer (Raspberry, Peach, Coconut and Lemon lime)
  • Vita Quench (Lemon and Lime, Mixed Berry, Cranberry and Orange, Mandarin, Orange and Mango)
  • Thriftee (Orange Mango, Raspberry, Lime, Pineapple Orange, Orange, Blackcurrant)
  • Barker and Halls Low Calorie Cordial (Low Cal Lemon Barley, Low Cal Orange Barley)
  • Bickfords Diet Lime Cordial
  • Hansels Cocktail Quench (Mojito, Lemon Lime and Bitters, Cosmopolitan)
  • H2Go Zero Water (Boysenberry, Lime, Summer Fruits)*
  • Powerade Zero*
  • Water with a teaspoon of protein powder (stay away from sugary protein powders)

Exercise Following Bariatric Surgery

Whilst in Hospital

Walk around the ward frequently – at least once an hour when you are awake.

First Four Weeks after leaving Hospital

  • Start by exercising 10 minutes per day. If this feels okay, then increase to 15 minutes and continue to increase the duration until you are at your pre-surgery levels of exercise.
  • Stop if you feel any discomfort.
  • By four weeks after surgery you should be at your pre-surgery levels of fitness.
  • There are some restrictions on the type of exercises you can do in these four weeks.
  • Recommended exercises for the first four weeks after surgery  include;
  • Walking
  • Exercycle
  • Biking
  • Cross-trainer machine
  • You are able to start swimming or water walking after two weeks as long as your wounds are clean and dry.
  • Not recommended exercises include:
  • Avoid lifting weights more than 3kg.
  • No abdominal strengthening exercises.
  • Avoid high intensity exercise.

Impact sports such as running, or weights are not recommended in the first four weeks.

Four Weeks after leaving Hospital

  • After four weeks impact sports can be reintroduced at a light intensity.

Six Weeks after leaving Hospital

  • By six weeks following surgery there is no restriction with exercise.
  • Any and all kinds of exercise are great!
  • Exercise following bariatric surgery can maximise the results of the surgery and in the long term, can help with weight maintenance.
  • We recommend exercising 5-6 times per week, for at least 30 minutes per session. If this is not realistic for you, please discuss this with the team to set realistic goals.

After Recovery

After surgery, your weight will continue to decrease and soon you will have recovered physically from the surgery. It is then that the success of the surgery equally depends upon you as much as the surgery. It will require a lifetime of lifestyle and nutritional changes for best and sustained results. Problems (like weight gain) can occur after, but should not be inevitable. There are a few tips that when followed can help you cope with the changes to your stomach after surgery

  • Stop eating if you feel full. Listen to your body. Understanding fullness, and responding to this will avoid bloating, vomiting and Dumping syndrome. It is best to stop eating once ‘satiety’ is felt. Wait 5-10 mins and consider continuing to eat.
  • Chewing your meals is best. Count 20 chews per mouthful. Each mouthful should only be a teaspoon in size. This does slow your eating down, but as you will be having small portions than before, mealtime should be the same as your family/friends
  • Avoid drinking fluids 30 minutes before or after your meal. This will contribute to bloating and nausea
  • Eating on the run, or in stressful environments have been shown to lead to bad habits. Set time aside to eat properly.
  • Protein should be the main source of calories in your diet. Your Dietician will explain sources of them. Calories just from carbohydrates will not provide your body with sufficient building blocks for cell growth and repair. Always eat your protein first in you meals. Consider freezing meals each week into appropriate sized portions.
  • Continue to take your multivitamins and other vitamins recommended life long. Your body will not be as efficient in absorbing these from your diet as before surgery. Without these supplements you can experience anaemia and/or thinning of your bones.
  • Continue to eat ‘the right’ choices as outlined by your Dietician and Surgeon. Avoid casual snacking on high sugar snacks.
  • Constipation can be an ongoing issue. This is mostly due to insufficient fluid intake (aim &gt;1500ml/day) or lack of fibre. Carring and regularly sipping on a drink bottle with water or fruit tea can assist with fluid. maintenance. Increasing dietary fibre can be hard. Laxatives such as Kiwicrush, Psylium husks or laxsol are generally tolerated well. It is best to avoid Lactulose
  • Exercise is regular part of your new life. It is important to do 30-45mins of strenuous exercise at least 5 times a week. Fast walking is acceptable, but it may be an idea to engage a personal trainer at the beginning to give you advice and ideas that best suit you and your daily schedule. Post operative exercise regime is not optional

Post operative blood tests

Blood

Procedure

Frequency of Monitoring

HbA1c

Sleeve gastrectomy

Gastric bypass

As appropriate in those with preoperative diabetes

Lipid profile

Sleeve gastrectomy

Gastric bypass

Monitor in those with dyslipidaemia

U+E, LFT, FBC, ferritin, folate, Calcium, vitamin D, PTH

Sleeve gastrectomy

Gastric bypass

At 3, 6 and 12 months in the first year, then annually.

Vitamin B12

Sleeve gastrectomy

Gastric bypass

At 6 and 12 months in first year, then annually

Zinc, Copper

Gastric bypass

Annually.

Monitor Zinc if patient has unexplained anaemia, hair loss, changes in taste perception. Monitor Copper if unexplained anaemia and poor wound healing.

Vitamin A

Gastric bypass

Annually. Monitor if concerns regarding steatorrhoea or symptoms of vitamin A deficiency. May need to monitor in pregnancy

Vitamin E, K

Gastric bypass

Measure vitamin E if unexplained anaemia, neuropathy. Consider measuring INR if excessive bruising/coagulopathy as may indicate vitamin K deficiency

Post Operative Multivitamins

You will require life long multivitamin and elemental supplimentation.

  • Daily Multi-Vitamin
  • Daily Oral Calcium
  • 3-6 monthly Vitamin B12 Injections (alternatively you can have sublingual (under Tounge) vit B12 via amsnutrition.co.nz )

Multivitamin

  • Centrium Advance 50+ (x2 per day)
  • Celebrate Bariatric Multivitamin (2x per day)
    • Through amsnutrition.co.nz

Oral Calcium (only Gastric Bypass)

  • Calcium citrate 500mg twice a day (do not take with meals)
  • If concerns a bone density scan can be arranged at 2-3 years post operatively to exclude Osteoporosis (thinning of bones)

Vitamin B12 (only Gastric Bypass)

  • Intramuscular injection (1000mg) 3-6 monthly
  • Daily sublingual (under tongue) available if preferred

Nutritional deficiencies – What to look for post bariatric surgery

Protein malnutrition / protein energy malnutrition

Protein malnutrition can occur for a number of reasons including poor dietary choice, an over tight gastric band, anastomotic stricture or protein malabsorption. It may present several years following surgery. Protein energy malnutrition is accompanied by oedema. In all cases of suspected protein malnutrition the patient must be fast tracked back the Bariatric team

Anaemia

Iron deficiency anaemia

Whilst iron deficiency anaemia is relatively common following the gastric bypass, it must not be assumed that this is the only cause. Other causes should also be considered and investigated if appropriate.

If additional oral iron does not correct the iron deficiency anaemia, parenteral iron or blood transfusions may be necessary. Ensure that the patient maintains levels with oral iron supplements. These should be taken with meals or drinks containing vitamin C to aid absorption and at a different time to calcium supplements.

If the anaemia is not due to iron deficiency or blood loss, other nutritional causes should be considered. These include folate, vitamin B12, zinc, copper and selenium.

Folate and vitamin B12

Low folate levels may be an indication of noncompliance with multivitamin and mineral supplements. However, it could also be an indication of severe malabsorption especially if there are other nutritional deficiencies. Megaloblastic anaemia is caused by folate deficiency or vitamin B12 deficiency. Vitamin B12 deficiency, if untreated, results in irreversible peripheral neuropathy. Therefore it is essential that vitamin B12 deficiency is considered before recommending additional folic acid. Those patients who are vitamin B12 deficient should have levels corrected with intramuscular injections of vitamin B12. Once corrected, three monthly injections of 1mg vitamin B12 will maintain levels.

Calcium, vitamin D and parathyroid hormone levels

Vitamin D deficiency may result in secondary hyperparathyroidism to maintain calcium levels.

Zinc, copper and selenium

Unexplained anaemia, poor wound healing, hair loss, neutropaenia, peripheral neuropathy or cardiomyopathy may be symptoms of zinc, copper or selenium deficiency and so levels should be checked if there are any concerns. Zinc and copper share a common pathway so supplementation with zinc can induce copper deficiency and vice versa. Information about any additional over the counter supplements the patient may be taking is essential. If additional zinc supplementation is required, a ratio of 1 mg copper for every 8 to 15 mg zinc must be maintained.

When to request specialist biochemical / nutritional advice or to refer your patient:

Diagnosis and management of micronutrient deficiency syndrome can be complex and so when in doubt it is recommended that specialist advice is sought. The following are examples of situations where this is appropriate.

  1. Newly identified biochemical deficiency, where there is differential diagnosis (there can be causes other than previous bariatric surgery) or its appropriate investigation and treatment are uncertain.
  2. Unexplained symptoms that may be indicative of underlying micronutrient / trace element deficiencies.
  3. Women who have undergone previous gastric bypass or sleeve gastrectomy and who are planning to become pregnant or who are pregnant.

Post operative multivitamin

  • These are best started upon discharge. A chewable form is recommended for the initial 2 weeks.
  • Celebrate Bariatric chewable Multivitamin can be ordered through amsnutrition.co.nz
  • Centrium Advance 50+ or Centrium Woman’s multi (x2 per day) once on pureed diet (2-3 weeks post procedure)
    • Berocca can also be commenced post postoperativley (you will need to bring this to the Hospital)
  • Calcium Citrate is recommended 500mg daily
    • Do not take with meals

Oral Vitamin D 5000IU weekly

    • 6-12 monthly Vit B12 injections 
    • possible oral solutions available through amsnutrition.co.nz

   

Cost

The cost of surgery includes Private hospital, Surgical and Anaesthetist charge. Please note that there will be additional costing if a repair of hiatal hernia, or if you have had previous weight loss surgery (i.e. “Redo surgery”).

Laparoscopic Sleeve Gastrectomy= $19 833

Laparoscopic Roux-en-Y Gastric Bypass= $22 000-23 000

Costs does not include pre and post-operative consultation with Mr Barnaby Smith, Dietician and Psychologist. Preopertive Very Low Calorie Diet (VLDC i.e. Optifast) and postoperative multivitamins also not included.

Sharon Hilton

Sharon is a Registered Nurse with over 30 years’ of experience.  She has a Masters in Health Practice in Nursing (with Distinction). This has enabled her to gain specialised knowledge, adding a solid academic foundation to her clinical expertise.

Sharon has been co-ordinating the Weight Loss Surgery (Bariatric) programme at Tauranga Hospital since its inception 10 years ago. During this time she has developed a wealth of knowledge and experience, to contribute to this field. Sharon runs a free bi-monthly support group for people both before and after their surgery.

“I am passionate about supporting and educating people undergoing this life changing surgery. Observing people achieve their weight loss goals to improve their health and sense of well-being is immensely satisfying”

 

Contact

Ph: 0278395603

Email: bns.tauranga@gmail.com

Hours: 08.30-17.00 Monday – Friday