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.

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.

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

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

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

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
  • Optisource

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

POSTOPERATIVE CARES FOLLOWING GASTRIC BYPASS

Day of Surgery

  • DIET: Sips clear fluids at 40-60ml per hour
  • We encourage you to mobilise to chair and bathroom immediately following surgery
  • Oral Pain relief encouraged

Day 1 postoperatively (First full day following surgery)

  • DIET: Aim to drink 1000ML HALF STRENGTH OPTIFAST, approx 100ml per hour)
  • Discontinue intravenous fluid
  • Remove urinary catheter / Abdominal drain/ Pain pump if present
  • Increase mobilisation
  • Blood tesT
  • Crush medications as indicated
  • If Diabetic, continue to check blood sugars four times per day. Your diabetic medication might be decreased or stopped
  • Oral pain-relief only
  • Prepare for discharge following day

Day 2-7 postoperatively

  • DIET: Full strength Optifast as tolerate (100-150ml/hour)
  • Continue mobilising/ walking/ Time out of bed
  • Today is the usual day of discharge

Day 7 postoperatively

  • DIET: Pureed Food (consistency of mashed with fork)
  • Aim for 6 small servings a day. Each meal equals approximately 4-6 tablespoons over 30mins
  • Avoid liquids with meals (do not drink 30 mins before or after eating)
  • Lean ground meat/ poultry/ fish
  • Cottage cheese Soft scrambled eggs
  • Cooked cereal
  • Soft fruits/ Cooked vegetables
  • Strained creamy soups
  • Consider driving of pain well controlled
  • Remove dressings if needed (for optimal healing it is best to tape wounds for 4 weeks)
  • If at any stage you feel unwell post operatively it is important to contact us (especially in first week post operatively) such as; FEVERS/ SWEATS/ DEHYDRATION/ SEVERE ABDOMINAL PAIN/ CONCERN OF INFECTION

3 weeks postoperatively

  • DIET: Soft Diet

6 Weeks postoperatively onwards

  • DIET: Light Diet
  • Each meal is approximately 1-1.5 cups of food
  • Stop eating when you feel full
  • Avoid liquids with meals (do not drink 30 mins before or after eating)
  • Start daily Chewable Multivitamin (x2) (Centrium or similar)
  • Start daily Calcium 1500mg (divided into three doses of 500mg)
  • Start vitamin D 3000 IU daily
  • Iron supplementation may be required. Some/all may come from a multivitamin

Post Operative Follow-up

Surgical review

  • Week 2
  • Week 6
  • 6 months following surgery

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

  • Week 2

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

Postoperative Concerns

There are specific postoperative concerns that you should be aware about

following weight-loss surgery

Dumping Syndrome

Result from the rapid transit of eaten foods and “Dumping” through into small bowel. This is mostly after a Gastric bypass, compared to a Sleeve gastrectomy. Dumping syndrome is associated with eating refined sugars and foods with high glycaemic carbohydrates. Occasionally, but less commonly caused by dairy and fatty foods. Sweating, heart pounding, light-headedness and nausea can be experienced either &lt;60mins or 1-3 hours after. If you experience these symptoms it is best to talk to your Surgeon or Dietician regarding strategies to reduce this.

Low Calcium/ Thinning of the bones

This is due to the lack of absorption of calcium and Vitamin D following your surgery. Replacement therapy is vital to avoid this. You should be taking two multivitamin tablets daily with additional daily Calcium and up to fortnightly Vitamin D.

Bone density scans are recommended at 2 and 5 years following your operation.

Anaemia

Iron and Vitamin B12 absorption following surgery is affected. Replacement and monitoring are important, and again regular multivitamin is recommended. A 6 monthly Vitamin B12 injection at your GP practice. Regular (6monthly) blood tests will diagnose any anaemia.

Diarrhoea

Not uncommon, especially following Gastric Bypass. After infective causes excluded can be treated by medications and diet. Occasionally caused by undiagnosed Lactose intolerance.

Low blood sugars/ Dehydration

As your stomach will be smaller, you will be unable to fluid load prior to exercise. It is best to anticipate any exertion by starting to drink water an hour before with small sips. Always have an appropriate protein/energy bar available (non-sugary).

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