Perioperative Bariatric Surgery Instructions

Thank you again for entrusting us with your bariatric surgery. Please review the following material BEFORE SURGERY and keep this packet with you at all times. For work and travel purposes, we suggest that you make a copy to keep and take along with you including

DAY OF SURGERY.

IN GENERAL, BOTH BEFORE AND AFTER SURGERY:

1. For any questions regarding your non-bariatric surgery medications such as blood pressure, diabetes, or any other medical questions that are not listed below i.e. unrelated to your surgery: you need to contact your PCP.
2. For dietary questions such as vitamins, proteins, and stages of diet, “can I eat this now or not”, and the like: you need to contact the independent dietitian you saw preoperatively.
3. For all other questions, call University Bariatrics.
4. NEVER use email or the website contact box for medical questions. It will not be checked on time and you can jeopardize your wellbeing as a result.

ONE MONTH PRIOR TO YOUR OPERATION:

1. If you are taking aspirin or Plavix or other newer types of blood thinners, you need to check with your primary care doctor or cardiologist or neurologist to see if you can go off of them completely before surgery OR when can you safely discontinue them, if at all
2. If you are taking Coumadin (warfarin), you need to inquire similar to above and if necessary, be given instructions for a Lovenox bridge.
3. All other NSAIDS (ibuprofen (Motrin, Advil), Aleve, Indomethacin, etc) must be stopped now prior to surgery. Please make sure your surgeon is aware of any other blood thinning medicines or over the counter supplements such as fish oil and garlic. In general, avoid all herbal type supplements for the few weeks before surgery. Tylenol (acetaminophen) is OK if taken up to safe daily dose.
4. Stop taking any birth control pills or patches. Use other methods!
5. Stop taking any herbal medications and supplements. These include fish oil pills, garlic supplements and essentially anything that is good for your heart by ‘thinning’ your blood: it’s bad for surgery as it increases odds of bleeding. The vitamins and supplements advised to you by the dietitian are typically an exception. Check with us if you have any questions.
6. Make sure you have all of your postoperative vitamins and protein shakes etc all set up.

TWO WEEKS PRIOR TO YOUR OPERATION:

1. Start doing the items listed under ONE MONTH if not done already.
2. Make sure you have completed all of the program requirements including a thorough history and physical and medical clearance from your primary care MD.
3. Make sure you have ride to and from the hospital

TWO DAYS PRIOR TO YOUR OPERATION:

1. Begin a clear liquid diet
2. At 9am, consume the entire bottle of Magnesium Citrate.This is an over the counter item found at any drug store, or laxative section of the store. If for any reason you have been told by your doctors (medicine, kidney specialists) to avoid Magnesium products, YOU MUST TELL US.
3. Do not eat or drink anything after midnight the night before surgery except your medications with a sip of water.
4. The team will have reviewed your medication instructions with you at the preoperative appointment. If contacted by anesthesia service, they will go through your medications as well, especially those that need to be held or taken on the day of surgery.

ONE DAY PRIOR TO YOUR OPERATION

1. Do not shave anything. We will do it for you on the day of surgery. It increases risk of wound infections.
2. The night before surgery: full body shower with water and soap
3. You are not to eat or drink anything after midnight the day prior to your surgery.

DAY OF THE SURGERY:

If you are on regular medications like blood pressure medicines, you should take these with a sip of water only. Please do not take oral diabetes medicines and talk with your primary care doctor as to how much insulin you should take if you are on insulin.

1. You are to come to the facility at the designated time to be prepared for surgery. It would be best to have someone with you at all times.
2. You will first go thru admitting office and have paperwork done.
3. You will then go to the preoperative holding area where you will change into a surgical gown and your belongings will be collected and given to family members or stored away. An IV will be started by the preop staff and you will be given some fluids and a blood thinner shot in your abdomen or thigh area. This is all routine. You will also have a chance to meet with your surgeon in the holding area prior to the surgery. Others who visit you will be the anesthesiologist and the operating room nurse. You will be asked a bunch of questions first, and when everyone is done, the anesthesiologist will give you a “happy juice” via your IV to start the sedation process. You may not recall much about this stage after your surgery.
4. You will then be transferred to the operating room and be readied for surgery. This includes an oxygen mask, a foley catheter, special boots on your legs, etc. There will always be several staff members in the room with you as well as your surgeon and anesthesiologist.
5. Once the surgery is completed, you will be transferred to the recovery room (PACU) and will be monitored for a while before being sent to the surgical floor. It is normal to have pain and nausea after surgery and medications will be given to you to alleviate both conditions. Sensation of urge to urinate is common and is related to having the foley catheter. You can “go” without any reservations. The catheter will do its job.

IN HOSPITAL STAY:

DAY OF SURGERY:

Once you go to the floor, the postoperative process kicks into a more aggressive mode.

1. You will be expected to walk every 4-6 hours starting 3 hours after arrival on the floor. You are at risk of pulmonary embolus and walking is the best way to battle that. This sounds very difficult at first –it is- but is mandatory. You will have squeezy-boots on your legs to help prevent clotting but walking is #1.
2. You need to be sitting in chair the rest of the time except when really sleepy. This will help take pressure off of your lungs and also keep you mobilized.
3. You have to use the incentive spirometer device 10x every hour to inflate your lungs. This may result in coughing for which, you have to use the Cough Buddy by hugging it firmly and take pressure off of your abdomen. This will also help prevent pneumonias.
4. You will have a drain coming out of your abdomen, which will be removed prior to your discharge. This is often the only item causing pain after surgery.
5. You are not allowed to drink or eat anything the first night. Mouth swabs are OK.
6. You will have a PCA (patient controlled anesthesia) machine, which you can push whenever you have pain. Remember, only you are to use it and you cannot have your family push it for you.
7. Call your nurse if you have nausea and have any other concerns.

DAY 1 AFTER SURGERY:

1. Your surgeon will see you first thing in the morning and examine you and make sure everything is Ok from the night before. He may start you on sips of water.
2. You will probably have a swallow test called upper GI this morning. You will go to radiology for that and be asked to swallow a few sips of contrast and have a special film done. If concerns exist, a CT scan may be done too the same time. The contrast does not taste good so be prepared for it. The swallow test may be omitted entirely at your surgeon discretion.
3. After the swallow test and if all is OK, you will be started on Bariatric Diet which is clear liquids with applesauce. You are to follow a specific regimen ie 15cc or 30cc every 15 minutes and the nurses will give you a form to fill out about your oral intake. You are in charge of that and only you should fill it out. You don’t have to finish the tray nor will you like everything that is on it. Go easy and stop if any belly pain or nausea and vomiting.
4. Your surgeon will most likely stop the PCA and start you on oral painkillers as well as some of your home medications. They are all liquid or crushed pill in applesauce.
5. The walking regimen is increased and you are to continue with the incentive spirometer.
6. The urine catheter will be removed as well unless there is a medical need to keep it. It will not be left in place due to your convenience since it can be a nidus of infection.
7. The IV fluids will be cut down or discontinued as well. The IV itself stays though.
8. Remember: Even-though you are flagged as a bariatric surgery patient with specific dietary and activity instructions, you should be the PRIMARY vigilant person in charge of your care. This includes
   1. watching out for non-crushed or non-liquid medications,
   2. sugary drinks or food items that are not part of your diet,
   3. the necessity to use the incentive spirometer every hour,
   4. walking every 4 hours starting 3 hours after surgery is done,
   5. documenting how much you have been drinking while there,
   6. Letting your nurses know that they need to inform us if your heart rate is over 110 or you are having temperatures above 101 or sudden onset of left shoulder pains.

DAY 2 AFTER SURGERY:

1. Your diet will be advanced today to 30cc every 15 minutes if you did well the day before.
2. If all is well, you will be discharged after 12pm and after you have shown to be able to take at least 500cc orally without any problems. Your discharge medications will be reviewed with you and will include many of your home medications and two new ones: an acid blocker and oral painkillers. You will get a prescription for those two to fill out at your own pharmacy.
3. You obviously will not be allowed to drive home or take a cab!! You must have arranged for a ride home way in advance.
4. If you are not discharged, then it’s the same routine as the day before.

AFTER HOSPITAL:

If not done already, please call University Bariatrics at (805) 379-9796 and make a follow-up appointment to be seen in the 2-3 weeks after surgery. You should do the same with your PCP.

LAB WORK:

A complete list will be provided to you at the first postop visit. These labs need to be done every three months at the minimum. We encourage you to bring the lab results with you to your appointments and review them in person with the bariatric surgery team and also discuss these results with your primary care physician (PCP) and address any irregularities. Your PCP is an integral component of your weight-loss journey & we are available should they have any questions. The attached guideline for micro and macronutrient problems after bariatric surgery can be very helpful.

WOUND CARE:

1. Keep the puncture sites clean and dry.
2. You may experience slight bruising at the trocar sites, this is normal, and will disappear with time.
3. You may take a shower, making sure the puncture sites are thoroughly dry after bathing. This can be accomplished by reapplying gauze dressing if you experience drainage from the wound site.
4. If there is glue or steri-strips (butterfly strips), expect that they will fall off on their own, but if they remain after 8-10 days, you may remove them. They are easiest to remove in the shower. Don’t touch any staples. We will remove them in office.

OTHER PROBLEM SIGNS:

If you have any of the following signs, you need to contact us immediately. Depending on your symptoms, you will be asked to come to clinic or present to ER for further evaluation.

1. Your temperature is over 101˚ F degrees Fahrenheit
2. You experience vomiting, not related to overeating, eating too fast, eating the wrong food, or not chewing the food well.
3. You experience diarrhea not related to eating the wrong food.
4. Severe constipation unrelieved by the use of mild laxatives.
5. Feel your heart is racing and for sure if you measure it to be over 110 bpms.
6. ANY abdominal pain or cramps not in the same area as menstrual cramps in women and any type of cramping abdominal pain in men
7. ANY shortness of breath
8. ANY pains in your lower extremities
9. ANY feeling of something out of ordinary
10. Be aware of signs and symptoms of infections. These include:
    1. Increased redness, swelling and pain at the wound site.
    2. Drainage that is cloudy, has a color and/or odor
    3. Excessive bleeding
    4. You have a temperature elevation greater than 101 ˚ F.
    5. Productive cough
    6. Burning, odorous, or cloudy urine

DO NOT USE EMAIL OR THE WEBSITE CONTACT FORM TO INFORM US OF THE ABOVE OR ANY OTHER CLINICAL ISSUES. PHONE CALLS ONLY. Failure to do so can result in serious harm or even death. We are available to you on a 24/7 basis. Please note that the after-hours number is only for urgent medical conditions & emergencies. Do not use this number to call about your appointments, hospital paperwork, diet questions, disability papers, any information already listed on this packet, or anything else that can wait until the next business day.

ACTIVITY:

You may experience general fatigue for several weeks after surgery. This is normal. Therefore space your activities. For example: In the morning you might have breakfast, rest for 15 – 30 minutes, then take a shower.

Walking to toleration is encouraged. This assists with recovery, develops muscle and burns calories.

1. You may climb stairs in moderation.
2. Refrain from lifting more than 10 lbs. for at least 2 weeks.
3. Sexual activity may be resumed after three weeks, if comfortable.
4. Return to work only after approval of the surgeon.
5. Continue to use your incentive spirometry. 1000 cc equals one quart of air moving in/out of your lungs.
6. Avoid prolonged sitting or lying down. Elevate your feet by using pillows or footrest to raise your feet higher than the level of your heart.
7. Do a few foot exercises every half-hour to keep the blood moving in your lower extremities.
8. Avoid sitting with crossed legs or lying with crossed ankles.
9. Avoid tight clothing

DIET:

Follow the post-operative Roux-en-Y Gastric Bypass diet per instructions. The instructions are the same for sleeve gastrectomy. For any diet questions, it would be best to contact the dietitian directly vs. going via our office. They are independent practitioners and want to be kept abreast of your dietary concerns directly. This will also avoid conflicting info.

1. Continue your protein supplements right after surgery
2. Begin your multivitamins. Calcium can wait till 30 days from now.
3. Drink slowly
4. Eat slowly
5. Don’t drink beverages with meals.
6. Chew all foods thoroughly
7. Learn to listen to your body
8. Exercise!!

SPECIAL CONSIDERATIONS:

1. Very dark and small quantities of urine indicate you need to increase your fluid intake.
2. You should have a bowel movement at least every three days. If you find that you are constipated, you may use a gentle laxative such as milk of magnesia, or a liquid stool softener.
3. Female patients – avoid pregnancy for two years following this procedure by practicing effective birth control measures. Remember that birth control pills may have the opposite effect after gastric bypass! Previous infertility is not a protector either.

MEDICATIONS:

1. You should have discussed your postoperative medications with your PCP and came up with alternatives to extended release or large non-crushable pills.
2. The pain medication for home is in liquid form or crushed pill for easier ingestion. This medication may be irritating to the stomach lining; it is advisable to take this with a teaspoon of applesauce or non-fat yogurt. It may also be constipating. Use of a stool softener or gentle laxative may be needed if this occurs.
3. For lesser discomfort use plain Tylenol. This is an over the counter item and comes in a liquid form. You may need to ask specifically for the liquid adult form.
4. You will be given a prescription for a PPI medication. This drug needs to be taken for a minimum of 3 months. If the PPI given to you is not part of your insurance formulary, your pharmacist needs to find out what other PPI is covered and call us.
5. Don’t use NSAID or oral steroids. Inhalers are OK.
6. Enteric-coated or sustained release medications cannot be crushed.
7. If the medicine is in capsule form, ask the pharmacist if it can be opened and mixed with liquid food or applesauce.
8. Pills larger than 8 mm in size should be avoided especially in the first three months.

PLEASE REVIEW THESE INSTRUCTIONS AS SOON AS POSSIBLE. WE EXPECT YOU TO HAVE QUESTIONS AND WANT YOU TO ASK THEM AS SOON AS POSSIBLE AND AT LEAST TWO WEEKS BEFORE YOUR SURGERY.

BRING THIS PACKET WITH YOU TO THE HOSPITAL

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BARIATRIC SURGERY: PERIOPERATIVE INSTRUCTIONS