GASTRIC BYPASS/GASTRIC SLEEVE

LAP BAND/REVISIONS

INFORMATION MANUAL

1106 Alston Avenue 13601 Preston Rd 6957 W Plano Parkway Suite 201 Suite 415-W Suite #2700 Ft Worth, Texas 75104 Dallas, Texas 75240 Plano. Texas 75093 P# 817-506-4360 P# 214-5062660 P# 214-5062660 F# 817-984-9189 F# 972-865-6996 F# 972-865-6996

www.barnesweightlosssurgery.com

introduction

Introduction

Contact Information:

Main Office: (817) 506-4360 or (214) 506-2660 Facsimile: (817)984-9189

Office Locations:

1106 Alston Avenue Suite 201 Ft Worth, Texas 76104

13601 Preston Road Suite 415W Dallas, Texas 75240

• In the event of a medical emergency you should call 911 or go to the emergency room, and notify your surgeon. Be sure to inform the emergency response team or emergency room staff that you are a bariatric surgery patient, and the name of your surgeon.

• During normal business hours, if you are experiencing a non-emergent post-operative complication or feel that you need to be seen by a surgeon, please call your surgeon’s office for an appointment.

• Please feel free to contact the program staff for any diet or non-emergent medically related questions.

Other Important Numbers:

Dietitian Name and Number: _______________________________________________________

Psychologist Name and Number: ____________________________________________________

Preferred Pharmacy: ______________________________________________________________

Other Healthcare Specialists: _________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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WELCOME TO A NEW START IN LIFE

Dr. Barnes and his staff would like to welcome you to his practice and are thankful you have chosen us to provide you with the skills to begin your journey to a new life. The most successful patients are educated and understand how to use the surgical tool (weight loss surgery) to aid them to obtain a weight that is healthy and allows them to enjoy life.

This manual is an education tool and assistant to you as you embark on this new life of health and should be read carefully and often to ensure you understand the concepts of life after weight loss surgery. It is intended to assist in education and help document your journey and should not be used in place of medical advice from your surgeon. This manual should be brought to each visit so any questions you have can be addressed and staff can utilize it to go over issues you may be having at the time of your visit.

Remember, each person is different and unique and your weight loss journey will be different from other patients. It is important to follow the advice of your surgeon to ensure you have the best results from you r surgery.

Congratulations!!

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PLEASE REPORT TO THE HOSPITAL AT:

bariatric

procedures

Updated 07/2011

BARIATRIC PROCEDURES

Importance of Pre-operative Education: • To understand Anatomy of your body and the changes after surgery • To understand diet and psychological changes and the importance of

these changes as you begin your weight loss journey • To understand the importance of your vitamins and supplement to

ensure health and success after surgery. • To understand the importance of continued medical care and

communication with your surgeon and his staff.

Pre-Surgery /Normal Anatomy

Updated 07/2011

• Volume: ~1.5 L LAPAROSCOPIC ADJUSTABLE BAND OR LAP-BAND

The adjustable gastric band is a restrictive surgical procedure that reduces the size of your stomach without cutting or stapling which decreases the amount of food you can eat at one time. This will help you feel full faster and feel satisfied for longer periods of time. You will have a port attached to the band that is placed flat against the muscle wall, below the fat and skin of your abdomen. The band is adjusted or tightened by either adding or removing fluid through the port. The gastric band is also known as the Lap-Band® or the Realize™ Band.

Advantages: • Simple and relatively safe • Major complication rate is low • No removal of any part of the stomach

or intestines

• Short recovery period • Reversible • After surgery- Your stomach volume is ~30-60 ml. • Decreased hunger

Disadvantages:

• Long term failure rate due to: o Balloon leakage, band slip, band erosion/migration, port infection

• Vomiting and nausea if food is not properly chewed or if food is eaten too quickly • Weight re-gain known to occur if dietary changes are not followed long term • Slower weight loss • Adjustments can be uncomfortable Band Adjustments: The band will need to be adjusted periodically to control hunger and enable weight loss to progress in the months following your surgery. Your first adjustment will be around 4-6 weeks following surgery. It is common to have swelling around the band due to the foreign body that was placed in surgery. It is important to give your body time to heal before doing the first adjustment.

Updated 07/2011

Roux-en-Y Gastric By-pass: Gastric Bypass

The gastric bypass is considered the Gold Standard and is the most common and successful combined weight loss surgery in the United States. During surgery a small stomach pouch is created which reduces the amount of food you can eat, then a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). The combined procedures reduce the amount of calories and nutrients the body absorbs which leads to weight loss and allows for maximum success.

Advantages: • Controls intake and allows rapid weight loss • Dumping syndrome • Faster Weight Loss • Patients lose 70-80 % of excess weight • Best Long Term Weight Loss • Post Surgery ~20-30 ml volume • It is done laparoscopic allowing quick

recovery • Highest weight loss • Decrease in hunger

Disadvantages: • Higher rate of initial complications • Vomiting if food is not properly chewed or if

food is eaten to quickly • Weight re-gains known to occur if dietary

changes are not followed long term. • Possible Vitamin/Nutrition Deficiency

Updated 07/2011

Sleeve Gastrectomy: Sleeve

The sleeve gastrectomy generates rapid weight loss by restricting the amount of food that can be eaten (partial removal of stomach) and removing the ghrelin to aid in hunger control without any bypass of the intestines or malabsorption. Approximately 2/3 of the stomach is removed.

Advantages: • The stomach volume is reduced to manipulate the amount of food you can take in while

maintaining its normal function. • Eliminates the portion of the stomach that produces the hormones that stimulates hunger

(Ghrelin). • The chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and

vitamin deficiency are less common than Gastric Bypass. • High Success in first stage procedure for high BMI patients (BMI >55 kg/m2). • Option for people with existing anemia, Crohn's disease and numerous other conditions that make

them too high risk for intestinal bypass procedures. • Is considered acceptable laparoscopically in patients weighing more than 500 pounds • Average Weight Loss is 60-70 % in the first year after surgery. • Your stomach volume following surgery is ~90 ml

Disadvantages of this weight loss surgery: • Higher potential for inadequate weight loss or weight regain than GBP • Patients with high BMI patients may need to have a second stage procedure later to complete their

weight loss. Two stages may ultimately be safer and more effective than one operation for patients that have a high BMI.

• No Dumping Syndrome which allows patient to consume soft calories like ice cream and milk shakes, etc., which can be absorbed and may slow weight loss.

Updated 07/2011

• This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur. Because the stomach is removed, it is not reversible; however it can be converted to Laparoscopic Roux-en y Gastric Bypass.

Steps to Success:

• Drink plenty of fluid- dehydration is the number one cause of hospital re-admission

• Be sure you get your Protein in everyday- 60-80 grams • Take your vitamins- Multivitamin, calcium citrate, B12, iron, Vitamin D,

Biotin • Exercise Everyday- at least 30 minutes • Pay attention to the reasons you choose to eat. Are you really

hungry? Emotional eating is common and it is important to develop healthy relationships with food.

• Chart everything you eat or drink daily. • Chart your exercise daily • Do not give up and ask for advice from your surgeon if you encounter

complications

• Do not drink at least 30 minutes prior to eating or 30 minutes after a

meal. • Sip –do not drink fast or use a straw • Plan your meals • Do not graze • Do not drink your calories- alcohol, carbonated drinks etc • Take 30 minutes to eat each meal and enjoy your food.

Updated 07/2011

• Take small bites and chew until food is almost dissolved • Do not use food to make you feel better emotionally

Steps Leading to Surgery

• Consult: Your Surgeon will complete a history and physical then he

will advise you on the bariatric procedure that he feels will benefit you the best.

• After consult, you will begin the Pre-Determination period that is

required by your insurance carrier to have your surgery approved. Each carrier has criteria or requirements that they feel is necessary to determine if your case is medically necessary. The criteria can include the following: Nutrition consult and diet monitoring Psychological Evaluation Stress echo, EGD, UGI, Blood test Previous medical records

o You may be requested to see a Physical Therapist for an evaluation o You may be required to have a sleep study.

o Insurance Approval: After you are approved for surgery by your carrier you will need to have another appointment, (2C) with Dr. Barnes and he will go over all test results and then approve you to schedule your surgery.

o Bariatric Advantage: You will need to purchase pre-op and post-op

kits from Bariatric Advantage.

o Education: You will attend a Pre-Operative Class with our Nutritionist and Psychologist.

o Pre-Admit: You will have a Pre-Admit appointment and will need to repeat labs, EKG and Chest X-ray. You must keep this appointment or your case will be canceled.

diet manuals

DR GREGORY S. BARNES, MD

DIET PROGRESSION

WHEN: 2-3 WEEKS BEFORE YOUR SURGERY

FOCUS ON RECOVERY

FLUIDS/FOODS YOU CAN HAVE

PROTEIN MEAL REPLACEMENT SHAKE

MIXED WITH MILK OR WATER

(BARIATRIC ADVANTAGE, DESIGNS FOR HEALTH, NEW WHEY, ISOPURE, MUSCLE MILK LIGHT, ADKIN’S ADVANTAGE SHAKES, EAS

ADVANTAGE/MYOPLEX LITE

WATER

CRYSTAL LIGHT

BROTH (CHICKEN, MEAT & VEGETABLE)

SUGAR FREE POPSICLES

STAY AWAY FROM

NO SUGAR

NO CAFFEINE

NO CARBINATION

NO CALORIES

GOAL: 60-80GRAMS OF PROTEIN EACH DAY. BEGIN VITAMINS

Vitamin and Mineral Supplementation

Individuals who have undergone weight loss surgery are potentially at risk for developing nutrient deficiencies

for reasons including reduced food intake and altered digestive functioning. This is why daily supplementation

of vitamins and minerals becomes an essential part of a healthy, post-op life. Barnes Bariatric Surgical

Solutions recommends Bariatric Advantage Multi Crystals for the first two weeks after surgery, followed by

the Bariatric Advantage Chewables paired with chewable iron and sublingual B12. Should your doctor

recommend additional calcium or Vitamin D, choose Bariatric Advantage Calcium Citrate Lozenges or Chewy

Bites, and dry Vitamin D or Chewable Gels. All weight loss surgery patients should take a multivitamin that

meets 100% of the Daily Recommended Intakes (DRI), with special attention paid to the following nutrients:

Vitamin/Mineral Males Females

Iron (Fe) 29 mg 29 mg

Thiamin (B1) 1.2 mg 1.1 mcg

Folic Acid 400 mcg 400 mcg

Biotin 30 mcg 30 mcg

B12 350 mcg 350 mcg

Vit K 120 mcg 90 mcg

Zinc (Zn) 11 mcg 8 mcg

Calcium (Ca) 1500 mg 1500 mg

Vit D 600 IU 600 IU

Vit A 3000 IU 2333 IU

Multivitamin/Mineral (MVM) – Three scoops of Bariatric Advantage Multi Crystals meet the DRI for all

nutrients except for Iron, which should be taken separately. Two Chewables will meet the DRI for all

nutrients except for Iron, Calcium and Vitamin D, which should be taken separately.

Iron (Fe)- Based on lab work and your doctor’s recommendations, an additional iron supplement may be

necessary. This is more likely to occur with patients who have undergone a Roux-en-Y Gastric Bypass

than other surgeries; however, this is determined on a case-by-case basis for each individual.

Calcium Citrate- Separate Calcium and Iron doses by at least 3 hours.

*Separate Multi Crystals

and Iron by at least 2-4

hours to increase

absorption of nutrients

*Separate Multivitamin and Calcium doses by at least 2 hours

*Separate Calci

Breakfast Lunch Afternoon Supper Bedtime

7:00 AM 12:00 PM 3:00 pm 6:00 PM 9:00 PM

Multi-Crystals or

Multivitamin, B12

Multi Crystals or

500 mg Ca + 200 IU Vit D

500 mg Ca

+ 200 IU Vit D

Multi Crystals or

500 mg Ca + 200 IU Vit D

Iron

DR GREGORY S. BARNES, MD

DIET PROGRESSION

STAGE 2

CLEAR & FULL LIQUIDS BEGIN SUPPLEMENTATION

WHEN: UPON DISCHARGE FROM THE HOSPITAL LENGTH 3 TO 4 WEEKS PER DOCTOR

FOCUS ON HEALING

FLUIDS/FOODS YOU CAN HAVE

PROTEIN: 60-80 GRAMS A DAY

HYDRATION: 60 OZ FLUID DAILY

SUPPLEMENTATION–BARIATRIC ADVANTAGE

BARIATRIC ADVANTAGE NECTAR

NONFAT MILK, SOYMILK, PLAIN OR BLENDED

SUGAR-FREE YOGURT, CREAMED SOUPS.

NO LUMPS OR CHUNKS.

STAY AWAY FROM

NO SUGAR

NO CAFFEINE

NO CARBINATION

NO CALORIES

GOAL: GREATER THAN 3 CUPS PROTEIN DRINK

GREATER THAN 5 CUPS CLEAR LIQUID + MULTI VITAMIN + IRON, CALCIUM, VIT D 1 SVG = 2 OZ = 1/4C = 4 TBL

LESS THAN 15 G SUGAR / SERVING LESS THAN 3G FAT / SERVING

STAGE 2 DIET FULL LIQUIDS

This diet will begin as soon as you get home and will continue until your 2-weeek post-op visit with the doctor

and dietitian. During this stage, clear liquids will be continued and it is vitally important that the texture of all

foods in this stage is liquid. Your new stomach pouch is not ready to handle solid pieces of food, yet! Failure

to abide by this stage could result in pain or discomfort. The goals are to drink enough fluid (48-64 oz/day) to

ensure proper hydration and enough protein (60-80 grams/day) to allow the body to heal and prevent too

much loss of lean body mass. Barnes Bariatric Surgical Solutions recommends Bariatric Advantage Nectar or

Progo as your protein drink. This highly bioavailable protein mix will help ensure that you are getting the

nutrition you need every day. You may count half the volume of your protein drink towards daily fluid intake

goals.

Liquid Guidelines Protein Drink Guidelines Bariatric Advantage Nectar

Protein optimal 20 grams protein/ scoop or serving 23 grams protein/ serving

≤ 15 g sugar/ serving < 7 grams sugars/serving 0 grams sugar/ serving

≤ 3 g fat/ serving < 5 grams fat/ serving 0 grams fat/ serving

Also during this time you will begin your post-op vitamin and mineral supplementation. It is important to start

with liquid or chewable varieties. We recommend Bariatric Advantage Multi Crystals paired with the Calcium

Citrate Lozenges or Chewy Bites, chewable iron and liquid vitamin D or chewable vitamin D gels.

Nutrient Goals 60-80 g protein ≥ 3 cups protein drink

60 oz fluid + ≥ 5 cups clear liquid Supplementation + MVM + Fe, Ca, Vit D

Allowed Liquids AVOID

Bariatric Advantage Nectar Alcohol

Bariatric Advantage ProGo Caffeine

CLEAR LIQUIDS Carbonation

Low-fat Cream Soups* Cereals (hot or cold)

Low-fat Cottage Cheese* Juice

Plain/ Blended Yogurt* Sugar

Skim milk/ Soymilk Thick Fluids

Sugar-sweetened desserts

*Blended/strained- NO SOLID PIECES

DR GREGORY S. BARNES, MD

DIET PROGRESSION

STAGE 3

WHEN: AFTER 2 WK FOLLOW-UP VISIT

UPON APPROVAL OF DOCTOR OR RD (2 WEEK TO 6 WEEK POST-OP)

FOCUS ON INTRODUCTION OF NEW FOODS

FLUIDS/FOODS YOU CAN HAVE

PROTEIN: 60-80 GRAMS A DAY

HYDRATION: 60 OZ FLUID DAILY

SUPPLEMENTATION–BARIATRIC

ADVANTAGE

BARIATRIC ADVANTAGE NECTAR

NONFAT MILK, SOYMILK, PLAIN OR

BLENDED SUGAR-FREE YOGURT.

SCRAMBLED EGGS

PUREED MEATS

SOFT FRUITS – NO SUGAR

COOKED VEGETABLES(FINELY CHOPPED)

STAY AWAY FROM

NO SUGAR

NO CAFFEINE

NO CARBINATION

NO CALORIES

CHOOSE PROTEIN FOR 2 OF 4 SERVINGS OF SOFT FOODS

GOAL: 2 CUPS PROTEIN DRINK 1 CUP SOFT FOODS

GREATER THAN 6 CUPS CLEAR LIQUID + MULTI VITAMIN + IRON, CALCIUM, VIT D 1 SVG = 2 OZ = 1/4C = 4 TBL

STAGE 3 DIET PUREED/SOFT

After you have met with the doctor and dietitian at your 2-week post-op follow-up visit, you will be instructed

to begin progressing your diet from full liquids to Stage 2, pureed/soft solids. The duration of this diet stage

varies according to individual needs (as assessed by your doctor) and generally falls between post-op weeks 2

and 6. The healing process is continued through the use of Full Liquids with the slow introduction of pureed

and soft foods. The key thing to remember about this stage is to keep foods soft and moist and chew

thoroughly! Fruits and cooked vegetables should be easily mashed with a fork and free of skins. Steam or boil

meats, then puree the cooked meats with broth to add moisture. Low-fat mayo and low-fat dressings are also

acceptable ways to add moisture. Be sure to read the nutrition facts labels; low-fat often means high sugar.

Nutrient Goals

60-80 g protein 2 cups Protein Drink + 1 cup Soft Foods

60 oz fluid + ≥ 6 cups Clear Liquid Supplementation + MVM + Fe, Ca, Vit D

1 svg = 2 oz = 1/4 c = 4 Tbl

Goal is four ¼ cup meals/day

REMEMBER! -Stop sipping liquids 30 minutes before eating meals; wait 30-60 minutes after eating to resume liquids.

-Eat protein first! Chew thoroughly!

-Stop eating when you are full, even if you have not finished all 4 tablespoons.

-Limit meal times to 20-30 minutes long.

-Continue logging food intake and physical activity!

Allowed Foods AVOID

Bariatric Advantage Nectar*

Bariatric Advantage Profect*

CLEAR LIQUIDS

FULL LIQUIDS

Eggs, scrambled*

Soft Fruits, finely chopped

Soft, Cooked Vegetables

Canned/Poached White Meats*

(chicken, fish, turkey. veal)

Steamed Tofu*

Alcohol

Carbonation

Cereals (hot or cold)

Dried Fruits

Fibrous Vegetables

Juice

Sugar

Tough/Dry Meats

Sugar-sweetened desserts

*Protein Foods; choose for 2 of 4 svgs of soft foods

DR GREGORY S. BARNES, MD

DIET PROGRESSION

STAGE 4

WHEN: BYPASS/SLEEVE: AFTER 6 WK FOLLOW-UP VISIT

(6 WK POST-OP TO LIFE)

BAND: -UPON APPROVAL OF DOCTOR OR RD (4WK-6WK POST-OP TO LIFE)

FOCUS ON LIFE LONG NUTRITION

FLUIDS/FOODS YOU CAN HAVE

PROTEIN: 60-80 GRAMS A DAY

HYDRATION: 60 OZ FLUID DAILY

SUPPLEMENTATION–BARIATRIC

ADVANTAGE

BALANCED DIET: ALL FOOD GROUPS

PROTEIN

FRUITS

VEGETABLES

LEGUMES AND WHOLE GRAINS

STAY AWAY FROM

NO SUGAR

NO CAFFEINE

NO CARBINATION

NO CALORIES

GOAL: 3 – 4 MEALS A DAY + 1 1/2 CUPS SOLID FOODS

+ GREATER THAN 7 CUPS CLEAR LIQUID

+ MULTI VITAMIN + IRON, CALCIUM, VIT D

1 SVG = 4 OZ = 1/2C = 8 TBL

REPLACE LIQUID CALORIES/PUREED FOODS WITH SOLID FOODS CUT FOODS INTO PEA-SIZED PIECES AND CHEW EACH BITE THOUROUGHLY.

STAGE 4 LIFE LONG NUTRITION SOLIDS/ MAINTENANCE

Now that your body has had a few weeks packed full of protein and healing, you are now ready to begin eating

solid foods again! Do not begin this stage until instructed by your doctor or dietitian. Now is the time to

remember that your band/bypass/sleeve is a tool to help you reach your weight loss goals and achieve a

balanced, sustainable, healthy lifestyle. Foods in the maintenance stage can be divided into 3 categories: Best

Choices, Poor Choices and Worst Choices. Foods that are solid, prepared in a low-fat manner, and fill you up

quickly are the Best Choices and will result in the most weight loss. Poor Choice foods include those that are

soft or mushy and will result in minimal weight loss. Worst Choice foods include crunchy, soft, and liquid

foods as well as fried, high-fat or high-sugar items. Worst Food Choices will result in no weight loss and

possibly even weight gain. Choose Bariatric Advantage protein drinks ≤ 2 times/week.

Nutrient Goals

60-80 g protein 3-4 Meals/day + 1 ½ cups Solid Foods

60 oz fluid + ≥ 7 cups Clear Liquid Supplementation + MVM + Fe, Ca, Vit D

1 svg = 4 oz = 1/2 c = 8 Tbl

Goal is three to four 1/2 cup meals/day

Best Choices Poor Choices Worst Choices

Beef, chicken, turkey, fish, pork, lamb, eggs,

tofu, TVP, tempeh

Fried meats, high-fat meats Milk, yogurt, cottage cheese

Nuts, trail mix, fried egg, peanut butter

Non-starchy vegetables Most fruits

Potatoes, starchy vegetables Banana, grapes, raisins, dried fruits

Fried vegetables Fruits canned in syrup, juice

100% Whole Grains (after protein needs are met)

Instant/cold cereals, muffins, biscuits, macaroni & cheese,

mashed potatoes

Chips, trail mixes, pretzels, nuts, French fries

Calorie-free/ sugar-free beverages

Cheese, nuts, refried beans, avocado

Cookies, cakes, pastries, ice cream, milkshakes, gelato,

Butter, margarines, regular mayo

Sports drinks

AVOID: Alcohol, carbonated beverages, sugar

REMEMBER! -Stop sipping liquids 30 minutes before eating meals; wait 30-60 minutes after eating to resume liquids.

-Eat protein first! Chew thoroughly!

-Do not “graze” or nibble on foods all day.

-Limit meal times to 20-30 minutes long.

-Continue logging food intake and physical activity!

phycosocial

support

Psychosocial Support

As you begin your life-changing adventure you will be required to make changes in your dietary and exercise habits this will demand behaviors change as well. Some patients experience the changes that occur as a result of dramatic weight loss after weight-loss surgery as being overwhelmingly positive. These changes can affect a variety of interpersonal situations, including everyday social interactions and relationships with close friends and loved ones. In addition to external challenges, patients may also be confronted with dealing with their own internal challenges. It is important to attend regular support group meetings and developed a supportive personal network to ensure long-term success following weight loss surgery. We recommend a pre-surgery Psychological evaluation and follow up visit at one year. .

Pre-Operative Psychological Evaluation:

Psychological Evaluation is required by most insurance carriers prior to bariatric surgery and is found to be beneficial in the pre-operative phase of your treatment by most surgeons you to have psychological testing and evaluation prior to your surgery. It is our goal to identify any barriers or behaviors that can affect your post-operative weight loss and mental health. BBSS will refer you to a Psychologist that has experience in bariatric care and understands the importance of the individual needs of our patients. However, if you are currently under the care of a mental health professional, you may also choose your current provider to provide your evaluation to BBSS.

Support Group:

BBSS is dedicated to providing support group that will meet monthly and in various locations to ensure patients have the opportunity to attend and utilize both the emotional support and education that is necessary for long term success after surgery. A schedule can be found on our website. www.weightlosssurgery.com The support groups are lead by a registered dietician and includes a scheduled guest speakers who present on various topics each month. We encourage you to participate both pre-op and post-op. WE encourage you to bring your family member or friend that supports and encourages you daily and find that this enables them to understand your daily climb to success. You are encouraged to bring your BBSS Manual and makes notes for future reference. Support groups help you to maintain personal accountability, celebrate personal successes, build new social networks, and discuss your personal challenges with others who have been where you are. In an effort to keep support group positive and supportive, please read the following rules. Bariatric Surgery Support Group Rules: • Privacy is important and should be respected at all times. Please do not

repeat what is said in your group. • You do not have to share or speak in group. Group is meant to be supportive

not judgmental

• Respect each individual choices • Only one person may speak at a time

• Turn all devices off for the meeting • Please do not dominate the conversation

• Meetings will begin and end on time

The pre operative period can be an exhausting experience and can take several months before you are ready for surgery. The insurance approval process can be overwhelming and may seem as if it is never-ending, but can be used as an opportunity to begin making lifestyle changes that will benefit you during and after your surgery. It is common to become frustrated with all of the different appointments and classes that are required.

Pre Operative Wellness:

Emotions can be mixed about your upcoming surgery even among your family and loved ones making this a difficult time. Many relationships will change following your surgery, so it’s important to explore these feelings in a healthy manner before surgery. It is important to discuss any future plans you have made with your family and friends that may be affected following your surgery. For example, if you are planning to start a new family in the next year or so, it is important for your partner to understand how your surgery will alter these plans. It may be beneficial to bring your key support persons to a seminar with you. You may also want to bring someone to a few of your appointments with the dietician or your surgeon. You should be aware of any major life changes that will occur around the time of your surgery. Every event in life can cause a considerable amount of stress. Pleasant as well as unpleasant events may require some adapting which could lead to stress. Some examples of major life events include change in employment or job responsibilities, addition or loss of a family member, change in living environment or location, change in marital or relationship status, change in finances, or holiday gatherings or vacations. Below are some websites with stress assessment tools: www.cliving.org/lifestresstest.htm www.roadtowellbeing.ca/questionnaires/life-stressors.html You should begin setting both short term and long term goals. It is important to set realistic goals and discuss them with your bariatric surgeon and staff. Your goals should be personal, based on the education you have received regarding post operative expectations. Be honest with yourself and begin taking personal accountability. Journals are excellent tools for tracking our emotions and are a positive release of any emotions that are difficult to discuss. If you haven’t already begun to journal, this is a great time to start. Always consider any recommendations made to you as a result of your psychological evaluation. It is important to have someone support you as you work through the upcoming challenges ahead of you. You may choose to see a spiritual counselor, a mental health professional, personal counselor, or life coach and they can be assist you as you determine new coping skills to get you through life’s most challenging moments. We

will be happy to give you a referral should you need one. Many employers also offer psychological counseling by way of Employee Assistance Programs.

surgery

Updated 02/2012

Getting Ready for Surgery • Keep all pre-op appointments and consultations. • Follow all instructions for Pre-op Diet • Begin your daily vitamins

• Begin Exercise daily to improve circulation and breathing ability • Avoid Aspirin, Coumadin, Plavix, Ibuprofen, Advil, Bufferin, and Alka-Seltzer as decided by your

surgeon. If you are taking these medications for heart, vascular, or neurological reasons, check with your doctor for specific instructions.

• Stop taking estrogen supplements one week before surgery. • Stop taking Omega-3 oils or supplements 2 weeks before surgery. • Quit smoking at least 6 weeks prior to surgery. • Stop drinking carbonated beverages. • Stop caffeine at least two days prior to surgery. • Avoid alcohol for at least two weeks prior to surgery. • Keep your skin clean and dry in the days prior to surgery. • If you are a woman of childbearing age, you should use contraception during the last 2 weeks

before your surgery. A positive pregnancy result will delay your surgery. • Nothing to eat or drink after midnight the day before surgery.

Things to have at home: • Prescription medication that the surgeon pre-scribed for after surgery • Chewable Gas-X or Surgeon Recommended Anti-acid • Liquid Tylenol • Clear liquids • Caretaker for 1-2 days to help you. • Bariatric Advantage Vitamins and Post-Op Kit

Updated 02/2012

BEFORE TAKING MEDICATION AFTER SURGERY CONSULT YOUR SURGEON

Over the Counter Medications: Miralax –stool softner Gas-X – gas reliever Metamucil Benefiber Regular Tylenol – if needed DO NOT TAKE NSAIDS The following drugs are NSAIDs or include NSAIDs in their formula and should not be taken after weight loss surgery:

Advil Aleve Amigesic Anacin Anaprox Anaprox DS Ansaid Arthrotec Ascriptin Aspirin Azolid Bextra Bufferin Butazolidin Cataflam Celebrex

Clinoril Combunox Darvon Daypro Disalcid Dolobid EC Naprosyn Ecotrin Equagesic Excedrin Excedrin IB Feldene Ibuprofen Indocin Indocin SR Indo-Lemmon

Indomethagan Lodine Lodine XL Meclomen Mictainin Midol IB Mobic Motrin Motrin IB Nalfon Nalfon 200 Naprapac Naprelan Naprosyn Nupin Orudis

Oruvail Pamprin IB Percodan Ponstel Relafen Rexolate Tab-Profen Tandearil Tolectin Tolectin 600 Tolectin DS Toradol Uracel Vicoprofen Voltaren

Updated 02/2012

The Day of Surgery Refer to your surgeon’s handout provided during your pre-admit class for specific instructions.

General tips: • Bring your insurance card and ID and BBSS Manual with you to the Hospital • Bring your bi-pap or c-pap machine if it has been prescribed. • Bring lip balm. • Bring comfortable clothes- a robe, and slippers. Shower the morning of surgery and wash your hair

as usual. You may brush your teeth the morning of surgery. • No gum, mints, or caffeine. • You may take your medications as instructed with a small sip of water. • Arrive at the hospital at the assigned date and time at least 2 hours prior to surgery • Do not bring valuables to the hospital with you. You will be asked to remove all undergarments,

jewelry, contact lenses or glasses, dentures or partials, and wigs or metal hair clips. • If you are having day surgery, bring someone who feels comfortable speaking with hospital staff. • You will receive a blood thinner in your abdomen the morning of surgery. • You will have an IV catheter placed and given IV fluids. (Some patients will receive a central line,

at the surgeon’s discretion). • You will be given a general anesthetic to prevent pain during the surgery. Be sure to inform the

anesthesiologist of any history of post-operative nausea. • Surgery can last from 30 minutes to 2 hours. Depending on your procedure, response to

anesthesia, and level of comfort, recovery should be about one hour. • You will have leg compression sleeves. These should be worn until you are able to walk at least

every two hours while you are here. • You will not be given anything to eat or drink until after your Upper GI swallow study. This is done

to check for proper placement of the band, leaks, or obstructions depending on your procedure. The contrast has an unpleasant taste, but you will only be required to take a small amount. Some people may experience diarrhea or constipation related to the contrast. You should notify your surgeon for constipation or diarrhea lasting longer than 3 days. Please do not ask for ice or water until this test has been cleared. You may use lip balm and mouth swabs to keep your lips moist. No gum or hard candy is allowed.

• The Upper GI is done on the same day of surgery for adjustable gastric bands and the following morning for gastric bypass and sleeve gastrectomy procedures. Once the radiologist has completed your swallow study you will be taken back to your room.

• Once your Upper GI has been cleared, you will be given a small amount of water. This should be measured in a medicine cup and sipped slowly over 15-45 minutes in order to avoid nausea and overfilling your pouch. You will soon receive a tray with a small amount of bariatric clear liquids. If at any point you feel “full” (a sensation of pressure, squeezing, or tightness) in the center of your chest or upper stomach, stop drinking. Remain sitting upright, and wait 20 to 30 minutes before drinking again. Do not use a straw to drink.

• You will use Incentive Spirometer for breathing. • Any routine medications you are given will be cut, crushed, liquid, or given through your IV. • You will feel drowsy and have some discomfort when you wake. Pain should be tolerable – less

than 5 out of a scale of 1-10. Inform your nurse if your pain medicine is not working. • You may have a pain pump with numbing medicine when you awaken. This usually lasts for 2

days and is discontinued once you go home. Your discharge nurse will instruct you on how to remove the pain pump.

• You should already have your pain prescription filled. If not, be sure to get a prescription before you leave the hospital.

• Your skin may be closed with staples, skin glue, steri-strips or stitches. Do not attempt to scrub off glue or steri-strips.

Updated 02/2012

What to expect the first few days after surgery: • No heavy lifting (5 lbs) for strenuous exercise for two weeks • It will be difficult to get the recommended 60 ounces of fluid and 60-80 grams of protein.

You should get at least 40 ounces of fluid and 40 grams of protein the first few days following surgery. However, continue to work towards end goal of 60 oz of fluid and 60-80 grams of protein a day. Your fluid intake is very important following surgery to avoid dehydration.

• Left shoulder pain or pain under your rib cage is common. You may also notice pain that moves when you change position. This is usually gas pain and should improve with walking. Mild abdominal pain is normal for up to 4 weeks after surgery.

• Sleep on your back if possible. If you must sleep on your side, use pillows to support your stomach. If you have a port avoid sleeping on your port incision.

• Do not drive while you are taking your pain medicine. • No baths, hot tubs, or swimming for at least 4 weeks. Shower as instructed by your

surgeon. • You may experience some pinkness, redness or bruising around the incisions. The area

around your incision may be firm, but should not be painful or feel warm or cool to touch. • A small amount of clear or light pink drainage is normal. • Do not apply ointments or creams to your incisions, unless instructed by your surgeon. • Your return to work is determined by your surgeon and the type of work you do and

should be discussed at your 2 week post op appointment . Typical return to work is 1-2 weeks.

• You will be required to crush or cut your pills if they are not available in liquid or chewable form. Not all pills can be crushed so be sure to check with your pharmacist. (Medications with CR, XR, ER, SR, or XL are examples of medications that should not be crushed or opened).

• No Advil, Aleve, Motrin, ibuprofen, naprosyn, or aspirin unless approved by your Surgeon.

• Be sure you understand how to take your pills before you leave the hospital. • Start vitamins and supplements in liquid or chewable form.

When to call your surgeon: • Bright red blood in your vomit or stools. • Excessive pain in your chest • Pain or swelling in your legs. • Frequent vomiting or diarrhea lasting more than 12 hours. • No bowel movements after taking milk of magnesia. • Uncontrollable pain (pain that hasn’t responded to two doses of pain medicine). • Fever over 101.5 F. or Heart rate greater than 125. • Milky or foul smelling discharge from your incisions. • Severe, unusual pain around your incisions or abdomen. • Difficulty breathing or shortness of breath. • Unable to tolerate fluids or to urinate. • If you feel something is wrong and or have any questions

vitamin

reccomendations

Vitamin Supplementation

It is important to realize that your diet is changing and quantity is much less, therefore you must take supplements. It is additionally important for gastric bypass and sleeve patients to take a sublingual vitamin B12 supplement since the new ouch cannot absorb B12 from the diet. Recommended Vitamins:

• Liquid or Chewable Adult Multivitamin- Two doses daily • Iron-

Ferrous Fumerate(18-29 mg) or Ferrous Gluconate/sulfate (300 mg)

• B12-500 mcg sublingual daily or 2400 mcg sublingual weekly Sublingual (under the tongue) – It is available through Bariatric Advantage or Pharmacies in spray or melt away tablet. IM (intramuscular shot) can be prescribed and administered by your surgeon Nasal Spray available by prescription

• Calcium Citrate 1000 -1500 mg Daily- should be taken in 500 mg doses with an hour between doses.

Calcium Citrate should be taken two hours prior to Iron.

bariatric

physical activity

Activity/Exercise Pre-Operative Exercise Program: Developing an individualized exercise and physical activity plan is one of the most important steps of bariatric surgery preparation. An exercise program should begin before and after your surgery. Plaza Medical Center has a comprehensive pre-op and post-op exercise program that was designed to evaluate, and treat patients in the bariatric program. After a physician referral is received, you will be contacted to schedule your pre-op physical therapy evaluation. At that time, you will be provided with registration information and location of the outpatient therapy clinic. Please make sure that you dress comfortably in workout clothes on your evaluation day, so you may demonstrate an understanding and the ability to perform your exercise program.

A highly trained licensed physical therapist will evaluate you pre-operatively. The therapist will assess your current functional ability including but not limited to the following: Strength, Endurance, Range of Motion, Balance, Gait/Walking, Transfers, Pain Level and Vital signs at rest and with activity. Once your initial evaluation is completed, the therapist will design an individualized exercise program that will be appropriate for your current physical level. The therapist will instruct you in the exercise program and will discuss safety concerns and other educational information as deemed appropriate for you. It is important to be as fit as possible before undergoing bariatric surgery. This will make your recovery much faster. Pre-operative exercises can help you: • Establish a cardiovascular routine and begin strengthening muscles • Enables you to become familiar with the various exercises • May help to decrease the likelihood of post-op complication • Can improve your overall health status • Set groundwork for continued exercise after your surgery Post-Operative Exercise Program: On day 1 after your surgery, a physical therapist and occupational therapist will evaluate you. The occupational therapist will evaluate you on activities of daily living skills, safety awareness and upper extremity strength. After your evaluation, the therapist will instruct and provide you with an upper extremity home exercise program. The physical therapist will evaluate your lower extremity strength, gait, functional mobility and safety awareness. Following your physical therapy evaluation, the therapist will instruct and provide you with a lower extremity home exercise program. It is essential to start exercising post surgery as soon as your surgeon says you are capable of exercising. Exercise and activity can: • Enha nce re cove ry from a ne s the s ia • Fa cilita te the re turn of norma l urina ry functions • Incre a s e circula tion • Re duce the ris k of blood clots • Improve ca rdiova s cula r function • As s is t in we ight loss success and • P romote overall health maintenance Exercise should be an important component in everyone’s daily life. A well balanced exercise program should include a combination of aerobic/cardiovascular, strengthening/resistance and flexibility/stretching exercises initiated before and after surgery to safely enhance weight loss and increase muscle mass. Below are some general exercises that you can start doing now before you are set up with your individualized exercise program designed by your physical therapist. You should start out by doing each exercise 5-10 repetitions based on your tolerance level and continue until after your surgery. Recommendation is that you would at least do the exercises daily for 30 minutes. Discontinue any exercise that causes pain, discomfort and/or is difficult for you to perform

Aerobic/Cardiovascular Exercises: Theses exercises use larger muscles and raise your heart rate. They help to build endurance and provide for greater ability of the muscle to burn fat. Examples include walking, jogging, running, aerobic dance, hiking, bicycling, and/or swimming.

Strength/Resistance Exercises:

These exercises increase your physical strength, build lean muscle mass, make your muscles and bones stronger, prevent muscle atrophy and increase your metabolism. Examples include weight lifting using free weights, weight machines/equipment, and/or resistance bands/tubes.

Flexibility/Stretching Exercises:

Flexibility/stretching exercises tone your muscles, increases freedom of movement and improve posture. In addition, it releases muscle tension and soreness, enhances relaxation, and reduces your risk of injury during exercise. Some tips for safe stretching include: • Spend at least 5-10 minutes warming up your muscles before

you start stretching. For example walking gently while swings your arms in wide circles

• Start each stretch slowly, exhaling as you gently stretch the muscle and hold each stretch for 10- 30 seconds

• Do not bounce during stretch • If a stretch hurts, ease up. Do not strain or push a muscle too far • Do not hold your breath while stretching

Key Things to Remember When Starting Your Exercise Program: • Check with your physician about any possible medical problems that you may have that

would limit your exercise program • It is important to find an activity that you enjoy • Find an activity that you are physically capable of doing • Start slow and work up. Begin with 10 minutes a day for 5 days and then work up to 20

minutes 5 days a week. Set your goal to be 45-60 minutes a day for 5 days a week. • Exercise does not have to painful or expensive to be effective. • You can begin by Walking!! • Set goals • Change up your exercise so you do not become bored. • Extra skin after weight loss is positively impacted by exercise and muscle requires more

calories to maintain than fat. SO BUILD MUSCLE. • Track your exercise and weight • REWARD YOURSELF

Working Through Your Exercise Challenges:

• List the major obstacles that prevent you from exercising and analyze them one at a time. Identify what has to happen for you to overcome them.

• Visit several different gyms or exercise programs and price match to meet your needs and resources.

• Think of physical activity as opposed to exercise. Physical activity can be structured or non-structured. Structured activity = exercise which has a specific intensity, duration and frequency. Non-structured activity = anything in addition to sleeping, eating, and resting, i.e. housework, daily activities or occupational activity.

• If time is an issue, break your activity down into a weekly prescription. For example, exercise 150 to 300 minutes a week. This can be broken down into the following schedules: 150 minutes a week = 30 minutes for 5 days or 50 minutes for 3 days. 300 minutes a week = 60 minutes for 5 days or 30 minutes twice a day for 5 days

• Add exercise to your journaling experience.

*If you are working with a personal trainer, it is important to choose someone who you feel comfortable discussing your nutritional requirements with.

Personal Food Log Record what you have eaten as soon as possible after meals. This makes it much easier to remember what and how much you eat. Remember the following: Preparation: How was the food cooked? Baked, grilled, fried, steamed, or broiled? Fresh, frozen or canned? Portion size: Indicate how much of each food you eat by using cups, ounces, teaspoons, or tablespoons. For meats, estimate the ounces you eat. (A deck of cards or a computer mouse is about a 3-ounce portion.) Include the fluids that you drink: List the amounts and the types, and the times that you drink them. Include the “extras” or condiments: Do you put cream or sugar in coffee? Is your tea sweetened or unsweetened? Do you use ketchup, mustard, mayonnaise, steak sauce, or salsa on foods? Be specific: If you eat bread, is it white, wheat, whole wheat, rye, honey wheat or multigrain? If you drink milk, it is whole, 2%, 1%, skim, soy, or rice milk? Hunger Scale: 1 = not hungry, 2 = somewhat hungry, 3 = moderately hungry, 4 = very hungry, 5 = starving Fullness Scale: 1 = still hungry, 2 = slightly full, 3 = satisfied/comfortably full, 4 = very full, 5 = stuffed Additional Comments: Record the circumstances under which each meal was consumed. For example, were you eating while watching TV, bored, stressed, grabbing something in a hurry, having a food craving, or at a social event?

Meal/ Time Food/ Beverage Method of

Preparation Serving

Size

Number of

Servings

Hunger Level

Fullness Level

Comments (mood/location)

Personal Non-scale Victory Log Use this section to chronicle your personal successes that can’t be measured by a scale • Reflect on this list when you get discouraged • List discontinuation or decreased dosages of medications • List the day you throw out your C-pap machine • Use this list to help you renew your commitment to a healthier you • Share your wow moment at support group

Date My Wow Moment How This Event Changed My Life

How My Life Was Hindered In the Past

How I Rewarded Myself

Photo Log Use this section to chronicle your progress with photographs

_______________Pre-op

_______________Pre-op

_______________Post-op

_______________Post-op

_______________Post-op

_______________Post-op

_______________Post-op

_______________Post-op