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Einstein Bariatrics
Handbook for the Bariatric Surgery Patient
Ramsey Dallal, MD
Amanda Hatalski, MPAS, PA-C
Bariatric Surgeon
Physician Assistant
Alfred Trang, MD
Annette Merlino, MPAS, PA-C
Bariatric Surgeon
Physician Assistant
Ian Soriano, MD
Betty Lawhorn, RN, BSN
Bariatric Surgeon
Nurse
Call (215) 663-6422 or (484) 622-7700 for any emergency anytime!
Einstein Medical Center, Elkins Park
Einstein Medical Center, Montgomery
Phone: 215 663-6422
Phone: 484 622-7700
Fax: 215 663-6494
Fax: 484 622-7710
60 East Township Line Road
609 West Germantown Pike, Suite 140
Elkins Park, PA 19027
East Norriton, PA 19403
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WELCOME to Einstein Bariatrics, the comprehensive weight loss specialty center from Einstein Healthcare.
Einstein Bariatrics was created with quality in mind. The surgical team has performed thousands of weight loss
procedures and has been involved in the care of many more. And although the surgeon is a primary force directing
your care, a bariatric center, just like a transplant center, involves a team of expert people. Our registered dietitians,
nurses and anesthesiologists all have an expertise in bariatric surgery. Einstein Healthcare has fully supported the
development of the bariatric surgery program and is intimately involved in ensuring the nursing floors; operating
rooms and all the ancillary staff are integrated into the program.
This educational handbook is designed to help answer many of the questions you may have about bariatric
surgery performed at Einstein Bariatrics.
Our Website (www.einsteinbariatrics.com) is also a great resource with lots of educational materials.
Best Regards,
Ramsey Dallal, MD
Alfred Trang, MD
Ian Soriano, MD
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TABLE OF CONTENTS
The obesity epidemic ......................................................................................................................................................... 4
Indications for Surgery ....................................................................................................................................................... 4
How do I select a Bariatric Surgeon? ................................................................................................................................. 5
Insurance ........................................................................................................................................................................... 5
Minimally Invasive Surgery ................................................................................................................................................ 5
The Roux en Y Gastric Bypass ............................................................................................................................................ 7
Frequently Asked Questions about the Gastric Bypass ..................................................................................................... 9
The Adjustable Gastric Band ............................................................................................................................................ 13
Frequently Asked Questions about the Adjustable Gastric Band.................................................................................... 14
Sleeve Gastrectomy ......................................................................................................................................................... 15
Frequently Asked Questions about the Sleeve Gastrectomy .......................................................................................... 16
LifeStyle Management Program ...................................................................................................................................... 18
Pre-operative Tests .......................................................................................................................................................... 19
Minerals and Vitamins after Weight Loss Surgery – Gastric Bypass/Sleeve Gastrectomy .............................................. 21
Pre-Operative Patient Instructions .................................................................................................................................. 23
Other Common Questions ............................................................................................................................................... 24
PHASE DIET INSTRUCTIONS ............................................................................................................................................. 26
What to expect in the hospital ........................................................................................................................................ 32
Discharge Instructions ..................................................................................................................................................... 34
What to know the first few days after surgery ................................................................................................................ 37
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The obesity epidemic
The rising problem of obesity has been in the news daily over the last several years. As new research becomes
available, the devastation that obesity will have to individual lives, our health care system and to the national
economy becomes more and more evident.
It has been estimated that if obesity were cured in America, more than 100,000 deaths each year would be
prevented. A morbidly obese male has a life expectancy 13 years less than a non-obese individual! And yet, there is
no national movement against obesity as there is against wars, environmental issues and pollution, which effect far
fewer lives. There is a lack of empathy of the obese by the non-obese population because of the mistaken belief that
a person can easily lose 100 or more pounds by simple will power. Unfortunately, this is not true. Although the cause
of obesity is not understood, what is well documented is the complete failure of diet and exercise regimes in this
population to have any lasting effect. Yes, the treatment is simple – eat less, exercise more. But, 95% of obese people
will regain any weight lost through any weight-loss program.
Surgery is the only reliably proven long-term treatment for patients who have more than 100 pounds to lose.
Indications for Surgery
Pati ents are candi dates if they meet the fol lowing criteria.
BMI range >40 OR BMI >35 with a significant weight related co-morbidity
A patient must have capacity to understand the procedure and life style changes
Age range 15 years – 74 years*
No active drug and/or alcohol abuse
Willingness to participate in long-term follow-up
Willingness to take vitamins and minerals as prescribed
To calculate your BMI – go to www.einsteinbariatric.com
*Teenagers must go through our specialized adolescent program
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How do I select a Bariatric Surgeon?
One hour in the operating room and an overnight stay can “cure” a patient of diabetes, hypertension and
sleep apnea. Quality of life dramatically improved and life expectancy is potentially increased. Too good to be true?
Unfortunately, the pressures placed on surgeons to perform these procedures has resulted in a large variation
in complication and success rates with the operation. Laparoscopy has been a tremendous improvement in bariatric
surgery. Even the most complex and sick patients can get back to work within a week or two. However, the techniques
necessary to perform these operations laparoscopically are difficult to master. A number of studies have
demonstrated that a minimal of 100 supervised cases are necessary to become simply proficient with the technique.
Furthermore, a system must be in place for the long-term care of the patient’s psychological, nutritional and medical
needs for successful outcomes after these procedures.
Insurance
Insurance
Many insurance companies will pay for bariatric surgery when deemed medically necessary. Almost always
that means having a minimum BMI of 40. Patients with a BMI between 35 and 40 who have significant weight-related
medical illnesses such as diabetes may also be candidates. Einstein Bariatrics can help you obtain insurance
authorization for surgery by determining medical necessity. The only way to know if your insurance company covers
surgery is to get an explanation of benefits. If your contract with your insurance company has an exclusion to
bariatric surgery – you will not be covered. If you insurance company covers surgery, you will want to know your
deductible and co-pays. Some insurers require a medically supervised diet of varying lengths (6 months or longer).
This means you must have weekly documented weights by a physician.
CALL OUR OFFICE and we can find out whether your insurance covers bariatric surgery services.
Minimally Invasive Surgery
Minimally invasive surgery, also called laparoscopic surgery, is where operations are performed using a
narrow magnification camera, called a laparoscope, and narrow surgical instruments. Only small incisions are needed
which helps to optimize patient comfort and outcomes. Gallbladder surgery was one of the first laparoscopic
procedures developed because the skills involved are relatively basic to learn. Whereas gallbladder surgery is routine
among most practicing surgeons, other procedures are much more advanced and require specialized training.
Study after study has documented the benefits of laparoscopic surgery. Most obviously, post-operative pain is
markedly decreased. These incisions cut very little skin, muscle and nerve and thus cause much less pain than the
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large traditional incisions used for surgery. Patients can breathe, cough, and get out of bed to walk much easier
without the typical pain from traditional open surgery. This translates into a decreased risk of certain complications
such as pneumonia, blood clots and other problems seen after surgery. Because laparoscopic cameras magnify the
images on a large TV screen, we can see the intestines and internal organs much better than through a traditional
incision. This allows for an exactness and visual sensitivity that cannot be achieved with the unaided eye.
Minimally invasive surgery techniques have cut recovery times for many operations from weeks (or months)
to days. The more cutting performed by the surgeon, the higher the stress on your body. With more stress there is an
increase in heart and kidney problems as well as a decrease in immune function. Smaller incisions also result in a
much smaller chance of developing significant infections. There is also a decreased formation of internal scar tissue,
or adhesions.
Incredible advances have occurred over the past ten years in the techniques and skill of laparoscopic surgery
specialists who now routinely perform many complex surgical procedures. To perform these procedures safely a
surgeon must be an expert in the specialty of laparoscopic surgery. Laparoscopic surgery for obesity is one of the
most complex intestinal surgeries being performed today. Therefore, laparoscopic weight loss surgery should only be
performed by surgeons who have considerable skill in performing advanced laparoscopic surgery.
Advanced laparoscopic surgery is far too complex to learn during a weekend, or even a weeklong course and
most general surgery training programs do not provide enough training for their graduates to perform the more
advanced laparoscopic procedures.
These advanced laparoscopic surgery techniques required for bariatric surgery are difficult to learn and
require extensive experience. You need to be certain that your surgeon is truly an expert before you agree to them
performing this type of operation.
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The Roux en Y Gastric Bypass
The gastric bypass is the most commonly performed operation for weight loss in the United States. In the
U.S, approximately 140,000 gastric bypass procedures will be performed in 2011, an amount dwarfing the number of
adjustable gastric band, duodenal switch and sleeve gastrectomy procedures done. Furthermore, since the gastric
bypass has been performed for almost 50 years, surgeons have become very comfortable with the understanding of
the risks and benefits of the procedure. By shear volume of cases combined with the volume of scientific research,
the gastric bypass has become the “gold standard” operation for weight loss in the U.S.
One of the biggest advancements in the gastric bypass operation has been the technique used to enter into
the abdomen – the laparoscopic approach. Although the laparoscopic approach has a number of potential
advantages over the traditional open operation, the training and expertise necessary to perform the laparoscopic
approach safely is considerable.
Surgeons at Einstein Bariatrics have successfully performed more than 99% of gastric bypasses
laparoscopically. The laparoscopic approach has a number of advantages.
a) Generally 5 tiny incisions are necessary. Four are about ½ “ long and one is 1” long. These incisions are
too small for any significant infection to occur and the risk of developing a hernia is less than one
percent. The risks of infection, wound problems and hernias are close to 30 percent with the traditional
open procedure.
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b) The operation, in expert hands, can be performed quicker than an open operation. In fact, average
operating room times are close to one hour. Less time in the operating room means less anesthesia and
anesthesia-related complications.
c) Less pain. Patients, although sore in the first few hours, need only Tylenol with Codeine the day after
surgery. Many patients do not require any medications for pain by the time they go home.
d) Quicker return to work. Patient can often return to work in one week. We generally recommend two
weeks off work to be on the safe side.
e) As patients are walking the day of surgery and discomfort is easily controlled, patients are at lower risk to
develop blood clots, pneumonia, bed sores or other complications resulting from prolonged immobility.
The gastric bypass has been proven in numerous studies to have good long-term weight loss. The average
weight loss often peaks at 18-24 months after surgery – but half of all the weight loss often occurs in the first six
months. The gastric bypass, through multiple studies, has been shown to improve or cure diabetes, hypertension,
arthritis, venous stasis disease, certain types of headaches, heartburn, sleep apnea and many other disorders. Most
importantly, the gastric bypass has demonstrated significant improvements in quality of life.
Regardless of the entry technique (laparoscopic or open), most surgeons perform the operation in a very
similar manner. The stomach is cut to form a small pouch (usually one ounce in size) and the remaining stomach and
first 1-2 feet of small intestine are bypassed. In the standard gastric bypass, the amount of intestine bypassed is not
enough to create malabsorption of proteins and other macronutrients. However, the bypassed portion of intestine is
especially adept at absorbing calcium and iron – thus, anemia and osteoporosis are the most common long-term
complications of the gastric bypass and must be prevented with lifelong mineral supplementation. Other clinically
significant deficiencies have been identified such as thiamine and Vitamin B12. Lifelong follow-up with a bariatric
program is mandatory to monitor and prevent nutritional complications. Most surgeons recommend specific
supplements to prevent these long-term complications.
The mechanism in which the gastric bypass works is complex. After surgery, patients often experience
significant changes in their behavior. Most state that they do not get hungry frequently and that their hunger is
fleeting. Patients often state that they enjoy healthy foods and lose many of their food cravings. Rarely do people
feel deprived of foods. These complex behavioral changes are partially due to poorly understood alterations in the
hormones and neural signals produced in the GI track that communicates with the hunger centers in the brain. One
interesting hormone that has recently been studies is ghrelin. Certainly the small size of the stomach pouch restricts
the volume of food people eat as well. Thus, the decrease in hunger and the rapid feeling of fullness accounts for
most of the weight loss after a gastric bypass.
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Another mechanism of weight loss after the gastric bypass is called dumping syndrome. Dumping syndrome
causes the intolerance to sweets after surgery. Dumping may result in lightheadedness, flushing, heart palpitations,
diarrhea and other symptoms immediately after eating desserts. Some people are extremely sensitive to sweets for
the rest of their lives; other patients lose some or all of their sweet sensitivity over time. The exact mechanism of
dumping syndrome not entirely understood.
The mortality risk with the gastric bypass in expert centers appears to be less than 0.5%. Because of the
increasing popularity of the procedures, some surgeons have been tempted to perform the operation without
adequate training or an environment supporting long-term follow-up. Some studies have demonstrated that the
mortality rate from hospitals with a low experience with the procedure is far higher than the 0.5% reported by expert
centers. The most important questions to ask your surgeon: How many surgeries have you performed? Have you had
any deaths?
The two most common causes of death after a gastric bypass are an anastomotic leak and a pulmonary
embolism. An anastomotic leak can be rapidly deadly if not recognized and treated early. A “leak” occurs when
intestinal fluids leak out freely into the abdomen. Symptoms of a leak may include, severe chest pain, shortness of
breath, anxiety, heart palpitations and abdominal pain. Prompt treatment is critical. A pulmonary embolism is caused
from a blood clot that forms in the leg that breaks off and gets lodged in the lungs. Prevention is the key to this
complication. Blood thinners, leg compression devices and early walking are measures used to prevent blood clots.
Other complications include bowel obstruction, strictures, ulcers, bleeding and prolonged nausea. The open
operation generally has a higher frequency of wound problems such as infections and wound hernias than the
laparoscopic approach. Please see the written consent form for a more detailed written listing of complications. A
frank discussion with your bariatric surgeon about the risks and benefits of surgery is critical to understanding the
operation.
Frequently Asked Questions about the Gastric Bypass
Do you do the operations laparoscopically?
Yes, in fact, surgeons at Einstein Bariatrics have performed more than 2000 weight loss operations laparoscopically.
Even in patients with previous abdominal surgeries or who are extremely overweight.
What does the name "Roux en Y gastric bypass" mean?
The operation is named after a common method of using small intestines as a means to bypass (re-route) food or
gastrointestinal secretions. It was first described by the Frenchman, Cesar Roux (1857-1934), as a means to bypass a
blocked stomach caused from severe scar tissue after peptic ulcer attacks. The “Y” comes from the vague similarity
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the stick figure representation of the procedure resembled the letter. The Roux-en-Y procedure has over the years
been modified for use in many surgical procedures including liver transplants, pancreas operations, and cancer
operations of the stomach and bile ducts. Often people simply call the procedure a gastric bypass or a RNY.
Are there important aspects of the anatomy that help with long-term weight control?
Yes. The original size of the pouch is important—if it is too large it may enlarge substantially over time and result in
becoming a “second stomach.” The most common initial size of the pouch is 20cc, or about one ounce. The small
pouch must also be created in such a way that it has a small outlet. This outlet is also called a “stoma.”
For the gastric bypass, the surgeon should be meticulous in creating the outlet correctly since small differences in
technique may result in outlet, or stoma, enlargement. If the outlet is too large, food will not remain in the pouch
long enough to provide the feeling of satiety (lack of hunger). Maintaining that feeling of satiety requires keeping the
pouch stretched for a while after each meal.
Some surgeons believe that changing the length of the roux limb may result in additional weight loss. The roux limb
length is defined as the amount of intestine from the stomach to the hook-up (anastomosis) of the intestine. We may
increase the length of the roux limb in patients whose BMI is greater than 50.
Will I be able to eat normally after the gastric bypass?
You will certainly eat differently. Patients experience significant lack of hunger after the gastric bypass. This is most
significant immediately after the operation, but changes over time. Patients also become very full (satiated) after
eating small amounts of food. After a gastric bypass people generally are satisfied with the foods that they eat, they
generally can eat regular food (with the exception of sweets) and many of their previous cravings are gone. In the
first several months of the operation, patients have to adapt suddenly to their new eating style. There is a lot of trial
and error in food selection. Within a few months, eating is much easier.
I have a severe medical problem. Am I still a candidate for surgery?
High risk patients often have the most to gain from massive weight loss. Massive weight loss improves almost every
organ system. Surgeons at Einstein Bariatrics have successfully operated on patients who have been on the heart
transplant list, who have terribly controlled diabetes and who have a number of chronic medical disease such as
multiple sclerosis, Ulcerative Colitis, liver disease, etc.. You will need to discuss how your chronic medical condition
changes the risks and benefits of the operation with your surgeon.
Is there any pain with the laparoscopic operation?
Unfortunately, there is no way to eliminate pain after this operation. Immediately after surgery, patients do
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experience discomfort. However, all patients are walking and drinking the day of surgery. By the next morning,
patients often say that they feel they have done too many sit-ups and are simply sore. By the time patients go home,
most do not need pain medications.
Can this operation be reversed?
The surgeon at Einstein Bariatrics has managed thousands of bariatric surgery patients. Technically, the operation
can be reversed, but in practice, that is generally never required.
What happens to the bypassed stomach?
Nothing. It has a good blood supply and produces some very important enzymes and hormones. Nothing is removed
from your body after surgery – there is no need.
Do you accept my insurance?
Einstein Bariatrics accepts all insurance payments. You insurer may have specific exclusions to bariatric surgery.
Einstein Bariatrics will call your insurer for you to determine your coverage and any limitations on that coverage.
How long is the hospital stay?
80 percent of patients leave the hospital after spending one night, the rest typically leave after spending two nights
in the hospital.
I had a gastric bypass/lap/band/VBG/etc... several years ago and I have had problems (weight regain, reflux,
vomiting). Can I be seen for a possible revision of my surgery?
Yes, Einstein Bariatrics performs revisional surgery, although some insurers have onerous restrictions to some types
of revisions. We ask that you complete the registration packet and insurance information. Also, we require that all
patients who are evaluated for previous weight loss surgery obtain an Upper GI series BEFORE seeing the surgeon.
Also, if possible, the surgeon would like to old operative records. These records can be obtained by calling your
original surgeon’s office.
If I get pregnant will I be able to get enough nutrition for my baby?
Many patients have gotten pregnant after bariatric surgery. In fact, several studies have demonstrated that
significant weight loss can improve fertility.
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We strongly discourage all women NOT to get pregnant in the first year after the operation. This may cause
significant fetal problems as your body may not have enough vitamins and proteins stores for the both of you. After
the majority of weight is lost and you are nutritionally stable, pregnancy has been shown to be very safe. Overall,
there is no difference in fetal outcome after having bariatric surgery when compared to the general population;
however, follow-up with us is very important to ensure your nutritional status is acceptable to have a child.
Will I need plastic surgery after the procedure?
Patients who lose significant weight may require excess skin to be removed. There is not much a patient can do to
prevent this excess skin from becoming a cosmetic problem. Depending on how much weight is lost, this can amount
to 20 or more pounds!! We usually recommend waiting 18-24 months after surgery to have this performed if desired.
We can recommend plastic surgeons that are specialized in taking care of our patients.
What about Hair Loss ?
Temporary hair loss is expected to occur with weight loss - whether with Weight Watchers or gastric bypass. Usually
hair loss starts between 6 and 8 months after surgery and then completely re-grows. Hair loss is not patchy, nor is it
ever complete. Although there are a lot of remedies (biotin, protein, zinc, selenium, etc..) that are reported - none
have been proven effective in preventing hair loss.
How much weight loss should I expect? – Gastric Bypass
Weight loss after bariatric surgery is described as Percent Excess Weight Loss (%EWL). Excess weight is defined as a
person’s actual weight minus their ideal body weight (IBW). IBW can be estimated by the formula:
Men: 106+6*(height in inches-60)
Women: 100+5*(height in inches-60)
Example:
So, for a 5’5” woman, her IBW = 100+5*(65-60) = 125 pounds
If that woman weighs 325 pounds, her excess weight is 200 pounds.
If that woman loses 100 pounds, she has lost 50% of her Excess weight (%EWL=50%).
After a gastric bypass, the reported long-term weight loss varies from person to person. We can only estimate the
amount of weight loss. Also, keep in mind that many weight loss operations, including the gastric bypass have
significant weight loss in the short term. Long-term weight loss is much more important. On average, the %EWL after
6 months, 1year and 2 years will be 50, 70 and 75 percent. The average patient is female with a BMI of 48. There is
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significant variation, such that 95 percent of people will have lost between 95 and 60 percent of excess weight at 2
years.
So, a woman who weighs 325 who is 5’5” has a gastric bypass. She would be expected to lose 160 pounds at 2 years.
However, she could lose as much as 190 pounds, or as little as 120 pounds. There is one predictive factor in guessing
how much weight a person will lose. Patients who are very heavy and patients that are only slightly overweight, often
lose weight at a predictably different rate. For instance, a patient who weighs 600 pounds, will never achieve a
weight close to ideal with any bariatric operation. That person may lose 300 pounds, losing
60% of excess weight. Furthermore, a patient who weighs only 220 pounds would be
expected, on average to lose a higher percentage of excess weight that a person weighing 320
pounds. That is, the skinnier you are, the more likely you can achieve a weight closer to your
ideal.
It is normal and expected to gain some weight back after 2 years. The amount of weight
regain is difficult to predict. One person may not regain any weight; another may regain 30 or
more pounds. On average, patients regain 10-15% of their excess weight back in the long
term.
The Adjustable Gastric Band
The Adjustable band is a prosthetic device made out of plastic. It was FDA approved for the
treatment of weight loss in the middle of 2001 after being studied in the United States. There
are two brands of Adjustable gastric band, the Lap-Band System (by Allergan) and the Realize
band (by Johnson and Johnson). The Adjustable Band is an adjustable ring that is placed over
the upper stomach to create a small pouch. The ring is attached to tubing which itself is
attached to a port that lies under the skin. The tightness of the ring is adjusted during routine
office visits. If a patient does not experience adequate weight loss, fluid is added through the
port and the band tightens creating a smaller pouch and a sense of early fullness after meals.
If too much fluid is present such that the patient cannot tolerate any solid food, fluid is
removed from the band. Using these adjustments, the band can be fine-tuned for each
patient. Currently, thousands of Adjustable Bands are placed in the United States every
month. The Adjustable Band has some advantages over the gastric bypass. Firstly, the there
are little to no risks of vitamin or mineral deficiencies. Secondly, the risk for serious
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complications is much less. Lastly, the operation is entirely reversible. Unfortunately, the weight loss is significantly
less than that of the gastric bypass and without repeated adjustments, no weight loss would occur. Surgeons at
Einstein Bariatrics have performed and managed the Adjustable Band in hundreds of patients.
Frequently Asked Questions about the Adjustable Gastric Band
How many adjustments are necessary before I start losing weight?
Because of the special diet we place patients on after their operation, many patients lose some weight even without
any adjustments. The first adjustment occurs at 6 weeks post-operative. We wait that long in order to allow the band
to scar in place. On average, four adjustments are necessary before the patient is losing weight at an expected pace.
Some people need only one adjustment; others may need five or six.
1. How are the adjustments performed?
In the office, your surgeon or his assistant will clean the area on top of the port with alcohol and then numb
the skin with lidocaine using a small needle. A larger needle is then placed through the skin and into the port.
Saline is then injected at amounts decided on by the surgeon.
When do I know that I need an adjustment?
Are you losing weight? We expect an average of 1-2 pounds a week. Do you feel full after eating solid foods?
You should then have fluid placed in your band. Do you experience reflux or vomiting - then your band may
be too tight. Adjustments can be made every couple weeks as necessary.
What is the weight loss expectation with the Adjustable Band?
Is it used for weight control?
All surgical programs with enough experience to be called experts in Adjustable Band surgery seem to find that
patients will lose an average of 40% of their excess weight. The weight loss occurs over a period of 2-3 years, with the
majority of weight loss in the first year. Excess weight is defined as a person's current weight minus their ideal body
weight.
What are some of the potential complications of the Adjustable Band?
The Adjustable Band is a much less complicated procedure than the other bariatric operations. Because of this,
there are few potential complications possible immediately after placement of the Adjustable Band. There are some
long-term complications possible that are unique. First, the Adjustable Band can "slip." That is, the Adjustable Band
can twist out of position and cause reflux and difficultly with foods. Weight loss can be affected. This can be
diagnosed by an X-ray - however, only your surgeon will be experienced enough to diagnose this problem. A slip
occurs in 2 percent of patients and requires an operation to fix. The Adjustable Band has been known to erode into
the stomach. This occurs in 2 percent of patients. This can be a serious problem that requires an operation and
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removal of the Adjustable Band. Rarely, the Adjustable Band can become infected which is generally a cause for
removal. In previously designed bands, the port was found to fracture easily - this has now been addressed with a
new port design.
If I "skip" and drink with a meal or eat too much soft, high calorie food during one meal, have I "ruined the whole
thing?"
No. But do not make a habit of it.
How much weight loss should I expect? – Adjustable Band
Weight loss with the Adjustable Band is less than that of the Gastric Bypass. Weight loss is also more variable and
unpredictable. One patient may lose tremendous weight while another no weight at all. Weight loss, on average, is
about 40% of excess. So a 325-pound woman who is 5’5” tall would be expected to lose about 80 pounds.
Sleeve Gastrectomy
The Vertical Sleeve Gastrectomy is a relatively new
procedure that has been shown to be effective in
weight loss. A sleeve involves cutting the stomach into
a long skinny tube and removing the remaining
stomach. This procedure was first performed as a
stand-alone operation more than 10 years ago. It has
gained popularity over the last several years because
it is generally easier to perform and does not involve
intestinal re-routing as the gastric bypass. The weight
loss of the sleeve gastrectomy seems close to that of
the gastric bypass (or perhaps slightly less). Most
studies suggests that the risks of the sleeve are similar
to that of the gastric bypass. While not proven, the
sleeve may have fewer problems with ulcers and iron
deficiency anemia. However, there may be an
increased chance for gastro-esophageal reflux disease and vitamin B12 deficiency. There are some patients who may
be particularly great candidates for a sleeve gastrectomy – those with substantial prior abdominal operations or
those with very very high weights.
Surgeons at Einstein Bariatrics were some of the first in the country to perform the Sleeve Gastrectomy. The followup care and all instructions are identical to that of the gastric bypass.
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Frequently Asked Questions about the Sleeve Gastrectomy
Who should have a sleeve gastrectomy? This The sleeve gastrectomy seems to have similar weight loss to the gastric
bypass, and much greater than the adjustable gastric band. Some studies show the weight loss to be perhaps slightly
less, on average, than the gastric bypass. Also, most studies have shown the risks to surgery being nearly equivalent
to the gastric bypass. Furthermore, we have much better long term data on the gastric bypass than the sleeve
gastrectomy, such that it is possible that the long term weight loss may be found in the future to be less than the
gastric bypass. So, if the weight loss is nearly the same and the risks are the same, why should a person have the
sleeve at all? There are two major reasons to seriously consider the sleeve gastrectomy as your procedure of choice
for weight loss. First, the concept of having your intestines re-routed as in a gastric bypass may feel too radical a
procedure for you. The sleeve feels more comfortable for some patients. Secondly, some patients who have had
extensive prior abdominal operations may be at higher risk for post-surgical complications with a gastric bypass than
a sleeve. This is especially true for patients who have had previous intestinal surgeries or big hernia operations. Also,
a sleeve gastrectomy is easier to perform in patient who have very high a BMI or weight (greater than 500 pounds).
Are there any nutritional benefits to the sleeve gastrectomy compared to the gastric bypass? Although not proven,
there likely is less of a risk of iron deficiency anemia than with the gastric bypass. However, there may be a greater
chance of developing vitamin B12 deficiency.
Can you get dumping syndrome with the sleeve gastrectomy? The intolerance to high calorie foods – namely
desserts and really fatty foods, is due to food bypassing the lower stomach. Since this does not happen with the
sleeve gastrectomy, patients do not experience dumping syndrome after this operation. This fact may be one reason
why some studies show the weight loss with the operation as slightly less than the gastric bypass.
Are there complications that occur more often with the sleeve gastrectomy? Yes, there seems to be a greater
chance of reflux disease after a sleeve gastrectomy. Although reflux symptoms occur commonly initially after a
sleeve, in most people, this resolves quickly. There is a higher chance of injuring the spleen during the sleeve
gastrectomy. This may result in significant bleeding, conversion to a open operation and loss of your spleen. This risk
is small, however real. Also, there is a chance that the sleeve can be made too tight. This can cause lots of food
intolerance and may be difficult to correct without a major operation.
Are there complications after a sleeve gastrectomy that occur less frequently than a gastric bypass? Yes. The
chance of developing a bowel obstruction is much lower after a sleeve gastrectomy than a gastric bypass.
Is the sleeve gastrectomy good for diabetes? Yes, although it is not been proven yet to be as effective as a gastric
bypass. Some data suggests that improvement in diabetes may be somewhat less drastic than after a gastric bypass.
Well conducted studies comparing the two procedures have not been performed to date.
So how do I decide? In the end, we believe that for the average patient, the gastric bypass is the best procedure.
However, the sleeve gastrectomy is a close second. So close in fact that we are happy to enthusiastically support
most patients in whichever procedure they may chose.
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Is there a difference in the post-operative protocol after a sleeve gastrectomy compared to a gastric bypass? No.
Since the procedures are so very similar, there is no difference in any of the post-operative instructions. Patients who
have had a sleeve gastrectomy are difficult to distinguish from those that have had a gastric bypass in nearly every
way.
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Several of the main differences between the Adjustable Band and the RNY gastric bypass are summarized in the
chart below.
Adjustable Band
Gastric Bypass/Sleeve Gastrectomy
Complexity
+
++
Reversibility
Yes
Yes – but difficult and rarely done/ No
Early Complications*
Major complications very
uncommon.
Major complications uncommon.
i.e. bleeding, leak, swelling at stomach
i.e. Acute Slippage, Swelling
Possible late-term risks*
Band slippage, port complications,
erosions, esophageal dilation
Anemia, strictures, ulcers, vitamin
deficiencies, intestinal obstructions
Laparoscopic
Generally all
Nearly all (>99%)
Probable Weight Loss
40% excess weight.
60-90% excess weight.
May take 2-3 years.
Majority of weight lost in first year.
Insurance Coverage
Some plans
Many plans
Post-operative care
Band adjustments monthly –
average of four-to-six.
Standard appointments: 1-week,
1,3,6,12,18 and 24 months,
Life long follow-up.
then annually.
Life long follow-up.
Expected hospital stay
Outpatient or 1 night
One-to-two nights
Nutritional Deficiencies
None
Possible:
Iron, Calcium, B-vitamins,
Micronutrients
LifeStyle Management Program
At Einstein Bariatrics, we believe that successful patient outcomes are not solely based on the quality of the surgery.
Providing pre-operative education as well as long-term multi-specialty support to our patients is equally important
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Our registered dietitians, exercise specialists and psychologist offer educational tools that will help you.
Without exception, all patients associated with Einstein Bariatrics must use our recommended team of registered
dietitians and psychologists. The cost of these the consultation by the psychologist may depend on your insurance
company.
Pre-operative Tests
Initial Consultation
This consultation lasts about 1 hour. Your surgeon will discuss details about surgery, the benefits and the
complications. Before you can be scheduled for surgical consultation, you must have a completed registration packet.
Pre-operative tests will be ordered at the time of your consultation that may include:
A. Lab work: Every one is required to have specific laboratory testing
B. EKG: All patients must have an EKG performed
C. Sleep Study: many patients will be required to obtain a sleep study. Sleep apnea is a very common
disorder in overweight people. In patients with sleep apnea, blood oxygen levels can drop very low.
Complications such as heart arrhythmias, and heart attacks are common in this group of people. Although
inconvenient, this test is very important to your post-operative outcome. Patients with sleep apnea may be
at higher risk for certain complications. Diagnosing and treating this disorder before surgery may significantly
improve your post-operative course.
D. Stress Test/Cardiology: Patients at risk for heart disease will need a pre-operative stress test to decrease
the risk of any heart problems at the time of surgery. Often, before this test is performed, you must have
stopped certain blood pressure medications. Call the lab several days before you have this test to make sure
you are not taking a medication that would interfere with the study.
E. Other Tests: We require all patients to stay up-to-date with recommended medical tests – such as annual
mammography for women above the age of 40-50 and a colonoscopy every 5-10years in patients over the
age of 50.
Pre-operative Consultation
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Two weeks before surgery, a pre-operative consultation is required. The surgeon will review the consent form, preoperative diet and pre-operative testing.
A. All laboratory testing must be completed and available at least two weeks prior to the proposed surgery
date, to avoid postponing the surgery date. Your surgery will be postponed if we do not have lab results. If
laboratory studies warrant further testing, your operation may be postponed. All financial obligations
(surgeon and hospital) must be arranged before the surgical date.
B. Your consent and your exam must be read and completed before your pre-operative consults appointment.
C. Our specialists are adept at making sure your pre-operative studies are in order. They may find the need to
order additional tests depending on their findings and after interpreting the basic studies your surgeon has
ordered.
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Minerals and Vitamins after Weight Loss Surgery – Gastric Bypass/Sleeve Gastrectomy
Iron
The gastric bypass surgery typically results in only a minor amount of malabsorption. Iron is an especially important
mineral supplement to follow after a gastric bypass.
Iron is vital to the healthy exchange of oxygen from your lungs to your body. Iron atoms are incorporated in
hemoglobin, the major oxygen carrying protein in the body, and account for the red color of blood. Iron is present in
many foods and absorbed by the body. Without iron, the body cannot make healthy red blood cells and a condition
called iron deficiency anemia results. This anemia, when severe, can cause fatigue.
Gastric bypass patients are prone to iron deficiency because after surgery, food now bypasses the duodenum, the
most efficient area of the intestine that absorbs iron. Also, iron is more readily absorbed in acidic environments and
there is very little acid produced in the small gastric pouch. So, annual monitoring of iron and hemoglobin levels is
important.
In the majority of people, simple Multivitamin tablets contain an adequate amount of iron to prevent problems.
During follow-up test, some people are noted to have the beginnings of iron deficiency despite religiously taking their
vitamins. In these people (about ~15% of gastric bypass patients) a separate iron pill is necessary to take.
Premenopausal women and adolescent patients are most at risk for anemia.
One helpful hint: Iron absorbs better with vitamin C. So take your iron pill with your multivitamin. Iron absorption is
blocked by Calcium – so do not take your calcium and the same time as you take iron! Although some evidence
suggests that different formulations of iron (Iron sulfate, FeoSol, So-Fe, Iron Gluconate, Iron fumarate) result in
different absorption, the real clinical differences are not known. Some people experience minor side effects to iron
pills such as constipation. So if you are taking iron supplements, find the cheapest, tastiest formulation that doesn’t
cause GI upset. Take these supplements as directed and follow-up regularly with your bariatric program to ensure
healthy iron levels in your body.
Calcium
When bariatric surgery is performed in expert centers that stress long-term follow-up, most patients have little risk of
developing significant mineral and vitamin deficiencies. Calcium is an important mineral necessary for the
development of strong bones. Calcium is best absorbed in the duodenum – although the rest of the intestines also
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absorb calcium. Since the duodenum is partially or completely bypass after bariatric surgery, calcium deficiencies are
possible.
All patients after gastric bypass surgery should take between 1000mg and 1500mg a day of calcium to counteract the
decreased absorption from foods. This can be in the form of calcium carbonate (such as TUMS®, Viactiv®) or calcium
citrate (Citra cal), other various calcium citrate formulations can be found at Bariatricadvantage.com – a vitamin and
mineral on-line store. Calcium citrate has better absorption than calcium carbonate and may be especially good for
people who have had kidney stones in the past. Foods with high calcium content include milk, cheese, cottage
cheese, yogurt, broccoli, tofu, greens and eggs. Rare patients may need Vitamin D to enhance the Calcium
absorption.
With long-term follow-up, the earliest signs of calcium deficiency can be identified and reversed. One important
marker is the PTH level. PTH is a hormone the regulated calcium. If the PTH level climbs high, your body is in need of
more calcium. The PTH level should be checked once a year for life after gastric bypass surgery. Your bariatric
internist may even recommend yearly bone density measurements to monitor other early signs of calcium deficiency.
Calcium deficiencies can cause osteoporosis - or weakening of the bones. After the gastric bypass, decreased calcium
absorption may result in a higher incidence of osteoporosis. Osteoporosis develops only after years of decreased
calcium absorption.
Cobalamin (Vitamin B12)
Annual measurements of B12 levels and supplementation as necessary will easily prevent deficiencies. Vitamin B12 is a
very important factor in the formation of normal blood cells. Deficiencies in B12 can cause a special type of anemia
called “megaloblastic or pernicious anemia,” B12 deficiency is rare after a gastric bypass but can occur. Very severe
deficiencies can even cause neurologic problems.
B12 is a very interesting vitamin. It is only found in meats and requires a special enzyme called intrinsic factor (IF) to
bind to it before being absorbed. The stomach is the source of IF. Normally IF binds to the B12 in the stomach and gets
absorbed in the small intestine. After a gastric bypass, the IF is made in the “left-over” stomach – so it doesn’t bind
with the food immediately. The IF must first pass down through the duodenum, into the intestine where it will bind
to the B12 in foods.
The reason that gastric bypass patients are at risk for B12 deficiency is that acid is needed to break the B12 away from
the meat before it can bind to IF. There is only little acid produced in the new gastric pouch.
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Thus, after a gastric bypass, your body is able to digest and absorb B12 – some people just do not have enough acid in
their stomachs to pull the B12 away from the meats. B12 pill should work in people who need it after a gastric bypass.
B12 tablets that dissolve under the tongue bypass the entire system and get absorbed directly into the blood stream.
B12 injections are needed only in very rare cases.
Interestingly, B12 lasts in the body up to 6 months. So B12 deficiency takes years to develop. Reports suggest that B12
deficiency can occur in 12-33% of patients although deficiencies severe enough to cause symptoms are exceedingly
rare.
Thiamine
Thiamine is one of the B-vitamins. The B vitamin thiamine is essential for the metabolism of carbohydrates into the
simple sugar glucose. Significant thiamine deficiencies are very rare after a gastric bypass or a Lap-Band. In general,
patients with severe thiamine deficiencies have had a prolonged course of nausea and vomiting. There are lots of
potential symptoms of thiamine deficiency. These include changes in sensation of the toes and feet, irritability and
fatigue. In very severe cases, changes in mental alertness and heart disease may result. The thiamine stores are very
short lived and deficiencies can occur in just a few months. This is the reason why all patients after a gastric bypass
are required to take a multivitamin that is usually packed with B-vitamins. Thiamine is found in whole-grain cereals,
bread, red meat, egg yolks, green leafy vegetables, legumes, sweet corn, brown rice, berries, yeast, the germ and
husks of grains and nuts.
Other deficiencies are either extremely uncommon or of unclear significance. There are no reports (or perhaps only
extremely rare reports) of patients developing symptoms from or deficiencies in Zinc, Copper, Biotin, Selenium,
Riboflavin, B6, folic acid.
Pre-Operative Patient Instructions
1. Very low calorie diet for 2 weeks (or other length of time as discussed with your surgeon) prior to surgery.
The purpose of this pre-operative diet is to decrease the size of your liver, which can be markedly enlarged
due to excess fat accumulation. A smaller liver will improve the safety of the operation. This is not fun, but it
is important for your safety.
2. Plavix and Aspirin should be stopped at least one week prior to surgery unless specifically instructed
otherwise by your SURGEON. NSAID (e.g.: Aleve, Advil, Plavix, Celebrex, Vioxx, Ultram, Mobic, etc.) should be
stopped 48 hours prior to surgery. Regular Tylenol is okay. If you take Coumadin you must discuss this with
our medical doctors prior to surgery.
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3. If you take medications to control your blood sugar, you must discuss your diabetic regimen with our
physicians. Also, you will need to monitor your blood sugar carefully during your pre-operative diet to
prevent problems.
4. No herbal dietary supplements for 7 days prior to surgery (including Ginkgo Biloba, Ginseng, etc.).
5. Low calorie clear liquids only during the day prior to surgery (ex: water, broth, low-calorie clear juice, ginger
ale, Gatorade, Kool-Aid, strained fruit juices without pulp, apple juice, white grape juice, lemonade, low
sodium chicken broth, etc.). Desserts: Jell-O (lemon, lime or orange; no fruit toppings, Popsicles-no sherbets
or fruit bars). All should be sugar free or low sugar.
6. Other than the medications listed above, take all of your regular home medications up to the morning of
surgery with a sip of water. Otherwise, nothing by mouth, no food or beverage, after midnight on the
evening prior to surgery.
7. You will not be able to drive for about 1 week following surgery.
10. All women must observe strict birth control methods for 18 months after surgery corresponding to the time
of greatest weight loss. Please ask if you have any questions.
Other Common Questions
1. Can I chew gum? – Yes. Sugar free, of course.
2. Can I drink with a straw? – Yes. Not a Problem. Not sure why that myth is out there.
3. What can I drink in the first week after surgery? Any liquid that pours, that is not carbonated
and doesn’t have a lot of sugar.
4. Can I drink Soda? Yes, but it is not recommended. Wait at least a month after surgery. And
know that it is going to give you a lot of gas.
5. Will my stomach Stretch? No, it will not. This doesn’t not really happen – even though it is
commonly talked about.
6. It a month after surgery and I am uncomfortably constipated. What do I do if I am
constipated? It is normal to only have a bowel movement every few days. They’re a number of
things to do if you are severely constipated. Firstly, try Metamucil wafers or powders. Second,
you can try docusate which is a stool softener. Lastly, you can try a more potent laxative. In
order of increasing potency, you can try Milk of Magnesia, Magnesium citrate or Fleets
Phosphosoda. Use as directed on the bottle.
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7. Is smoking bad for me? Smoking and the gastric bypass do not mix. Smoking can cause
serious life threatening complications. Stop smoking immediately and ask your primary care
doctor on tips on how to quit.
8. I want to get solid foods, when can I do so? Follow the phase diet instructions. No
exceptions. If you eat something that gets stuck, you will feel extremely uncomfortable for
hours. Do not do it.
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PHASE DIET INSTRUCTIONS
***FAILURE TO FOLLOW THESE INSTRUCTIONS CAN INCREASE YOUR SURGICAL COMPLICATION RATE, AND CAUSE
SIGNIFICANT DISCOMFORT**
Pre-Operative Diet: Two Weeks before Surgery

All of our patients have some degree of fatty liver disease. In many patients – the liver size is can
be more than double that of normal due to the storage of fat in the liver. Since the liver lies over the
stomach, a pre-operative diet will improve our ability to perform the procedure safely.

Select a protein supplement
1. Less than 200 calorie per serving
2. Greater than 14 grams of protein per serving
3. May contain vitamin and mineral supplement. Make sure the shake does not contain ephedra or
any other herbal drugs.
4. Examples of acceptable options are: GNC-Pro Performance Whey Protein shake/powder, RiteAide-Designer Whey Protein, Prostat, Ultra Pure Protein, HMR, etc.


Drink 5 protein shakes per day.

The goal is to provide approximately 800 calories/day

Minimum of 50-gm/day proteins for women and 80-gm/day proteins for men.
Eat low calorie items including broth, diet jell-o, sugar-free popsicles and non-starchy vegetables
such as lettuce, bell peppers, carrots and onions. Calorie-free salad dressings are acceptable. An
example of a calorie free salad dressing is Walden’s Farm, vinegar is also allowed.
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
Drink only Calorie free liquids such as; Crystal Lite, sugar free Kool Aid, diet ice tea, diet soda

Start taking two multivitamins a day. If you are anemic, our team may also recommend
taking additional iron supplements.
One Day before Surgery

Stop drinking protein shakes and eating low calorie items.

Begin drinking only sugar-free, or low sugar, clear liquids: Crystal light, Popsicles, Jello, broth, Diet
7-Up, Diet Sprite, fruit ice, and small amounts of coffee or tea.

Do not eat or drink after midnight during the night before surgery.
Postoperative
The goal during the post-operative diet phases is to allow a period of time for the stomach to heal. After
surgery there is swelling at the surgical site and this gradually decreases over 30 days. During this time, food that
gets stuck at the surgical site may induce vomiting. Therefore, please follow the Phase Diet Instructions for one
month following surgery. The instructions below call for 14 days of liquids, followed by 14 days of pureed-type foods.
Phase 1: LIQUID STAGE 0-14 days from Surgery

The only goal is to stay hydrated. Do not worry about calories. You can only drink as much as your
body tolerates. This amount will increase every day. Below are GOALS – you may not achieve
those goals for several weeks.

For the first week drink clear liquids, you can gradually add in milk- based products into your diet.

Drink liquids slowly. Take a few sips, then wait 1-2 minutes for stomach to empty.

Drink at least one protein shakes per day to supplement protein intake.

Eat low fat soup, skim milk, dilute cream of wheat, cream of rice cereal (not rice!), sugar free
pudding, sugar free jello, popsicles.

Between meals or snacks, drink calorie-free beverages such as water, Crystal-Lite, diet Snapple,
Propel, etc. Do not drink any carbonated beverages.
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
Your goal is to drink 64 oz. of liquid per day. You may not achieve this goal for several weeks.

Take chewable vitamin mineral supplements beginning one week after surgery.
- 1500 mg calcium per day (Viactiv, Tums, etc.)
- Take multi-vitamin supplements every day. Other options include Flintstone Complete, Centrum
Chewable or any liquid or chewable supplement providing 100% of the RDA for iron, thiamine,
riboflavin, B12 and other B vitamins.

Phase 2
- Gastric Bypass patients may need to take Iron Supplements for life – depending on
the advice of the surgery team.
PUREED/BABY FOOD CONSISTENCY: Weeks 3 & 4 after Surgery

The goal is to stay hydrated and improve your PROTEIN intake.

Your goal is to drink 64 oz. of liquid per day.

Continue to take your vitamin supplements and calcium as directed above.

Try and take two to three protein shakes per day to supplement your protein intake.
1. Eat high protein items first at meals: Cottage cheese, low fat soups, light yogurt, as these are
tolerated start adding puree chicken, turkey fish, eggs. (baby food consistency)
2. Eat vegetables next: pureed or ground up vegetables
3. Starches during this phase include: cooked cereals, pasta, sweet potatoes or mashed potatoes.
4. Snack on fruit. Mashed or pureed canned fruits, make sure the fruit is mixed in their own juices, not
in heavy or light syrup. Fresh fruits are not allowed at this time.
5. Try and get a minimum of 50-70 grams of protein per day.
Phase 3
Normal consistency foods. Eat when you are hungry and stop when you are full.
General Guidelines
 The goal is to begin to eat normally over the next couple months.
 START SLOWLY – YOU WILL NOT LIKELY BE ABLE TO EAT RED MEATS AND BREADS IMMEDIATELY.
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 Trial and error is the key. Many people will take several months before they are truly on an
unrestricted diet.
 Try one new food at a time. If you have trouble – wait a week before trying again.
 Eat when you are hungry. Some people rarely get hungry. If that is the case, try and eat 2-3 small
meals a day, which are high in protein.
 Avoid Grazing on foods all day!
 Drink calorie free beverages in between meals.
 Drink at least 2 quarts of calorie-free beverage per day. NOT DRINKING ENOUGH CAN PUT YOU AT
RISK FOR DEVELOPING KIDNEY STONES.
 Overcooked and dry meats are hard to eat after surgery.
 Bread only in very small quantities, if at all. Breads will tend to get “Stuck.”
 Carbonated beverages will sometimes cause increased gas and bloating.
 Chew well and eat slowly

Stay away from simple sugars such as: cookies, cakes pies, candy.
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Protein guide
Protein is the main substance that the body uses to build and repair tissues such as muscles, blood, internal
organs, skin, hair, nails, and bones.
Recommended protein intake is 50-70 grams
per day.
Meats
Grams of Protein
Better Choices
1 oz of Chicken, turkey
7
White meat, breast, no skin
1 oz of roast beef, pork
7
Sirloin, ground round, fresh
ham
1 oz Fish
7
Fresh or frozen cod, flounder,
haddock, halibut, trout, tuna fresh or
canned in water, salmon
1oz of Shellfish
7
Clams, Crabs, scallops, shrimp,
lobster, imitation crab meat
1 oz Game, Veal, Lamb
7
Duck or pheasant (no skin),
venison, buffalo, ostrich
Cheese
Grams of
Protein
Better Choices
1 oz of cheese
7
Reduced fat cheese with less
then 5 grams of fat per ounce
¼ c. of Cottage Cheese
7
Fat Free or 1% fat
¼ c. Ricotta Cheese
7
Fat Free or Low Fat
Dairy
Grams of
Better Choice
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Protein
Milk
8
Fat Free or Low Fat (1%)
Mighty Milk
14
Skim or Low Fat milk with 1/3
cup of dried milk mixed in
Soy Milk
8
Low Fat, Calcium Fortified
1/3 cup of powder milk
7
¼ c. Yogurt
3
Non-Fat or low fat, flavored with
a nonnutritive sweetener
Eggs
Grams of
Protein
Better Choices
1 Large Egg
7
2 Egg Whites
7
¼ c. Egg Substitute
7
Beans and Soy Products
Grams of
Protein
Better Choices
½ c. Beans and peas
3
garbanzo, pinto, kidney, white,
split, black eyed peas
½ c. Tofu
7
2 Tbsp peanut butter
7
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What to expect in the hospital
You have finally made it to the day of surgery! This is the most exciting day - and day with the highest anxiety.
Knowing what to expect will help you and your family tremendously.
Admission
The first place to check in after you arrive at the hospital is the admissions department. They will check you
into the hospital and send you to the pre-operative holding area.
The pre-operative holding area
You will first meet the nurses who will ask you to change into a hospital gown. All of your office paperwork
(labs, tests and records) should have been faxed from our office to the pre-op area. Once you have changed, the
nurses will put an IV in your arm. Through this IV, you will receive fluids and medications. The anesthesiologist will
then speak to you about the type of anesthetic and medical history. You will see your surgeon before your operation.
Once you are ready for surgery, you may receive some light sedation. The wait time for the OR may be a few
minutes, or, if the previous cases were delayed, there may be a wait of a coupe hours. We understand that waiting
can cause anxiety and we hope that long waits are uncommon.
The operating room
You will first be asked to move from the gurney to the operating room bed. This bed is very narrow. A
circulating nurse will be in the room and help position you on the operating room table. There will be a scrub nurse in
the operating room dressed in a sterile gown. The scrub nurse will be preparing all the equipment necessary for the
operation. The anesthesiologist will place monitors over your heart and place a mask of oxygen over your mouth.
Once he is ready, you will be put to sleep. Most people do not remember much of their operating room experience.
Your surgeon, with his assistant will perform all aspects of the operation. Your assistant may be another surgeon, a
physician’s assistance, a nurse practitioner or a surgeon in training.
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Although almost all patients wake up in the operating room, they are typically too drowsy to remember
anything until the recovery room. You will typically stay in the recovery room until you are awake enough and
comfortable. Your vital signs will be closely monitored as well. You will not be able to see your family until you leave
the recovery room. Typically some blood work is drawn in the recovery room.
The Bariatric Floor
The Bariatric Floor is where you will spend the remainder of your hospital stay. Bariatric nurses will monitor
you once you arrive to the floor. Although almost all of our procedures are performed laparoscopically, there is still
some discomfort involved. Pain usually resolves to a minor level after a few hours. Pain is controlled through a “PCA,”
or patient-controlled analgesia. A PCA is a special pump that contains a narcotic (typically morphine). Every time you
press a button, a small dose of morphine is given through your IV. The PCA is very convenient because you do not
have to wait for a nurse to receive pain medication. Every patient will have his or her blood sugars monitored in the
hospital. If your blood sugar immediately after surgery is elevated and you require a small dose of insulin – do not be
alarmed. The body normally will boost blood sugars as a response to the stress from surgery. Good control of blood
sugar prevents infections.
The day of surgery, typically all patients are required to walk the hallways assisted by the nursing staff. The
first times up, patients may experience some dizziness from the medications received during surgery. Also, once
awake, you will be started on sips of water. Patients who have had the Adjustable Band procedure often go home the
same day as their procedure.
The day after surgery you will be started on a Phase I diet. If you tolerate this well, then your IVs will be
discontinued, your PCA will be removed and you will be started on Tylenol with Codeine for pain management.
Throughout the day, your pain should become minimal and your energy level should improve. By the afternoon, most
people feel good enough to go home. Some people complain of cramping and bloating, or still are fatigued from
surgery and require an additional night in the hospital.
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Discharge Instructions
General Instructions
1. Feeling tired: You have had major abdominal surgery, with general anesthesia, and it is normal to
“drag”, feel fatigued, or to feel like the wind has been taken out of your sails for a period of 1-3
weeks from your surgery date, but you should slowly regain your strength and endurance. When in
doubt about what to do use common sense or, if necessary, you can call us.
2. Shower: You can get all of your incisions wet after leaving the hospital. We recommend that your
refrain from soaking in a tub or swimming for 1 week.
3. Activity: If you are comfortable doing a particular activity than it is OK. You cannot rip, pull or tear
anything done in surgery. If it hurts – don’t do it. You may walk as far as you feel like, but do not over
do it. When you feel tired or start hurting, then stop and rest. You may go up or down stairs
immediately, but remember to move slowly and deliberately, especially for the first few days. Sit-ups
and weight training may be started two weeks after surgery.
4. Incisional Pain: Although many of our patients have little or no pain by the time they are discharged
home, everyone responds differently. It is normal to have some abdominal wall pain, incisional pain,
pain sometimes along the rib margins, muscle spasms, and other “aches and pains” related to this
surgery. Take your pain medication when necessary and sometimes a heating pad or hot water
bottle is helpful, but be careful not to burn your skin. Call us if your pain seems to be increasing.
5. Bloating and Gas pains: It is normal to have bloating and crampy pains starting around 2 days after
your surgery. These pains may last 24 hours. Once your bowels start working, the discomfort usually
resolves quickly.
6. Sex: Waiting around a week is advised only because you may be sore.
Driving A Car and Returning to Work
7. Driving a car: You should not drive a car while having pain or taking pain medication. Your reflexes
and response time may be affected.
8. Time off of work : One-Two weeks after laparoscopic surgery. This may vary on an individual basis.
We recommend planning for two weeks off. We will not give more than 2 weeks off of work unless
there is a specific medical need as determined during the post-operative visit.
Medications
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9. You can resume your regular medications once you return home. This especially includes
medications for blood pressure and depression.
10. You will be able to take any of your medications whole. There is no need to crush pills.
11. If you take medications for diabetes, you should be very careful to check your blood sugar frequently
after surgery to prevent hypoglycemia. You will need less medication for diabetes after surgery.
12. Frequent NSAIDS are to be avoided for life after bariatric surgery. If you have a medical condition
that demands taking these drugs, you should only take them for a limited time (less than one week)
or you should check with your physician about taking anti-ulcer medications.
13. Minimize unnecessary pills after surgery.
14. Needs for medications to treat Cholesterol, High Blood Pressure, Diabetes, Heartburn, Arthritis and
other ailments will often decrease dramatically over the first several months after surgery.
15. You can wait 1 week before starting your vitamins.
16. Pain Medications: You will be given an oral narcotic pain medication, Tylenol with codeine elixir. We
will prescribe alternatives if you are allergic to codeine or have specific other medical needs.
Initial Post Operative Diet
17. Follow the Phase Diet Instructions strictly and without exception.
Vitamins and Minerals
18. After gastric bypass surgery, you MUST take vitamin and mineral supplements for life. This is NOT
optional! Calcium and iron are normally absorbed in the area of intestine which is bypassed. Failure
to take additional amounts of these nutrients in the diet could eventually lead to medical problems.
19. Vitamins
A. Calcium
1. 500mg of Tums three times a day.
2. Calcium Citrate has better absorption.
B. Multivitamin
1. We recommend taking two Multivitamins.
2. Alternatives include two chewable or liquid adult formulation multivitamins a day of
your choice.
C. Iron- required in pre-menopausal women or if indicated by bariatric team
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1. Ferrous Sulfate (FeSO4) 325mg PO once a day
2. Ferrous Gluconate one tablet PO once a day
3. Most common complaint is constipation and GI upset. Because of this complaint, we
do not routinely give iron. Pre-menopausal women should take iron however starting
a month after surgery.
B. Follow-up care:
1. Gastric Bypass / Sleeve Gastrectomy
A. 1 week post-op check
1. Purpose: To ensure your physical health and provide education
B. 1-month, 3-month, 6-month, 1-yr, 18-month and 2-yr
2. Adjustable band
A. 6-week follow-up for an adjustment
B. Monthly for the first six months and then as needed.
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What to know the first few days after surgery
For any questions or concerns – call the office. Twenty-four hours a day, seven days a week a bariatric surgeon is
available.
Signs of a Leak
A leak is the most worrisome complication after a gastric bypass. A leak should always be considered as a potential
diagnosis when patients call with any type of compliant. A leak most commonly occurs in the first days of surgery.
Rarely, leaks can be diagnosed in the first days after discharge to home. Your surgeon is the only person that is
qualified to diagnose and treat a leak. A leak always is evident by significant symptoms. Patients that feel good, do
not have a leak. Symptoms of a leak include severe, worsening chest pain and shortness of breath, a racing heart,
fevers, inability to tolerate liquids and severe abdominal pain. Patients with a leak have no doubt that something is
wrong. If you think you may have a leak- call us. If you are unsure – call us.
Vomiting
If you vomit or you are unable to tolerate drinking liquids. Call us right away.
Malaise
It is normal to feel slow after surgery – almost like recovering from the flu. But if you are getting worse every day or if
you are simply not thriving at home. Call us right away.
Depression
There are patients that experience something like the “baby-blues.” This emotional period after surgery is caused
both by temporary chemical imbalances after surgery and the psychological stress of forced dietary change. Please
call your surgeon if you have significant symptoms of depression and need help.
Fever
If your temperature is MORE than 101.5 F, call us right away. Temperatures less than 101.5 are typically not
significant.
Lightheadedness
If you feel dizzy when you stand up, you may be dehydrated. Try drinking more fluids. If you are taking blood
pressure medications, stop them and call the office.
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High blood sugars
Diabetics should have remarkable improvements in their blood sugars after surgery. If you are a diabetic, you should
monitor your blood sugar closely and if greater than 200, call your doctor that manages your blood sugar. If you are
unable to reach that person, call your surgeon.
Shortness of Breath
If you develop sudden-onset chest pain and shortness of breath, call your surgeon immediately.
Leg swelling
Call the office immediately if you have significant leg swelling. A blood clot that develops in your leg can be
associated with swelling and pain, especially in the calf.
What to expect the first week after surgery
So you were discharged after 24-48 hours from the hospital. You felt pretty good in the hospital and you
arrived at home. Now what?
The most common complaint after surgery is fatigue. You are going to feel exhausted for a few days (rarely,
weeks). This is normal and part of the healing after major surgery.
At home, your pain should become minimal very quickly. In fact, many people do not require pain medication
after the first couple days. You should not develop shortness of breath or chest pain. Minor shoulder pain is expected
– and this is pain referred from your diaphragm. You should not develop any leg pains.
You should not have any significant nausea and you should NOT throw up on liquids once you get home. Call
the surgeon immediately if you are unable to tolerate liquids.
Your first bowel movement may come anywhere from 2-5 days after surgery. There should be no significant
blood in your bowels. If your bowels are deep tarry black – call the surgeon immediately. If there is bright blood in
your bowel movements, call the surgeon immediately. Your first bowel movements will typically be loose. You may
have several loose bowel movements a day for a week. Once your bowels start working, any cramping and bloating
you have should resolve.
Your incisions may drain clear or yellowish fluid for a couple days. Rarely, patients may have significant
drainage of pinkish fluid. None of this drainage is serious or significant. Infections in laparoscopic wounds are rare.
And when they do occur, they are usually self-limited and minor. If you experience significant growing redness that
radiates several inches from the wound, this may represent a wound infection. Sometimes, the small wound doesn’t
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heal well and the incision opens up. This is not of any concern. An open laparoscopic wound will heal well, does not
need stitching and requires no antibiotics. You have absorbable sutures underneath the skin. Sometime a little bit of
the knot of the stitch peeks out of the corner of the incision. This is nothing to worry about. Your steristrips will be
removed at the time of your follow-up appointment.
Believe it or not, despite your very low calorie intake, you may not lose that much weight the first week. This
is very common considering the amount of fluid you received in the hospital.
Remember, the key is that patients should be feeling better and better every day, if not- CALL! You should
be scheduled to see your surgeon after 1-2 week surgery for a checkup. Our office number works 24/7!!