Gastric Bypass: Post Op Appointments

• Surgical Followup
• Side Effects
• Diet Following Surgery
• Cottage Cheese Test
• Keys to Success
• Support Groups
• Gastric Bypass: Discharge Instructions
• Adjustable Gastric Band: Discharge Instructions
• Gastric Bypass: Post Op Appointments
• Adjustable Gastric Band: Post Op Appointments

First office appointment after surgery

These guidelines are written for 7-10 days after release from the hospital, or 1-2 weeks after the day of surgery.

What you are likely to be experiencing

Pain

You probably have moderate pain, or maybe soreness, at one or more of your incisions.  The incision on the lower left is most likely to be sore, since it has the largest incision in the muscle.  You can help the pain resolve most quickly by steadily increasing your physical activity.  It turns out that a substantial part of the pain comes from the stiffness of decreased movement, so walking and other gentle but increasing activity will help work these sore areas out.

Confusion about appetite

Most patients do not have hunger at this early time after surgery, though many have experimented with various soft foods.  Some patients do experience “hunger pangs" or stomach “growling" that seems to be satisfied by food.  First of all, don’t worry if the concept of hunger is a bit confusing for now; the nerves of hunger attached to your stomach are irritated and “stunned" by the recent surgery.  You will feel normal hunger again, though it may be several weeks or even a couple of months from now.

Each person’s experience is unique so it is impossible to give general advice except:  do your best to “listen" to your stomach pouch and let it guide you about when to eat – don’t listen to your old habits, or TV commercials, or your Mom, or any other outside influences.  Most people find that they will successfully learn the new type of hunger sensation, allowing them to feel well and lose lots of weight.  If you are not sure, the best move usually is to drink liquids and avoid food – most people feel better the less they eat.

Irregular bowel movements

Any degree of bowel function may be seen at this time, ranging from constipation to frequent loose BM’s.  Most will settle into a pattern of a BM every 2-5 days after a while.

Your main goals at this time, and new instructions

If you are progressing without undue difficulty, your next planned appointment will be in about one month.  These are the general guidelines for that time period.

Fluids

It may be difficult to get in enough fluid to maintain adequate hydration during this time.  You must take small sips on a near-constant basis, keeping fluid within reach at all times.  You will know you are taking enough fluid if you pee several times each day, and if the color of your urine is very light, almost like water.  At this stage, most patients find they can’t eat and still get an adequate amount of fluid to drink.  The main priority at this time after surgery is fluid, more than food.

Vitamins

You should have begun your regular routine of Multivitamins with Iron twice per day, and supplemental Calcium.  We’d also like you to take a B₁₂ “dot" that absorbs under your tongue once each day.

Diet progression

Over the next month you will probably get hungry from time to time.  It is OK to begin trying any kind of healthy food, including crunchy vegetables and seafood or meats.  It must be emphasized that you should only try something if it appeals to you.  The goal of learning is to find the least amount of eating that will give satisfaction, not to find out how much you can hold.  This means if you are not hungry, don’t eat.  If you are not hungry all day, don’t eat all day.

Exercise and physical activity

As long as you are not experiencing any complications, the surgeon will release you from any medical restrictions on your activity.  For now, you are likely to be sore and you will limit yourself somewhat, but this soreness will pass over the next several weeks and it is a good thing for you to steadily increase your physical activity.  Basically, if the activity does not hurt it is OK to do it.  The following activities are frequently questioned, and they are OK to restart as long as you do not experience pain:

• Driving (if you are not requiring pain medication)
• Sex
• Lifting
• Going up and down stairs
• Aerobic exercise such as walking, treadmill, or bike.

Speak to your surgeon about your work situation.

What may happen before your next appointment

Fatigue

About 1/3 of the time, a patient’s physical and mental energy will drop significantly around 2-4 weeks after surgery.  This is a fairly natural response to the stress of surgery, combined with the semi-starvation being imposed on your body.  The fatigue and emotional distress will pass naturally with some time, but we firmly believe that exercise helps the body shake off this protective phase more quickly.  For more on this problem, check the page on side effects on our website.

Nausea, vomiting, or intolerance to foods that “worked before"

Most patients find that if they stick to very small amounts of food or liquid, they handle things OK for the first several weeks.  About 1 in 10 patients experience setbacks in their diet tolerance between 3-5 weeks after surgery.  They find that foods that worked well previously (eggs, yogurt, beans, etc.) begin to cause pain, nausea, and vomiting.  Some patients say that the smell of food begins to bother them.  Patients who throw up usually feel a bit better, though the pain and nausea can last for several hours after eating.  What happens is that sometimes the healing process of the stomach pouch and the small intestine causes the connection (the stomach outlet) to scar down and become narrow.  Over 10-14 days this will soften and open up again as the healing process continues, so our usual advice is to ride through this phase by switching the diet back to thin liquids only (water, tea, Kool-aid, Gatorade, etc.).  On rare occasions, the outlet narrows so much that the patient cannot even keep liquids down, and in this case you should call the office to discuss the situation before you become dehydrated.

If you cannot take in liquids, we will make arrangements for you to be seen by one of our GI doctor colleagues so that he/she can look into your stomach pouch using a scope passed down your throat – if necessary a balloon can be used through the scope to stretch the outlet and allow consumption of liquids while the healing process resumes.  While we certainly don’t desire that this upper scope procedure be necessary, we can reassure you that most patients are not bothered by it.

Call us if you experience any of the following:

Fever

Many patients run a “low grade" temperature in the range of 99 or 100 degrees, and this is usually a stress response of the body to surgery.  On the other hand, a temperature of 101 or higher may be an indication of a significant problem and if you experience this you should call us.

Intolerance to liquids

We are not really worried about how much food you eat for now, and even zero food is OK for a few days in a row.  On the other hand, you need to maintain your body’s hydration, so if you ever experience more than about 10 hours of inability to handle water or other thin liquids you should call us.

Shortness of breath

In the first few weeks after surgery you will get “winded" easily while walking or doing other physical activity, and this is OK.  On the other hand, if you suddenly have difficulty catching your breath while you are sitting still or doing minor physical activity, this may represent an emergency called a pulmonary embolus (PE for short).  This is a situation where a blood clot that formed in the large veins of the leg around the time of surgery breaks off and floats to the vessels of the lung – this is potentially serious, or even fatal.  The risk decreases steadily after surgery, but the potential remains up until around 6 weeks after post-op.  If this happens to you, go immediately to the nearest Emergency Department and tell them that you might be having a Pulmonary Embolus.  Call us from the ER, or after the fact, but the first priority is to go and be evaluated.  The good news is that PE is very rare and most such ER visits turn up negative, but there is no way to know until being evaluated medically.

Your best way to prevent a PE is to exercise – walk early after your surgery, and walk often.

 

Second office appointment after surgery

At this point, you should be at about 1 month since you were last seen in the office, or

5-6 weeks out from your surgical date.

What you are likely to be experiencing

Pain

Most pain should be resolved by now, or at least improving steadily.

Appetite

You may be getting an idea of what hunger feels like for you.  Most patients eat 1-2 tiny meals each day, though (as always) you should not force eating even this little bit if you are not hungry.

Energy

Most patients are experiencing a steady improvement in their energy level, and overall sense of well-being.  This improvement is usually best in patients who have begun a regular exercise program.

Your main goals at this time, and new instructions

If all is going well, your next planned appointment will be planned for about 3 months from now.

Exercise

The level of exercise tolerated varies dramatically between patients.  The general goal is for all patients to try regularly to do more each day, until they are doing at least 20-30 minutes of brisk activity at least 5 times per week.  Don’t let yourself be put off by this goal; do what you can and know that every little bit helps.

Shift to solid proteins

Between now and your next appointment, you should be experimenting with solid proteins (seafood is usually easiest, then poultry, then red meat) and gradually making these the foundation of your diet.  Still, we are not instructing you to force eating any food – the idea is to try these types of food in tiny amounts at first and gradually transition to them as tolerated.  Most patients find that chicken or similar foods act “big" inside the stomach, and sit “like a brick" for many hours after being eaten.  You should recognize that these effects are good – if you eat solid protein then your hunger will be satisfied by a tiny amount of food (better weight loss) that contains nutrition.  As your diet “normalizes" you should minimize carbohydrates, whi*****lude starches such as potatoes, rice, bread, and pasta.  You should also avoid fruit juices because of the natural sugar included.  Fresh fruits are OK in small amounts – these should be thought of as “dessert."

Stay hydrated

It may still be a struggle for you to take in all the fluid that your body needs.  You will know if you are succeeding by observing the color of your urine; very dark urine indicates that your body feels dry and is trying to hold onto fluid.  Your goal is to give your body plenty of fluid to work with, so that you put out very light colored urine, almost like water.  If you have not developed the habit of keeping fluid close at hand all the time, try to work on this.  If food is getting in the way of taking in enough fluid, then cut out the food.

Take pictures every month

Many people find it is difficult to change the self-image as they shed dramatic amounts of weight.  Most find it is helpful to have pictures that objectively demonstrate the change in appearance as the weight comes off.

Checking routine blood work

We will want to check screening labs just before your next appointment.  Your surgeon or the staff should give you instructions about arranging for the labs to be drawn prior to the appointment, so that the results are available at the time you are being seen by the surgeons.

Work

If you have not yet returned to work, you should discuss the timing with your surgeon.

What may happen before your next appointment

Hair loss

About half of our patients notice profound hair loss at 3-5 months after surgery.  The change can be quite worrisome; the hairbrush fills every time, the shower and clothes and car are all covered with hair, etc.  We believe this is caused by a response of the body to the stress and semi-starvation of the first few weeks after surgery.  The hair loss begins as the hair roots “wake up" and begin to grow new hair, which pushes out the old.  The hair loss usually lasts for 4-8 weeks.  We do occasionally see patients whose hair visibly thins a bit, but no patients have required wigs.  Your hair will return to its normal thickness (probably with improved texture) over time.  It is not necessary or beneficial to take extra vitamins or protein to “treat" the hair loss.  For more about hair loss after gastric bypass check our website on the side effects page.

 

3-5 months after surgery

What you are likely to be experiencing

Appetite

You are probably getting hungry on most days, though not necessarily for 3 regular meals every day.  You can probably handle a variety of foods, though you likely still have the occasional episode of pain or nausea or vomiting if you try to eat something that does not “work."

Energy

Most patients have a high energy level at this point after bariatric surgery.

Self image issues

Many patients have difficulty changing their internal self image to match the dramatic external changes that are taking place.  We do not have an ideal answer to this problem, though we believe that taking pictures of yourself each month does help.

Relationship changes

Your changing appearance will inevitably and significantly alter all of your important relationships:  most patients report that they are treated very differently by spouses, co-workers, friends, and family.  Some may welcome your changes, others may be threatened.  Many will expect more from you, now that you appear more capable.

More time on your hands

You may be finding that food was not only a means of sustenance, but that food and the activities around it (shopping, preparing, eating, etc.) were like a hobby or a companion for you.  Now is the time to choose positive ways to fill the time void you may be experiencing where food used to be.

Finding that weight loss is not “fixing" your life

Some patients come into the gastric bypass while experiencing profound disappointment in relationships, work/career, or other areas of life.  Those who hope that weight loss will turn those areas around are usually beginning to experience recurrent disappointment at this stage.

Your main goals at this time, and new instructions

Your body and your stomach function will continue to change, but at a much slower pace.  You should be working to solidify your new lifelong weight control habits.  Unless you are experiencing difficulties, your next appointment is likely to be about six months from now, close to one year after surgery.  After that, we will expect that you check in for routine followup on a yearly basis (or sooner if needed).

Exercise and Diet (Keys to Success)

It is time to re-examine the habits that you have built so far to get the best results out of your stomach pouch “tool."  Your surgeon and the supporting staff will give you feedback on the progress of your weight loss and where you are likely to “settle out."  You should receive an additional handout called the “Keys to Success" that describes the optimum use of your pouch/tool.

Fiber

Your intestines (especially your large bowel) are evolved to handle a significant amount of bulk in your diet.  The simple fact is that your little stomach pouch will not let you consume enough bulk (in food) to ensure optimum function over time, possibly leading to severe constipation or a slightly higher chance of diverticular problems.  When patients are handling solid foods well (usually at about this time) we recommend that they begin taking supplemental fiber as part of their daily routine.  We think that any product containing psyllium seed or psyllium husk should be OK – commonly available products include Metamucil, Fibercon, Benefiber, and Citrucel.  We find that the powder forms of supplemental fiber give more reliable results than the tablets.  We recommend you take 1 tablespoon of fiber, twice each day.  Last, make sure you are drinking plenty of liquids – hydration is also a key to staying “regular".

Vitamins, Iron, Calcium, and B₁₂

Don’t slack up on those vitamins just because you feel good overall!!  You will need these supplements daily for life.  Check with our dietician if you are not clear about what supplements you should be taking, going forward.

Routine blood work

We will want to check screening labs prior to most of your future appointments.  Your surgeon or the staff should give you instructions about arranging for the labs to be drawn prior to the appointment, so that the results are available at the time you are being seen by the surgeons

What may happen before your next appointment

Increased tolerance to food

Most patients experience a transition where “suddenly" eating becomes easy and enjoyable again, usually around 6 months after surgery.  You may also find that your capacity for food (how much you can hold) increases at about the same time.  This is normal.  This change is caused by the normal softening and expansion of the stomach pouch – we can reassure you that you will continue to lose a little more weight, and then maintain the lower weight for the long term.  For Band patients, this softening is part of the reason we will probably need to do several further adjustments for you.

Hair loss

If you have not experienced major hair loss yet, you are almost “out of the woods."  Nevertheless we do occasionally hear about significant hair loss up to about 8 months after Weight Loss Surgery. The change can be quite worrisome; the hairbrush fills every time, the shower and clothes and car are all covered with hair, etc.  We believe this is caused by a response of the body to the stress and semi-starvation of the first few weeks after surgery.  The hair loss begins as the hair roots “wake up" and begin to grow new hair, which pushes out the old.  The hair loss usually lasts for 4-8 weeks.  We do occasionally see patients whose hair visibly thins a bit, but only a few patients have required wigs.  Your hair will return to its normal thickness (probably with improved texture) over time.  It is not necessary or beneficial to take extra vitamins or protein to “treat" the hair loss.

Slowing of weight loss

Very naturally and appropriately, your weight loss should be slowing.  You will begin to experience “plateaus" where your weight remains the same for 1-3 weeks, then drops again.  These plateaus do not mark the end of your weight loss, but they do mean that you are 15-25 pounds away from your “settling weight".

Abdominal pain, or constipation

About 1 in 20 patients will experience really severe cramping or gas-like pain in their abdomen at 8-15 months after WLS.  If this happens, you should call our office.  Many cases like this turn out to be caused by severe “upper" constipation – you should be able to avoid that particular problem by taking the fiber and fluid as outlined above.

Fatigue, dizziness, easy bruising

Some patients experience recurrent fatigue at 6-12 months after gastric bypass, after having had excellent energy for the first few months.  Sometimes these patients also experience easy bruising, or dizziness, or ankle swelling, or changes in their menstrual cycle.  This set of problems usually passes on its own, but if you notice any of these symptoms you should call and arrange to be seen by your surgeon sooner than your “routine" appointment – the surgeon will probably want to recheck labs and discuss your protein intake, along with possibly recommending exercise or dietary changes.