Life after Weight Loss Surgery (WLS)

Special considerations for first 12 weeks postop:

• Day of surgery
• Ambulation will begin
• DVT prophylaxis 

• Morning after surgery
• Upper GI with gastrografin or barium may be ordered to verify patency of surgery
• If fluoroscopy is normal, then oral fluids will be started immediately
• Have the patient use a 30 ml medication cup, to begin to learn the proper volume to be consumed at each time … the patient should be encouraged to sip liquid throughout the day, for a total goal of 48 - 64 ounces/24 hours. 

• Post op Diet
  • Patients usually progress from a clear liquid diet, to full liquid diet, to a pureed diet, to a regular diet
• Post op diet orders differ depending on how quickly the patients will advance from a liquid diet to a regular diet.
• Depending on the procedure, patients may be on a strict diet for first 3-6 months post op
• The average adult stomach is about the size of a quart, the average gastric pouch after weight loss surgery is 30ml – 50ml.
• After 6 months, a 30ml gastric pouch may stretch to about the size of ½ cup measure
• Nausea and vomiting are VERY common post-operatively. N/V can be minimized if the patient adheres to the diet as ordered, i.e., small sips of liquid throughout the day, for a total of about 48-64 fluid ounces per 24 hours. If vomiting or diarrhea continues for more than 24 hours, the patient MUST contact their surgeon immediately as the patient is at a high risk for dehydration.
• Obstructions during the first 3 months post op are common among patients who are NON-COMPLIANT with the dietary restrictions
• Internal sutures and staples must be given a chance to heal before the digestive tract can tolerate the movement of solid foods through it.
• Medications will need to be liquid or pulverized, or they may cause an obstruction. Something as small as a vitamin can get caught as it passes through the internal surgical sites; patients must truly understand the danger of eating solid food too soon.
  • REMEMBER:  the patient may already have a baseline nausea which may make it nearly impossible for the patient to be able to tolerate bitter crushed pills. Some patients find that ½ teaspoon of a liquid like "Catalina" salad dressing can mask the bitterness of pulverized medications and can improve compliance.
  • After 1-3 months, patients should be able to again swallow pills
• Providers should avoid ordering "sustained release" medications as there is a reduced transit time which alters absorption.

Weight Loss:

• Reaches a maximum in 18-24 months when the patient begins to maintain their weight or gain weight
• Most patients will lose weight, then gain some weight and then plateau
• Weight management MUST be a daily focus or patients will regain their weight

Resolution of Comorbidities

• Arthritic pain
• Improved in 73% of patients
• one of the last comorbidities to improve post op due to the years of damage to the joints
• Asthma
• Resolved or improved in 82% of patients
• Cardiovascular disease
• Risk reduction by 82% in patients
• Degenerative Joint Disease
• Resolved in 44-88% of patients
• Depression
• Resolved in 55% of patients
• Diabetes
• COMPLETELY Resolves in 75% of patients
• For some reason yet to be determined, 90% of patients will become normoglycemic within 2 or 3 days following their surgery and cease to need their oral diabetic medications, even BEFORE weight loss occurs.
• Resolved or improved in 86% of patients
• Exertional Dyspnea
• Improved in 88% of patients
• Gastroesophageal reflux disease
• Resolved in 72-95% of patients
• Hyperlipidemia
• Resolved in 63% of patients
• Resolved or improved in 93% of patients
• Hypertension
• Resolved in 60% of patients
• Resolved or improved in 78% of patients
• In fact, some patients will experience HYPO-tension after their post op weight loss!
• Liver Disease (Non-alcoholic Fatty Liver)
• Improved steatosis in 90% of patients
• Resolution of inflammation in 37% of patients
• Resolution of fibrosis in 20% of patients
• Metabolic syndrome
• Resolved in 80% of patients
• Migraines
• Resolved in 57% of patients
• Peripheral edema
• Improved in 89% of patients
• Polycystic Ovarian Disease
• Resolved Hirsutism in 79% of patients
• Improved or resolved menstrual dysfunction in 100% of patients
• Pseudotumor Cerebri
• Resolved in 96% of patients
• Sleep apnea
• Resolved in 74% of patients
• Resolved or improved in 74-98% of patients
• Urinary incontinence
• Improved in 81% of patients
• Venous statis disease
• Resolved in 95% of patients

Mortality: 89% reduction in 5-year mortality rate.

Life Long Care

• Annual visits with the bariatric surgeon

• Periodic blood work to determine healthy balances at the cellular level may include:
• Complete blood count
• Comprehensive metabolic panal
• Liver function tests
• Hemaglobin A1C
• Iron with TIBC and Saturation
• Ferritin
• Folate
• Vitamin B12
• Vitamin D
• Thyroid function studies 

• Dexa Scan

Nutritional balance

• Malnutrition is a lifelong risk for post op bariatric patients who have had combined restrictive malabsorptive procedures such as the Roux-en-Y gastric bypass
• Patients must eat their protein sources FIRST at each meal (then carbs, fruits, vegetables)
• Patients must avoid foods high in fat content or sugar content to avoid a dumping syndrome.
• WLS patients are at a high risk for development of both macronutrient and micronutrient deficiencies

ASMBA (2008)

Buchwald (2004)

Virji (2006)

Pories (1995)

Dowd (2005)

Huang (2003)