Contact Information. We will contact you to book appointments. Surgery dates cannot be given until 2 weeks before a surgery date is secured.

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1 Contact Information Bariatric Surgery Program Raleen Murphy - Nurse Practitioner Phone: Registered Dietician Phone Receptionist available from 10:00 14:00, Monday - Friday The office will be closed on major holidays. For emergencies, please visit your nearest emergency department. We will contact you to book appointments. Surgery dates cannot be given until 2 weeks before a surgery date is secured. The information in this document was adapted from the following sources: Capital Health Sleeve Gastrectomy Hospital Discharge Instructions Up To Date Surgical management of severe obesity This document is a work in progress and may be adapted as deemed necessary by the Bariatric Surgery Program

2 Bariatric Surgery Program: A Patient s Guide 1

3 Laparoscopic Sleeve Gastrectomy (LSG) Surgery Overview LSG is a weight loss surgery where about 80% of the stomach is removed. After the surgery, the remaining stomach is sleeve-shaped and about the size of a banana. It will hold less than a cup. The surgery takes about two hours and patients usually go home from hospital about one or two days after the surgery. LSG is thought to help weight loss by reducing the amount of food a person needs to eat in order to feel full. Also, less hunger hormones are released from the remaining stomach, so patients have less hunger cravings. Weight loss surgery is not a cure for obesity. It is a weight loss tool. Healthy food choices, calorie control and regular exercise are necessary for long lasting weight loss. 2

4 Surgical Risks LSG is a complex treatment option for the complex issue of obesity. Risks of the surgery can include: infection leakage bleeding the possibility of conversion to an open procedure the possibility of blood clots rare but major medical problems such as heart attack, stroke or death The Bariatric Surgery Program How Is The Program Set Up? A referral is needed in order to consider patients for bariatric surgery. This can be made by your family doctor or another health care provider involved in your care. The Bariatric Surgery Program receives a high volume of referrals and currently, there is a long wait before patients can be assessed. An information session is your first contact with the bariatric surgery program. There, you will learn about: the surgery the risks of surgery the special diet before and after surgery what happens in hospital what the program expects from you what you can expect from the program. Sometime after the information session, you will be booked for a clinic appointment with the nurse practitioner and dietitian. You are expected to come to this clinic visit prepared with the following: A list of your medicines A food journal (1 week of full fluid diet; 1 week of healthy eating diet) If you have diabetes, a record of your daily blood sugar readings The information collected from your first clinic visit will help determine if this surgery is right for you. When your medical work-up is complete, you will be booked for a clinic visit with a surgeon to review the surgery and sign your consent, if appropriate. It is only after your visit with the surgeon that surgery can be planned. 3

5 How Do I Prepare? If you are serious about weight loss surgery, you have to be committed to the program. The surgery is not a cure for the problem of excess weight, it is only a tool. Making positive changes right away will be easier than trying to make many changes all at once after a major surgery. Here are some healthy ways that you can get started: Eat three meals a day Don t skip meals Limit snacking, especially at night Eat smaller portion sizes Eat more fruits and vegetables Eat less refined foods (prepackaged items, pastries, cookies, cakes, crackers) Cut back on caffeine, pop and alcohol If you smoke, it s time to cut back with a plan to quit. Call the Newfoundland and Labrador Smoker s Helpline for advice at or visit Introduce exercise. Walking and swimming are great ways to get started. Health Canada recommends 150 minutes of physical activity per week. Even 10 minutes sessions of physical activity spread throughout your week has health benefits. Take a daily multivitamin See your family doctor and make sure that any health problems you have are treated. The nurse practitioner and dietician of the Bariatric Surgery Program will also help you prepare. At the information session, you will be given information about following a diet that is important for recovery and successful weight loss after bariatric surgery. It will be important for you to keep a food journal of your daily intake and track your daily calories, protein, and fluid. The more practice you get with recording your intake before surgery, the easier it will be for you after surgery. Starting this diet before surgery can result in weight loss. Weight loss before surgery will help to make the surgery easier to perform and can reduce the risks of surgery for you. What The Program Expects From You Bariatric surgery is a planned procedure, not an emergency. It is a tool for weight loss, not a cure. Careful planning and preparation are keys to success. Being unprepared for your clinic visits will result in delays to surgery planning. Surgery will not be considered for patients who are not prepared for their clinic visit. If you 4

6 have questions about the program, diet trials, or your first clinic visit, contact the Bariatric Surgery Program at Surgical Planning After you have signed consent for surgery, there will be a wait until a surgery time becomes available for you. The length of time of your wait will depend on the current waitlist. The waitlist is expected to grow over time, given that weight loss surgery is in high demand. You will be notified of your surgery date about 2 weeks before. If you have important plans (i.e. vacation, work commitments, etc.) that prevent you from taking the surgery date offered, the team will book the next available surgery date for you. Sometimes planned surgeries are cancelled by the hospital with little notice. This is very unfortunate but out of our control. You will be booked again as soon as possible. The week before your surgery You will start the full fluid diet one week before your surgery. You will also receive an appointment with Pre-admission Clinic during the week before your surgery. This appointment is very important and will help you prepare for the day of surgery. Pre-admission Clinic (a few days before your surgical date) You will not be able to eat or drink for 12 hours before your pre-admission clinic visit because blood work will be taken there. You will meet an anesthesia doctor. Tests will be ordered to check that your heart and lungs are healthy enough for surgery. The day before surgery, you will drink clear fluids only. You will have nothing more to eat or drink after midnight before the surgery. If you have sleep apnea, you will be told to bring your CPAP/BiPAP machine to hospital on the day of surgery. The anesthesia doctor will tell you what medicines to take or not to take before your surgery. You will be told what time you should come to hospital on the morning of your surgery. Day of Surgery 5

7 The surgery takes about 2 hours to complete. You will be put to sleep for the surgery. After surgery, you will go to recovery room until you are fully awake from anesthetic and until your heart rate, blood pressure and breathing are stable. You will be transferred to the ward when your nurse and/or doctor feel that it is safe for you to do so. You will not have a tube in you bladder to drain your urine. You will be encouraged to get up to the bathroom soon after your surgery to empty your bladder You will not be allowed to eat or drink after surgery. You will have an intravenous (IV). Day After Surgery Starting the morning after your surgery, if you are not having any issues, you will be allowed to start to sip water. You will be given instructions about how to advance your diet by the nursing staff. The nurse practitioner and dietitian of the bariatric surgery program will visit you today. Discharge From Hospital The average stay in hospital is 1-2 nights. You will be discharged from hospital if no medical issues are identified and you are tolerating your fluid diet. When you are discharged, continue on the full fluid diet until your 4 week follow-up appointment with the nurse practitioner and dietician. If you live outside St. John s, you will need to make arrangements to stay within a 30 minute drive of the Health Sciences Center until 1 week after your surgery. If you do not have any family or friends in the area to stay with, you can contact the Agnes Cowan Hostel to make a room booking. The phone number is After your discharge, you should be able to look after yourself. It is not necessary for you to have someone with you at all times after surgery, although you may feel more comfortable if someone is available to help you. Follow-up Appointments You will have post-op follow-ups with your nurse practitioner and dietician at: 4 weeks 3 months 6 months 6

8 12 months 18 months 24 months yearly You will have a post-op follow-up with your surgeon at: 6 to 8 weeks It is very important for you to attend all follow-up appointments. If you are unable to keep an appointment, please notify the team at If you are not from the St. John s or surrounding areas and if travelling long distances for these appointments is difficult for you, please contact our office at We can discuss other arrangements (Telehealth) to follow you after surgery so that you don t have to travel far. Common Experiences After Surgery Fatigue Right after your surgery, you will feel drowsy. This will improve as your body clears the anesthetic/ medicine from your system. However, even as you recover, you may feel more tired than usual. This can last for a few weeks after your surgery while you are healing and getting used to your new diet. It is important to listen to your body and get enough rest while you are recovering. Nausea and vomiting You may feel stomach sick or vomit after surgery. You will be given medicine to help with stomach sickness. This should get better while you are in hospital. Contact your doctor or nurse practitioner, if you continue to have stomach sickness and/or vomiting after you go home and this prevents you from eating and drinking. You will vomit if you overfill your smaller stomach. This can happen if you drink too much or if you drink too fast. Do not drink fluids while eating. Drink fluids ½ hour before or after eating to prevent overfilling. Pain You will have pain at the incisions or cuts after surgery. Pain medicines will be ordered for you. It is important to tell your nurse if you are having pain so that you can receive medicines. This pain will settle over the next few days. You should hold a pillow across your cuts when you move using your stomach muscles, such as moving from lying to sitting or when coughing. Remember to breathe as you 7

9 move. Don t hold your breath. When you are discharged from hospital, you will be given a prescription for pain medicines. Only use your prescription pain medicines for moderate to severe pain and as directed on the packaging. You can use over the counter pain medicines like acetaminophen (i.e Tylenol) for mild to moderate pain. If you are not having pain, do not take the medicines. Gas Many patients have gas pain after surgery. During your surgery, your belly is filled with gas on purpose. This gas can get trapped in your body after surgery and it takes some time for your body to get rid of it. You may get pain as a bloating feeling or as pain in the shoulder. Walking helps your body move the gas. If you are very uncomfortable, speak with your nurse and/or medical team. Over the counter medicines such as TUMS or Gas X can help. Reflux (heartburn) Reflux can occur when contents from the stomach leaks back up into the esophagus (the tube that connects the mouth to the stomach). Reflux can cause a burning pain in the chest or make you feel as if food is stuck. Some patients find that reflux improves after surgery while other patients find that it gets worse. Reflux can get worse if you lie down too soon after eating or at night. Also, certain foods and/or medicines can make reflux worse. If you are experiencing reflux, speak with your family doctor, nurse practitioner or surgeon. Sometimes, a medicine can be prescribed to help. Activity You should move as soon as possible after your surgery. You will not have a catheter in your bladder, so your first time on your feet after surgery will likely be a trip to the bathroom. You will have intravenous fluids (IV) running into your vein. This will be attached to a pole with wheels and will need to be taken with you on your walks. Walking in your room and in the halls does help to exercise the leg muscles. This can help prevent blood clots from forming in the legs that could move to the lungs and cause breathing troubles. As well, walking helps your body get rid of gas and exercises the lungs to help prevent lung infections. When you are in bed, do leg and feet exercises every hour while awake. When you go home, you can start normal activities as soon as you feel able. Lifting should be limited to 20 pounds or less for about 4 weeks after surgery, or as directed by your surgeon. 8

10 Making exercise a part of your daily routine is important to your weight loss plan. Start with light exercise and slowly increase intensity over time. For example, start with a 10 to 15 minute stroll every day and work towards a 60 minute brisk walk. For some patients, this may take months to do. The most important thing is that you are working towards a daily exercise goal. As your weight drops, exercise should become easier and you can work on increasing the intensity and duration of your exercise. Some patients will require a little more help to develop a safe exercise plan. Please contact our physiotherapist at if you have any activity-related concerns. The physiotherapist can arrange a visit with patients before and/or after surgery. Care of your cut You will have a number of small cuts on your belly from the surgery. The cuts are closed with staples. After surgery, your cuts will be covered by bandages. In hospital, your nurse will check these cuts and make sure they are healing well. Usually the bandages are removed 2 days after your surgery and the cuts can be left open to air. You can shower 2 days after your surgery. When you are discharged from hospital, plans will be made for a community health nurse to remove your staples. This happens around 10 days after your surgery. You should not soak in a bath or go swimming until your cuts are well healed. This usually happens after a month. Once you are discharged from hospital, check your cuts every day and watch for signs of infection or active bleeding. Contact your surgeon or nurse practitioner if you notice: Drainage from a cut that is cloudy or foul-smelling. A fever and/or chills. Increasing redness, swelling and/or pain at a cut. A gush of bright red blood coming from a cut. Blood Clots After surgery, you are at risk of getting blood clots. To prevent blood clots from forming, you will wear support stockings during and after your surgery while in hospital. As well, you will be given a blood thinner shortly after your surgery and every day while you are in hospital. Walking around soon after your surgery helps to prevent the formation of blood clots. Contact your doctor or nurse right away if: you develop pain in your lower leg 9

11 You notice swelling, redness or tenderness in the lower leg that does not go away. You having trouble taking a deep breath and get pain with breathing This could mean that you have a blood clot. Eating and Drinking In hospital, your diet will slowly move from sips of water to clear fluids to full fluids. By the time you go home, you should be able to drink about 120 ml of fluid per hour (equal to 4 medicine cups). It may take you an hour to get that amount of fluid in after surgery because your stomach is much smaller than before. You should eat and drink very slowly. Stop when you feel full. Overfilling your stomach can cause pain, nausea and vomiting. When you are discharged from the hospital, you will stay on the full fluid diet for 4 weeks. It will be very important to track how much fluid, protein and calories you are getting in during the day. It is important to journal this information so that it can be reviewed with your nurse practitioner and dietician. Working towards a target of 60 to 80 g of protein per day is important for healing and to prevent muscle loss. As well, a lack of protein in your diet can lead to hair thinning and hair loss. On the full fluid diet, it will be difficult to reach your daily protein target without using a protein supplement such as a protein powder, pre-made protein shake or protein shot. Speak with the program s dietician if you have concerns. Getting in enough fluid will also be more difficult after surgery. It is best to sip fluids throughout the day. Try to drink at least 2 to 3 L of fluids per day to prevent dehydration and constipation. Add up the fluid you take in from protein shakes, water, soup, milk, etc. After 4 weeks on the full fluid diet, you will slowly move to soft foods and then solid foods. This is discussed in your first clinic visit with the dietician and nurse practitioner. Moving to solid foods too quickly can cause problems with healing and can stretch your stomach. By 3 months after surgery, you should be able to tolerate most foods. After surgery, many patients do not tolerate tough meats or starchy items such as breads, pasta, rice and potato. Bowel movements You may notice a change in your bowel habits after surgery. This is often due to the change in diet. Some patients have constipation while others may have diarrhea. The following may help: Diarrhea. Limit your diet to clear fluids for 24 hours. 10

12 If you smoke, please try to quit. Take in extra fluid to replace water lost through diarrhea. Read labels. Some sugar-free, no sugar added or diet products contain sugar alcohols (such as sorbitol, mannitol, maltitol) which can cause diarrhea. If you are having diarrhea, you should not eat or drink anything that has these products in them. If your diarrhea still continues for more than 2 days, notify your doctor or surgery team for further direction. Constipation. Increase your water intake. Aim for at least 2 to 3 L per day. Try drinking warm liquids in the morning Try 30 ml of prune juice in 30 ml of water Taking a daily fiber supplement, like Metamucil, can help. Exercise does help to make bowel movements regular If you do not have a bowel movement within 4 days, notify your family doctor, nurse practitioner or surgeon. You may need a stool softener, laxative, suppository and/or enema to help you have a bowel movement. Medications You will take a daily multivitamin for life after surgery. For the first 4 weeks after surgery, take a chewable multivitamin. It can be digested easier. A gummy multivitamin is not recommended because it lacks minerals. The medicines that you took before your surgery may change before you go home. Weight loss can change your need for medicines, especially those used to control diabetes and blood pressure. You may be given new information about how to take certain medicines after you go home. The following information will help to plan your health management: If you have diabetes: You must monitor your blood sugar more often. Test your blood sugar at least 4-5 times per day. It is better if you can check you blood sugar before every meal and 2 hours after every meal, as well as before bed. Keep a record of your readings. If you feel unwell, check your blood sugar. Notify your family doctor, surgeon or nurse practitioner if your blood sugar 11

13 readings are often running too low or too high. If you have high blood pressure: Have regular follow-up with your family doctor to have your blood pressure checked. Make sure you are drinking enough fluid to prevent low blood pressure. If you feel dizzy after surgery, have your blood pressure checked. If it is low, tell your family doctor, surgeon or nurse practitioner. Emotions After surgery, it is not uncommon for patients to report that they feel down or even depressed as they learn to cope with changes in their diet and body. The support of friends and loved ones is very important during this time. Seek out support groups in your area that may help you cope with your emotions. Individual counseling can also help you adjust. If you sense that your emotions are out of control, please notify your family doctor, surgeon or nurse practitioner for guidance. If you feel that you are at risk of harming yourself, call 911 right away. Weight loss Weight loss after this surgery usually happens over 1 to 2 years. For some, weight loss can be fast at first. It will slow down, which is expected and you should aim for 1 to 2 pounds a week after a few months. As your body weight lowers, you will need to work harder to lose further weight and reach your goals. Paying close attention to your diet by keeping a food record of what you eat and how many calories you take in will help you stay in control. Regular exercise is also important when trying to reach and stay at a healthy weight. Some weight can be regained over time. Speak with your surgeon or nurse practitioner about what is a healthy weight loss goal for you. 12

14 BMI Chart Weight (lbs) Height (in)

15 NOTES 14

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