Practical tips for bariatric patients following gastric bypass or sleeve gastrectomy surgery Information for patients, relatives and carers

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1 Practical tips for bariatric patients following gastric bypass or sleeve gastrectomy surgery Information for patients, relatives and carers Introduction This leaflet is designed to give you practical information about what to do following your gastric bypass or sleeve gastrectomy surgery. We hope this information will answer some of the questions that you or those who care for you may have. The leaflet is not meant to replace the consultation between you and your medical team, but aims to help you understand more about what is discussed. If you have concerns about any aspect of your recovery, please speak to a member of the medical team. What can I do when I first go home? Your dressings can be removed and the wounds left exposed with the surgical clips left uncovered. You will be seen in clinic approximately seven to ten days after your surgery to have your surgical clips removed. Until then you can: shower as normal climb stairs take walks (up to about 30 minutes each day) resume sexual activity You should avoid: heavy lifting for at least two weeks (unless otherwise advised) driving going to work for the first week following surgery Please note if you have a job that is physically demanding you may need to take more than one week off. If this applies to you please discuss this further with the bariatric clinical nurse specialist (CNS) team (contact details are listed at the end of this leaflet) or your GP.

2 What if I have abdominal pain? It is normal to have some pain and discomfort for a few days after surgery. You may also have some discharge from your wound that is clear or blood-stained. The discharge usually stops after a couple of days but, if it persists and your wound becomes red and inflamed, please contact the bariatric CNS team. It is important to follow the post-operative diet provided in your diet sheet to prevent abdominal pain. We advise that you only take the soluble pain relief that we give you. Non-soluble pain relief may get stuck in your new stomach due to the size of the tablets. If you are unable to tolerate the pain relief we provide, please check with us before trying an alternative. Please note you should not take aspirin, ibuprofen (e.g. Nurofen ) diclofenac (e.g. Voltarol ) or naproxen regularly unless this has already been discussed and agreed with your medical team. Many people feel bloated or have wind pain. This is very common and is often partly due to the new construction of your digestive organs. It can also be caused by swallowing too much air whilst consuming the liquid or puree diet you are having. One or more of the following may help: taking five millilitres of simethicone (e.g. Infacol ) four times a day this can be bought over the counter in most pharmacies and is very effective (you will be given a supply when you go home) taking peppermint oil capsules or drinking peppermint tea reducing your intake of wind-producing food such as beans, onions, cabbage, stone fruits, apples, broccoli, sprouts, garlic, honey, sugar-free gum/mints and foods that contain cow s milk eliminating one food at a time from your diet (then reintroducing it if there is no improvement) putting down your fork/spoon between bites whilst you are chewing this will help you to eat more slowly and help stop you gulping down too much air having probiotic yoghurts or drinks - these help put good bacteria back into the gut If you have persistent abdominal pain that is associated with a temperature and vomiting and it is becoming worse or is not relieved by painkillers, contact your bariatric CNS using the emergency number listed at the end of this leaflet. If you are calling outside the hours of to 16.00, call the Paterson ward instead. 2

3 What medication will I need to take? Before you leave hospital you will be given a list of medicines to take. Some of your usual medicines may have been altered or stopped (this is particularly likely if you have had the gastric bypass operation). If you are unsure about which medication to take please contact the bariatric CNS team. You will need to take a multivitamin and a mineral supplement for the rest of your life. You will also need to take the antacid medicine lansoprazole for life (unless you are planning a pregnancy or you become pregnant, in which case this should be changed - see page 7). We can only give one weeks supply of medication - you will need your GP to continue prescribing your medication after this. Patients who are at risk of developing a blood clot may be given blood-thinning injections to take home. You may also be prescribed ursodeoxycholic acid to prevent gallstone formation, which is common with rapid weight loss. This needs to be taken for six months. However, if your gallbladder has been removed, you will not be prescribed this. If you are taking the antidepressant mirtazapine, you should stop unless specifically advised to continue by the bariatric team. Taking mirtazapine can lead to weight gain after surgery. Your GP or the bariatric psychiatrist can advise you on alternatives. Do not stop taking antidepressant medication (apart from mirtazapine, as per the guidance above) without prior discussion and supervision from your GP. Depression can resurface once the initial happiness your weight loss brings has passed. Nausea, vomiting and heartburn If you feel nauseous, stop taking your ursodeoxycholic acid for one week to see if there is any improvement. If symptoms improve, restart the medication, taking one tablet in the morning and one in the afternoon. If your symptoms start up again when you restart the medication, please stop taking the tablets and contact your bariatric CNS. If you are unable to tolerate your diet or fluids and you are vomiting regularly for 24 hours you should contact a member of the bariatric team immediately. If it is out of hours you should go to A&E at St Mary s Hospital, on the first floor of the Queen Elizabeth the Queen Mother (QEQM) building. The following general suggestions may help you if you are experiencing nausea, vomiting or heartburn: ensure that you eat slowly, chewing well and taking a pause between bites (remember the rule of 20 - take nothing bigger than a 20p-sized piece of food in your mouth at a time, chew each piece 20 times, take 20 minutes over your meals and always eat your protein first) exclude foods known to be more difficult to digest such as bread, tough meats, pasta, rice and fruit with skin on if you are experiencing problems within the first two months of your surgery, try returning to a liquid or puree diet to see if your symptoms resolve - it may be that you need longer to progress through the phases of the diet 3

4 consider whether you have eaten something high in fat or sugar as this may be causing dumping syndrome (for details of dumping syndrome please see the diet booklet given to you before surgery) leave a time gap of at least half an hour between eating and drinking heartburn is common after surgery and symptoms should improve as you lose weight however, if it is severe and distressing you should contact the bariatric team for advice What if I have diabetes? It is important that you keep monitoring your blood sugar after your surgery, as advised in your discharge documentation. You will be given a chart on which to record your blood sugar reading before each meal and at bedtime. You should complete this every day and bring it with you to your first appointment after surgery. Your bariatric CNS will offer guidance on how often you should continue to test your blood sugar at this appointment. Diabetic medication may need to be adjusted as you lose weight. Please keep in touch with your bariatric CNS for advice about this. You should avoid sugary drinks (apart from when treating a hypo by drinking Ribena as per the guidance) and foods as these will increase your blood sugar levels. Fruit is natural sugar; remember that the riper the piece of fruit, the more sugar it will contain. Eat one piece of fruit at a time and spread the portions you eat throughout the day. If your blood sugar level is regularly above 12 mmol/l or regularly below 4 mmol/l you should call the bariatric CNS team. If it is out of hours please call the emergency bariatric telephone number, listen to the message and call the number that is given to you (see contact details at the end of this leaflet). Constipation After surgery your bowel motions may change. Most patients find that they are quite constipated for the first week after their operation. This can be improved by making sure you drink enough water and that you are as mobile as possible. If you are constipated you should drink at least 1.5 litres of fluid a day to ensure a good intake. You should not have fluids with your meals - have a drink 30 minutes before or after meals. Water is preferable, but you can also drink no-sugar squash, tea (or fruit tea) and coffee. You will be discharged home with lactulose (a stool softener) which you should take as directed if you have not opened your bowels for three days after surgery. Occasionally, laxatives such as macrogol (e.g. Movicol ), senna glycoside or glycerine suppositories may need to be given. If you have any concerns or worries about this please contact us. In the early stages following your operation, try the smoothie recipes in the diet booklet to provide additional fibre. These should not be consumed regularly in the long term though, as they are high in calories and can slow weight loss. Any increase in dietary fibre intake should be gradual and you should avoid foods that can cause dumping syndrome. 4

5 Diarrhoea Suffering from diarrhoea can be related to your medication. You should stop taking your ursodeoxycholic acid for one week to see if this leads to any improvement. If not, please contact your bariatric CNS. Wind pain is common and can be eased by taking simethicone (e.g. Infacol ), which we will give you when you go home following your surgery. Alternatively, you can try peppermint tea or peppermint oil capsules. These can be purchased from any pharmacy. Make sure you avoid foods containing nutrients that can worsen diarrhoea, such as fibre, caffeine, lactose (occurring in milk), sugar, alcohol and fats. You should also avoid foods that can cause dumping syndrome. When can I exercise? One of the greatest risks associated with bariatric surgery is getting a blood clot in either the calf or the lung. To help avoid this we advise that you move around as much as possible and suggest that you take a 30-minute walk each day. To make sure that you do not become dehydrated you should drink at least 1.5 litres of fluid per day. Even while sitting down and resting it is important to keep moving your calves. You should move your feet up and down and rotate your ankles, as if you were doing exercises when on an aeroplane. Other exercise should be gentle for the first two weeks following your operation, such as walking or cycling. You should not do any heavy lifting or weight training for at least two weeks. For optimal and sustained weight loss after bariatric surgery, a long-term increase in activity levels is essential, alongside a reduced food intake. When can I drive? You should not consider driving until after you have been seen in clinic approximately seven to ten days after your surgery to have your surgical clips removed. Following this you should contact your insurance company to find out their current guidelines before you drive. If you drive before the recommended time following surgery has passed and you have an accident, it may result in non-payment by your insurance company. You need to be capable of performing an emergency stop before you consider driving again following your surgery (contact the DVLA and your insurance company for further guidance on this). When can I travel? We advise that you do not fly at all for two to three days following surgery. After this, short-haul flights can be taken. You should not travel any longer distance until you have been seen for your first appointment with the bariatric team. This usually takes place about seven to ten days after your surgery. 5

6 When can I work? Generally we advise that you allow for one week off work, or until you are seen in the clinic (or by your GP) to have your clips removed. If your job is physically demanding you may require more time away from work. You should discuss this with the bariatric team or your GP. What can I drink? You should avoid fizzy drinks for life following your surgery as these can cause bloating and discomfort. Your fluid intake is important and you should aim to drink 1.5 litres a day (taken one hour before or after meals). Avoid high-calorie fluids including hot drinks made with sugar - if needed, you should use sweetener instead. You should have no more than 150 millilitres of fruit juice a day. If you wish to drink more than this you should opt for the no-added sugar variety of squash instead. Can I drink alcohol? You should not drink alcohol for three months after surgery and, after this, only in moderation and after eating food. The effect of alcohol can be greater after surgery. We suggest that you exercise caution the first time that you try alcohol after surgery. What can I eat? You will have seen a dietitian in the clinic before your operation who will have explained the postoperative diet to you. You will also have been given a diet sheet to follow. For the first seven days following surgery you will only be allowed a liquid diet. Remember that in order to help stop you feeling sick (or indeed vomiting), you must sip fluids. Using a straw can sometimes be helpful. Once you start eating again, take your time. You will never be able to eat as before and you should expect to feel full very quickly remember this is the purpose of the operation. As soon as you feel full, stop eating. If you try to hurry a meal or consume too much in one sitting then you will experience a lot of pain and are likely to vomit. If you are having problems with your diet or have particular questions you should contact the dietitians using the telephone/ address listed at the end of this leaflet. Pregnancy We advise patients to avoid pregnancy for a year to 18 months following surgery. Oral contraception can be restarted one month after surgery - please ensure that you use appropriate contraception during this interim period. If you are planning a pregnancy or you are pregnant you should ask your GP to change your antacid lansoprazole tablets to ranitidine tablets. You should also ask your GP to stop your Centrum or Forceval vitamins and start taking Pregnacare vitamins. These are available over the counter. 6

7 Can I smoke? We advise patients to refrain from smoking after surgery. Smoking will increase the risk of ulceration in the gastric pouch. What if I feel unwell? If you feel an increasing amount of pain, are vomiting, have a fever or have any serious problem or concern then you must contact us on the emergency phone number. Out of hours, please contact the Paterson ward and a member of the nursing staff will be able to help you. If you have a problem and are unable to wait for a member of the team to call you back please come to St Mary s Hospital s A&E department on the first floor of the QEQM Building. What follow-up appointments will I have after my surgery? Your follow-up appointments will be arranged as follows: 7-10 days after your surgery with the CNS at our outpatients clinic (you may be asked to go to your GP to have your surgical clips removed before this appointment if this is the case you will be advised accordingly before you go home following your surgery) 3 months after surgery with the dietitian at our outpatients clinic 6 months after surgery with the CNS at our outpatients clinic 12 months after surgery with the CNS at our outpatients clinic You will have a telephone consultation two years after surgery, following which you will be discharged from the service. You will need to ask your GP to refer you back if you need to be seen again. We can see you as an emergency if you are having problems. It is very important that you attend all follow-up appointments. You should not have anything to eat or drink for six hours before each of your appointments, apart from water. If you cannot attend any of your appointments please contact the call centre to rearrange. Our clinics are very busy and we can usually offer appointment slots that are no longer convenient for you to other patients. If you feel you need further psychological support please contact the bariatric CNS team. 7

8 Contact details Bariatric CNSs - for medical information, general enquiries and advice. The bariatric CNSs are available Monday to Friday, Telephone: bariatrics@imperial.nhs.uk Emergency telephone number (medical emergencies only): Dietitians - for information about the pre- and post-operative diet. Telephone: bariatric.dietitans@imperial.nhs.uk Administration - for information on dates for surgery and general enquiries. Telephone: Call centre - to change appointment times. Telephone: Paterson ward - telephone: How do I make a comment about my treatment? Please speak to a member of staff or contact the patient advice and liaison service (PALS) on (for Hammersmith and Charing Cross hospitals), or (for St Mary s Hospital). You can also PALS at pals@imperial.nhs.uk. Alternatively, you may wish to express your concerns in writing to: Chief executive complaints, Imperial College Healthcare NHS Trust, Trust Headquarters, The Bays, South Wharf Road, London W2 1NY. Alternative formats This leaflet can be provided on request in large print, as a sound recording, in Braille, or in alternative languages. Please contact the communications team on Bariatric Published: April 2015 Review date: April 2018 Reference no: 2548v1 Imperial College Healthcare NHS Trust 8