The Bariatric Surgery Journey
Pre-Bariatric Surgery Evaluation
To begin the process, each candidate must complete an online orientation and quiz. For your convenience, you can complete this process from the comfort of your own home. Someone from the Center for Bariatric Surgery will call you with your quiz results.
Complete a seven-day dietary recall. We ask candidates to record the type and quantity of food they eat for seven consecutive days, noting everything they eat and drink. It is important that they be accurate. We will have a rough idea of the accuracy based on the person's weight and the amount of calculated calories they need.
Bariatric Surgery Nutrition Counseling Schedule
In order to insure safety and to maximize weight loss results, regular nutrition visits are required both before and after your weight loss surgery. The bariatric registered dietitians staff at The Miriam Hospital is available to help you through your journey.
At this time, all nutrition appointments and classes are held via Microsoft Teams group classes, one-on-one telephone calls or remote video chats via the MyLifespan portal. For more information, call the Center for Bariatric Surgery at 401-793-3922.
Please be aware that certain health plans may not cover the cost of nutrition counseling and you will be responsible for the charge. Please contact your insurer to establish your payment responsibility.
Once an individual qualifies for a bariatric procedure, he or she must undergo extensive preoperative testing. Some of the testing may include:
- A psychological evaluation
- A nutrition evaluation
- A sonogram of the gallbladder
- An upper GI series in which the patient drinks barium and x-rays are taken
- A chest x-ray
- An electrocardiogram
- Measurements of energy expenditure and respiratory capacities
- A large amount of blood work
Once all testing, follow up and preoperative requirements are complete, the patient can be scheduled for surgery.
Preparing for Bariatric Surgery
There are a number of things patients must do before the operation that will help both the recovery from the operation and the ultimate result.
- Most important, if you are a cigarette smoker, you must stop smoking at least 2 months prior to surgery. Some insurance companies may require up to six months nicotine free. Studies have repeatedly shown that stopping smoking prior to surgery decreases the incidence of pneumonia and other respiratory problems.
- You must attend at least two bariatric surgery support group meetings at The Miriam Hospital prior to having a surgery date.
- You should also begin to build up your muscle strength before surgery by walking every day for 30 minutes. This will give you a greater reserve during the post-operative period, when muscle mass normally decreases.
- Finally, you must begin to mentally prepare for the procedure and the changes you will need in your lifestyle and dietary habits in order for you to be successful.
A time of minimal stress is best. It would be ill-advised to have the procedure following major life changes, such as a new job, change in location or death in the family. You need to give your full attention to this process and not be distracted by other events.
You should also make arrangements to have help available at home for the first two to four weeks to help with child care and daily living activities such as laundry, housecleaning, yard maintenance, grocery shopping, etc.
The Day Before Surgery:
The day before your surgery you will only be drinking clear liquids, as approved by your doctor.
- Do not eat or drink after midnight on the day before surgery, unless otherwise instructed by your bariatric team.
- Ask your doctor or nurse for more information.
The Day of Surgery:
Please bring with you a photo ID and your insurance card. Also bring your CPAP Machine, if one has been prescribed for you.
After you are admitted to the pre-operative holding unit you will:
- Have an intravenous started. (Sometimes an intravenous cannot be started because of the obesity or poor veins. In these cases, a special type of intravenous will be inserted into a vein in the neck or beneath the clavicle before surgery.)
- Receive an antibiotic and blood thinner.
- Have supportive stockings and compression devices applied to your lower extremities to help prevent blood clots and promote circulation.
- Be interviewed by members of the perioperative team, which includes registered nurses, anesthesiologist, surgical resident and your attending surgeon.
After your preoperative preparations are complete, you will be taken to the operating room for your surgery. Guests will be able to wait in the surgical waiting area.
After surgery, you will go to the post anesthesia care unit, until you are ready to go to your assigned room.
Recovery from Surgery
During the postoperative period you will have pain in your incision which will limit your ability to move and breathe deeply.
To prevent lung problems (pneumonia and lung collapse) and blood clots in your legs, it is extremely important that you get up immediately and walk. We expect that all patients will be out of bed on the day they have their operation and, if possible, walk. When laying in bed or sitting for long periods of time, you should practice the point and flex exercise with your legs and feet.
To decrease the likelihood of any respiratory problems, we require that you do frequent breathing exercises, as instructed by the respiratory, physical therapy and nursing staff. Some of these exercises are coughing, deep breathing and the use of an Incentive Spirometer, a plastic device used for breathing exercises that helps expand the lungs and prevent pneumonia. This reduces the risk of lung collapse and pneumonia.
Once home, you can shower as you normally would unless you have been told otherwise at the time of discharge.
For the first 2 weeks you should not:
- Drive a car.
For the first 4 to 6 weeks you should not:
- Lift heavy objects, such as grocery bags, laundry baskets, or small children.
- Shovel snow.
- Push heavy objects, such as raking leaves, pushing shopping carts or vacuuming.
- Start any formal exercise programs requiring lifting or straining.
You should immediately begin a daily routine of walking. You should gradually increase the distance you walk per day until it is more than one mile. The more the better.
You may resume normal sexual activity once you are comfortable, but do not strain. Most importantly, you should not get pregnant during the two years after surgery. Since this is the period of weight loss, the baby may be in jeopardy of not getting enough nutrition. Although pregnancies have been successfully carried out during the first 12 months, they should be avoided.
When to Contact Us
You should call the office immediately if you develop:
- A fever 101.5 degrees Fahrenheit or higher
- Severe abdominal or stomach pain
- Severe vomiting
- Swelling, redness, tenderness or drainage from your incision
- Swelling in the legs, especially if only one leg is involved
- Acute shortness of breath
Prior to discharge, we will tell you what medications you should continue to take. Since it is not unusual to decrease dosage of high blood pressure or diabetes medications after discharge, it is important to check with us prior to going home.
You will be sent home with a prescription for medication for pain control.
If you have any heartburn or bile taste:
- Elevate the head of your bed three to four inches
- Don't wear any constrictive clothing
After surgery you should take:
- Multivitamins, calcium, iron or other dietary supplements as directed by surgeon
This is something you need to do for the rest of your life or until we tell you differently. If you don't take these vitamins and minerals, deficiencies, anemia and bone problems may result.
- You may be prescribed a medication to help prevent blood clots to be used after you are discharged from the hospital.
When Will I Be Functional Again?
The specific bariatric procedure will determine the length of time until you are back to your pre-operative status, but general guidelines are:
- Weeks 2—4
- You should not schedule any extraneous activities for the first two weeks after discharge as it will take at least two to four weeks for you to begin to regain your strength. Don't forget, not only have you had an operation, but you are also on a very restrictive diet! It is normal to be tired and patients usually find themselves taking naps during the first few weeks.
After 4—8 Weeks
By four to eight weeks you will be ready to return to work and a full daily workload. If you return to a job outside your home, a gradual resumption of your workload over two to three weeks is ideal. If you can avoid heavy lifting, you should do so for four to six weeks.
Once discharged from the hospital, you will return to see your surgeon at their office at:
- 1-2 weeks
- 6 weeks*
- 3-4 months
- 6-8 months
- 12 months
- 18 months
- 24 months
- Yearly in anniversary month thereafter
*Note: If you have a gastric band, the first gastric band fill is done at six weeks and patients are seen at approximately every four to six weeks until they have achieved adequate band fills for proper restriction.
These visits are mandatory. If you do not agree to follow up with us in this manner we will not do the procedure. There are two important reasons for these follow-ups:
- We must be able to keep track of your weight and weight maintenance to be sure the procedure is working properly.
- We must make sure you do not develop any vitamin or mineral deficiencies following the operation.
You will have routine blood work on a set schedule to make sure that no abnormalities are developing.
During the weight loss period you will lose your body fat, with little change in your muscle mass. This is very important, since loss of muscle mass is a form of protein malnutrition that can have serious consequences. Some physical changes are commonly associated with weight loss:
As you get thinner, you will notice you will have a lot of extra skin. The younger you are, the greater the likelihood that your skin will still have enough elasticity to shrink as you shrink. This may be helped by daily exercises. Unfortunately, the shrinkage of skin is never 100 percent and usually is very little. Thus, it should be expected that your breasts will sag, as may your upper arms, abdomen and thighs. The firmness you had when you were obese is gone.
About 15 to 20 percent of people who lose 100 pounds or more ask for procedures to reduce the abdominal apron (tummy tuck), the sagging of breasts (mammopexy) or the extra skin on the upper arms (arm reduction) or thighs (thigh reduction). These are plastic surgery procedures which are usually not covered by insurance companies. Under some medically necessary circumstances, however, insurance may cover a large part of these expenses.
Another frequent complaint by patients after bariatric surgery is hair loss. This is probably partly related to some decrease in protein nutrition, but other factors also appear to be important. By three months, you may feel that you are going bald. In fact, you are not going bald. Almost all patients experience significant hair loss. By six months, hair growth should be returning to normal, and by one year, there should be little or no change from what you started with prior to surgery.
The type of bariatric surgery procedure you choose to have will determine your immediate post operative diet plan. You will be given specific instructions and guidelines as you go through the program.
Please keep in mind: This is just an example of what you will face post-surgery. Food and diet choices will be tailored to each patient's needs.
In addition, you can drink calorie-free liquids (especially water) as often as you want. It is essential that you maintain an adequate fluid intake by drinking at 48 to 64 ounces of fluid each day.
You should not drink and eat at the same time.
Some patients who have the gastric bypass surgery may have dumping syndrome. The dumping syndrome is a condition of crampy abdominal pain, lightheadedness and diarrhea that occurs when a high concentration of foodstuff, particularly sugars, rapidly enters the small intestine.
Avoid carbonated beverages.
It is essential that you change your eating behaviors in order to maximize weight loss and reduce the chance that you will develop nutritional deficiencies such as anemia, loss of bone or muscle mass from an inadequate intake of calcium or protein. Protein rich foods (low fat dairy, legumes, poultry, meat, fish, egg, and soy) should come first at a meal. You will require a protein supplement for several months.
Vitamin, mineral, and calcium supplementation is required for the rest of your life.
Examples of Food and Drinks That May Cause Stomach and/or Intestinal Distress
- Canned fruit in heavy syrup
- Fruit drinks
- Ice cream
- Alcoholic beverages
- Table sugar
- Maple syrup
- High fructose corn syrup
- Potato chips
- Corn chips
- Fried foods
- Fast food
- Hot dogs
- High fat gravies and sauces
- Pot pies
Recommended Foods and Beverages
- Decaffeinated tea/coffee
- High protein shakes
- Artificially flavored water (non-carbonated)
- Skim milk
- Low fat cheeses
- No added sugar, low fat yogurt
- Artificially sweetened puddings and custards
- Soy beverage (unsweetened)
- Lactose-free milk (if you are lactose intolerant)
- Unsweetened applesauce and canned fruits
- Ripe/peeled fresh fruit (banana, melon, pears, peaches)
- Blenderized fruit shakes
- Mashed or baked yam or sweet potato
- Soft cooked vegetables (summer squash, butternut squash, green beans, etc)
- Soft and peeled raw vegetables (tomatoes or cucumbers with no seeds)
- Vegetable soups
- Beef or chicken broth
Meats, poultry, fish, eggs*
- Chicken/turkey cooked in a moist way (stew/soup)
- Ground beef (meatballs, meatloaf, stewed) (Red meat may not be well tolerated for 6 to 12 months)
- Shaved lean deli meats (turkey, chicken)
- Fish (cod, flounder, sword, salmon) served moist
- Eggs (scrambled, hard boiled)
*serve with low fat sauces or low fat gravies to keep moist.
- Low fat crackers
- Hot cereals
- Unsweetened dry cereal (soaked in milk)
Surgical Risks and Possible Complications
The trade-off of having a weight loss procedure of any type is the complications associated with it. The incidence of death from the operation itself is approximately 1% or less, and 25-30% of patients will develop some form of complication after the operation. Fortunately, most of these complications are minor, consisting of wound infections, respiratory problems, hernias in the incision and vomiting.
Complications of gastric bypass:
- Anastomotic leak
- Micronutrient deficiencies
- Internal hernia
- Marginal ulcer
- Stomal stenosis
Long-term complications: vitamin and mineral deficiencies
The long-term complications of this operation are related to vitamins and minerals. Approximately 50 to 60% of patients will develop iron deficiency, 75% will develop low vitamin B-12 levels and 40% will develop low folate levels. These deficiencies, either alone or in combination, result in a 30 to 40% incidence of anemia which can be serious at times. In order to correct for these problems, patients are supplemented with daily iron, multivitamins, B-12 and folate pills. The addition of these vitamins and minerals eliminate these complications for the most part.
Complications of BPD (biliopancreatic diversion):
- Diarrhea and foul smelling gas, with an average of three to four loose bowel movements a day
- Malabsorption of fat soluble vitamins (Vitamins A, D, E, and K)
- Vitamin A deficiency, which causes night blindness
- Vitamin D deficiency, which causes osteoporosis
- Iron deficiency, a similar incidence with the Roux-en-Y gastric bypass
- Protein-calorie malnutrition, which might require a second operation to lengthen the common channel
- Ulcers (less frequent with duodenal switch [DS])
- Dumping syndrome (less frequent with DS)
Complications of gastric banding:
- Migration of implant (band erosion, band slippage, port displacement)
- Tubing-related complications (port disconnection, tubing kinking)
- Band leak
- Port-site infection
- Esophageal spasm
- Gastroesophageal reflux disease (GERD)
- Inflammation of the esophagus or stomach
- Vertical sleeve gastrectomy
- Anastomotic Leak
Since this procedure is relatively new, long-term risk and benefits are not known.
Risk of all Abdominal Surgery:
- Shoulder pain (related to microscopic surgery)
- Complications due to anesthesia and medications
- Injury to stomach, esophagus, or surrounding organs
- Deep vein thrombosis
- Pulmonary embolism
Can Patients Gain Weight After Surgery?
There are six reasons why patients either fail to lose enough weight or regain weight. Four are technically related to the procedure:
- Pouch enlargement
- Stomach enlargement
- Staple line disruption
- Band Slippage
However, these four causes are, in large part, related to poor eating habits, particularly frequent or constant overeating. The fifth reason is overeating and non-healthy food choices after the operation. The sixth and most frequent reason is lack of exercise. If a patient frequently eats high caloric foods and drinks high caloric liquids, he or she will gain weight.
The goal of the operations are to allow a morbidly obese person to undergo a significant weight loss and to give them the opportunity to maintain that weight loss through a surgical procedure that reduces the capacity and emptying of the stomach. It is hoped that through these means the individual will become motivated to undergo more physical activity and exercise, thus not only decreasing the amount of calories taken in but also increasing the amount of calories used.
Do people ever lose more weight than is safe?
Although anything is possible, patients rarely drop below their ideal body weight and in the rare person who does, it is generally for only a brief period of time.