Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

Instructions to follow before your procedure

1. 7 days before your surgery begin a SUGAR-FREE, LOW CALORIE, LOW FAT, CLEAR LIQUID DIET . The purpose of this pre-surgery diet is to shrink your liver so that Dr. Jay is able to see your stomach clearly. If you do not fully adhere to this diet, Dr. Jay may choose to postpone your surgery until you have complied with the liquid diet. (This diet helps make the surgery safe).

2. 7 days before your surgery discontinue: blood thinners (i.e. Aspirin products, Plavix, Coumadin, Vit. E, Fish oil) – make sure to discuss with your cardiologist or other specialist. Discontinue anti-inflammatories (i.e. Ibuprofen, Motrin, Aleve, Advil, Mobic, Celebrex, Bufferin, Alka-Seltzer,ect.) make sure it is okay with your PCP or the doctor that suggested you take the medication; in case they may want to place you on alternative medication. Women need to stop birth control medication.

3. Please note if you are taking diabetic medications, please check with your PCP or the doctor that suggested you take the medication; in case they may want to adjust your medications while on this pre surgery diet. (i.e. blood sugar levels usually drop, requiring patients to discontinue or take less diabetic meds).

4. 7 days before surgery avoid alcoholic beverages and smoking.

Day Before Surgery  You are required to take a laxative to prepare your bowels prior to surgery. Take OTC Magnesium Citrate. Flavors: Cherry, Lemon-lime, or Grape. Instructions: Chill dosage. Take between 12pm-6pm the day before surgery. Finish dosage in less than 30 minutes. DO NOT repeat even if no bowel movement.  Apply Scopolamine Base Patch behind the ear the night before surgery. (Rx only anti-nausea medication. This medication will be shipped to your home.)  Drink 2 full glasses of water before midnight.

Day of Surgery  Nothing to eat/drink after midnight the night before the surgery  Take Emend (Rx only, anti-nausea medication. This medication will be shipped to your home) on the morning of surgery with a baby sip of water.  No medications on morning of surgery unless instructed by anesthesiologist/surgeon; if you are unsure then bring all medications with you to the hospital  No makeup/face lotions/jewelry/hair accessories with metal  No contact lenses (bring contact case)  Wear loose fitting clothing  Leave all valuables at home  Bring D.L/Insurance  If you use a CPAP machine bring it with you to the hospital  Have a responsible adult available to drive you home 1 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

Post-Surgery Please notify office staff if you are taking or plan on taking any NSAIDS (long-term) as they are known to cause ulcers and erosions to the stomach & higher risk in bariatric patients. *Smoking has also contributed to many post-operative complications.

PRIOR TO SURGERY 7 day clear liquid diet prior to surgery 14 day clear liquid diet if BMI is greater than 50. Clear liquids listed below

CLEAR LIQUIDS PRIOR TO SURGERY & POST SURGERY FOR 3 WEEKS:  Protein shakes: Ex: Bariatric Advantage, Advocare, Slim Fast-low carb, Adkins Advantage Edge, Isopure, Premier protein, New Whey Shots, Whey protein powder mix, etc. Protein shakes will be your meal replacements and you’re allowed up to 4 per day, even though they’re considered a full liquid we allow you to have them during the clear liquid diet. They will give you the energy that you need.  Water / ice chips  Mild, clear juices ex: cranberry,  Tea apple or grape.  Coffee  Skim milk, light soy, or lactose  Crystal Light free milk  Sugar free Kool-aid, Tang,  Sugar-free or no sugar added lemonade, ect. popsicles or jello.  Diet Snapple  Low sodium broths

STAGE 1: BARIATRIC CLEAR LIQUIDS Discharge from hospital 1st week Use protein supplement 1-2 per day (goal 40-60 grams daily) along with clear liquids listed above. All protein shakes must be low in sugar high in protein. Make sure to keep in minimum of 48 oz. of fluid in daily, but STOP when you feel full! Each meal will equal about 2-4 oz or, or ¼ - ½ cup in volume (1 ounce= 2 Tbsp) Small amounts (1oz every 15min.). Sip slowly and stop when you feel full or nauseated. NO CARBONATED BEVERAGES. Start with very thin liquids and advance slowly to thicker liquids. Remember to walk, walk, walk! It is the key to faster recovery.

2 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

POST OP MEDICATIONS: 1. Begin a multivitamin and mineral supplement (liquid or chewable preferably) 2. Begin sublingual (under the tongue) B12 2500mcg-7500mcg weekly or Nascobal Nasal Spray B12 is available by prescription only taken once a week. 3. Begin Pepcid Complete chewable OTC or Dexilant 60mg prescription only for 6weeks after surgery (acid reducer) Directions for Dexilant: open capsule and mix with ½ teaspoon of yogurt or applesauce. 4. Hycet: Liquid pain medication. 5. Phenergan Syrup or Zofran: To prevent nausea and vomiting. 6. Compounded Pain Cream: Apply 1-2 pumps, 3-4 times a day around the incision with a maximum of 6 pumps per day for pain relief. Wash hands before and after application. Do NOT apply cream to open wounds. 7. Scar Gel: At 6 weeks post op you may start to apply 1-2 pumps to the incision 2-3 times per day for scar reduction. Please note medications will be shipped to your home once your address & insurance have been verified by the Apothecary Shop pharmacy. In the meantime, if you have questions please call the pharmacy at 214-357-8889.

STAGE 2: BARIATRIC FULL LIQUIDS Gastric Sleeve- Weeks 2 & 3 Continue multivitamin & mineral Add cream/ blended soups and drinkable yogurts NO chunks or lumps Use protein supplement 1-2 per day (goal 40-60 grams daily) 48oz of fluid daily Avoid sugar sweetened drinks, Carbonation, Caffeine, & Alcohol

STAGE 3: BARIATRIC SOFT Gastric Sleeve- weeks 4, 5, & 6 Continue all supplements (vitamins, minerals, protein) Begin calcium citrate supplement 1000 to 1200 mg daily (500mg doses with at least 1hr in between doses. DO NOT take at same time as multi- vitamin or iron.) Continue 48 oz- 64 oz of fluid daily GOAL: at least 60 grams of protein daily and exercise 20 minutes 5 times a week.

SOFT FOODS

 Cooked cereal  Mashed potatoes  Cream of rice  Crispy toasted bread  Cream of wheat  Low fat cottage cheese or ricotta  Malt-O-Meal  Low fat yogurt  Thinned grits or oatmeal  Low fat cheese

3 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

 Egg tuna  Vegetables (cooked, canned or  Canned chicken or tuna ( with pureed only if able to be mashed light mayo only) with fork)  Shaved deli meats  Fruits (Cooked, canned or  Flakey fish like tilapia or salmon pureed. Unsweetened applesauce, and bananas, Fruits only occasionally.)

STAGE 4 BARIATRIC REGULAR Weeks 7-3 months Ground beef & meats (Moist cooking) Continue all supplements (vitamins, minerals, protein) & fluids. May continue protein supplement (protein shake) if you’re unable to get 60grams of protein with regular diet. GOAL: Exercise/ planned activity 20- 30 minutes 5 times weekly.

REGULAR DIET

 Low fat soups  Cooked, canned or pureed vegetables  Wild rice, angel hair pasta, whole wheat  Cooked, canned or pureed, unsweetened pasta applesause, fresh fruit, bananas, some  Meats (Chicken, turkey, pork, beef, seafood. melons, citrus. (only eat fruits rarely) Cooking method same as above.)

3 MONTHS- Lean beef & raw veggies Weeks 3 months + Continue all supplements, fluids, protein, and exercise. GOAL: protein & produce. Lean beef now ok and raw veggies. Exercise/planned activity 45 min 6 times weekly.

Things to expect after surgery:  Up and walking shortly after surgery  Discomfort and drowsiness  Possible Upper GI study to check for problems about 1 hour after surgery  Nothing to drink until clearance from surgeon  Metallic taste and very dry mouth  Surgery can be inpatient and most likely you are discharged from hospital the following day.

4 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

Pain Overview:  Pain medicine will be ordered and administered via IV liquid oral medication  Expect some pain, but it should be tolerable, 5 or less on a scale 1 to 10  If pain medicine is not working, tell your nurse  Ask for pain medicine before going home to make your trip more tolerable  Get a prescription for pain medication to take at home  If pain medication is not working once you get home, call your surgeon’s office and have pharmacy phone number on hand  Left shoulder pain and incisional pain is common (left side is usually the most uncomfortable)

Incisional Care  Staples, sutures (stitches), skin glue, or possibly steri-strips  Pinkness or redness around incisions is normal ( bruising near incision or in abdominal area is normal)  May have some clear drainage  May have hardness around or under incision site(s)  Ok to wash with antibacterial soap but do not scrub or attempt to take glue off do not use alcohol or peroxide  No ointments or creams (such as Mederma) for 6 weeks. If pain cream is prescribed make sure to apply AROUND incision not on open wound.

Medications  Crush or cut pills for 6 weeks (liquid or chewable if available) – check with pharmacist about crushing pills. After six weeks, pills should be no larger than Aspirin size.  No NSAIDs (Non-Steroidal Anti-Inflammatory) such as Advil, Aleve, Motrin, Ibuprofen or any aspirin ( unless approved by Dr. Jayaseelan)  Find out about resuming medications before leaving the hospital  Start liquid or chewable multivitamin and B12, and Dexilant as instructed to begin in week 1  Calcium Citrate to be started week 4

5 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

Post Operative Instructions:  No lifting over 20-25 pounds for 6 weeks after surgery  No strenuous exercise for 4 weeks after surgery. Only walking is permitted and must be done daily ( at least 5 minutes every hour while awake to prevent blood clots)  Incentive spirometry- every hour to encourage deep breathing. Use this 4-5 times each hour while awake. Take it home and continue to use until 1st follow up.  Showers only. No submerging your incisions in water for 4weeks (bathtub, pools, lakes, hot tubs,ect.)  You may have left shoulder pain that is referred from surgery, walking will help this pain go away  Make sure you are having bowel movements daily. (Milk of Magnesia or liquid Gas-X can help with bloating and constipation.)  No driving until you stop all pain medications  You may continue to have some mild incisional pain for up to 4 weeks after surgery, especially if twisting or bending certain ways  Return to work in approximately 7-10 days  When back at work be sure to get up and move every hour for the first 4 weeks to help prevent blood clots  Be sure to drink at least 48oz of fluids each day the 1st week (64oz a day thereafter)  Be sure to get 40 grams of protein each day the 1st week (60 grams a day thereafter)  Measure your sips; they should be less than 30ml at a time about the size of a medicine cup.  Take Dexilant or over the counter PPI (Pepcid Complete chewable, Prilosec, Prevacid) for 6 weeks after surgery. You can continue to take if needed after 6weeks. You will open the capsule and mix with ½ teaspoon of thinned yogurt or applesauce.

Things to have waiting at home:  Chewable Gas-X & Milk of Magnesia ( for intestinal gas pain)  Extra Strength Liquid Tylenol ( or generic equivalent)  Liquid or chewable vitamins and calcium citrate  Protein drink or shakes and clear liquids  Comfortable walking shoes  Help and support around the house for at least 1 to 2 days

6 Revised 7/9/14. Sleeve & Bypass Procedure Instructions Dallas Bariatric Center

11970 North Central Expressway Suite 670 Dallas, Texas 75243 972.331.1111 | 972.331.1112 (fax)

CALL DR. JAYASEELAN’S OFFICE IMMEDIATELY IF DESCRIPTIONS LISTED BELOW OCCURS:  Bright red blood is in your vomit or stools  Excessive pain in chest or pain/swelling in legs  Difficulty breathing or shortness of breath  Inability to keep liquids down and no urination  Frequent vomiting or diarrhea lasting more than 12 hrs.  No bowel movements, even after Colace or Milk of Magnesia  Uncontrollable pain or severe unusual pain around incisions  Milky or malodorous discharge from incision  Fever above 100 degrees F.  Anything that doesn’t feel right to you!

Post op Care/ follow ups for Sleeve and Gastric Bypass patients:

 week 1  year 1  week 2  month 18  week 3  year 2  month 3  year 3  month 6  year 4  month 9  year 5

7 Revised 7/9/14. Sleeve & Bypass Procedure Instructions