Patient information for bariatric surgery

In an OAGB (one-anastomosis gastric bypass) operation, the surgeon makes the stomach much smaller by using special staples. They start at the lower part of the stomach, called the antrum (this is the bottom section of the stomach), and create a long, thin pouch.
The rest of the stomach stays inside your body, but food no longer goes through most of it. Instead, food goes straight into a lower part of the gut. This means it bypasses (skips past) most of the stomach and about one and a half metres of the small intestine (the long tube that helps digest food).
You will feel full more quickly, and take in fewer calories. 

RYGB involves the creation of a small pouch, at the top of the stomach (about the size of an egg) which is joined to the small bowel. This allows food to bypass the stomach (which remains in place) and enters the intestine lower down. 

The pouch is no longer attached to the stomach (called the remanent stomach) allowing digestive juices to filter in where the small bowel is re-joined to the duodenum (at the jejunojejunostomy).  

This works by limiting the amount that can be eaten and altering the appetite hormone production/pathway. It is very effective for weight loss but there is a risk of not getting enough nutrients.

Protein: Try to include a protein food at every meal. Aim for 60 to 80g protein each day. Focus on low-fat protein sources such as chicken, fish, turkey, beans, lentils or tofu or low-fat dairy.

Fats: Limit the amount of oil, butter or margarine you use. Cooking sprays are a good alternative. Try to avoid high fat foods such as cakes, biscuits or crisps.  

Carbohydrate: Limit starchy carbohydrates. Try to have 1 to 2 meals per day which do not include starchy carbohydrates. Choose wholegrain options if you do eat them. Aim for less than 120g per day.

Sugars: Avoid adding any type of sugar, honey or syrup to foods. Artificial sweeteners are ok to use. Aim to avoid eating any foods high in sugar e.g. cake, chocolate, sweets, fruit juice.

Meal ideas

Aim for a low-sugar, high-protein, meal-replacement shake to provide 800 to 1000 calories in total each day. Many of these shakes are low in fibre so it can be helpful to include 1 to 2 portions of vegetable or salad each day to help prevent constipation. 

When choosing your shake look for one containing 200 to 300 kcals and 20 to 30g protein per serving. Aim for a low sugar option, approximately 5g of sugar per 100g/100ml.

*vegan options

If you have diabetes treated with tablet medication and/or insulin you will probably need to change these medications. Your diet before and after surgery will have very little carbohydrate and can increase your risk of hypoglycaemia.  
We will help you make a plan in your pre-operative assessment appointment. You will need to monitor your diabetes control more closely during this time.

Bariatric surgery is high risk and there can be complications. Sometimes you may need to seen by us again at the hospital. Things to look out for are:
abdominal pain getting worse

• vomitting
• unable to eat or drink
• increased temperature
• shortness of breath
• swollen, red, or tender legs or calves

If you have any of these symptoms please go to the Emergency Department or contact the GP or Bariatric Team. 

You will normally have 5 to 7 abdominal wound sites which will have dissolvable sutures and surgical glue over the top. You can shower as usual but avoid baths until the wounds are fully healed.

Your wounds will usually be slightly red, tender and bruised during the first couple of weeks following surgery. 
If you experience any of the following signs of infection, please contact your GP or practice nurse:

• redness or inflammation spreading from the edges of the wound
• pain or soreness in addition to the discomfort experienced following surgery
• area around the wound feels warmer or hotter than the surrounding skin
• the area around the wound becomes swollen
• the edges of any part of the wound separates or gape open
• discharge or leakage from the wound

Fluids are essential to prevent dehydration following surgery. Dehydration can lead to:

• constipation
• headaches
• poor concentration 
• your body not working as well

Aim to drink at least 1.5 to 2 litres a day, taken between meals (remember, not with a meal) by having regular sips of fluid throughout the day. You should avoid fizzy drinks as too much gas in the stomach which can be uncomfortable. 

If you do not like water, try other drinks such as no added sugar squash, milk, sugar free flavoured water, adding a squeeze of lemon/lime into water. 

Tips to help with fluid intake

• Carrying a water bottle or a flask for hot drinks.   
• Setting an alarm can act as a reminder.
• Drink slowly, avoiding gulping water which may cause discomfort or bloating.
• Keeping track of fluid intake can indicate if goals are being met.

Constipation in the first few weeks following surgery is very common due to eating less and inadequate fluid intake. If bowels do not open for three days or more, using a gentle laxative such as liquid docusate sodium will help. If you cannot tolerate the laxative or is ineffective, please contact the Bariatric Team. 

Some useful tips to manage constipation

1. Improve fluid intake by taking regular sips, carrying a water bottle or flask for hot drinks will help, and setting an alarm to help as a reminder. 
2. Have a warm drink when you wake up to help stimulate the bowels.
3. Improve how much fibre intake (alongside the diet plan for after surgery).
4. Add linseeds or flaxseeds to yoghurt, soups, or cereal.
5. Your position on the toilet is really important, raising your legs for example on a stool will help when trying to poo. ]
6. Do not delay if you feel the urge to poo and give yourself plenty of time to use the toilet.

All medication including existing medication will be crushed or liquid for 4 to 6 weeks following surgery.

A-Z multivitamin supplements will need to be in chewable. 

We will give you discharge information on your medication and any equipment you need such as a pill crusher.
 

You will need to wear TED stockings to help prevent a blood clot (DVT) for 2 weeks following surgery.
 

You should be able to drive after two weeks. It is your responsibility to inform your insurance company that you have had surgery. You must be able to do an emergency stop and check your blind spot (look over your right shoulder) comfortably.

Following surgery, you will need thin liquids (drinks) for 2 days such as:

• water/ squash/ protein water/ tea and coffee/ semi-skimmed milk
• have small amounts of fluid (no more than 50mls) every 10 to 15 minutes
• aim to consume at least 2 litres of fluids each day
• even if you feel thirsty it is important you drink small quantities at a time
• avoid fizzy or high calorie drinks such as juices
• if you have stomach pain or nausea whilst drinking stop until the feeling has passed

Aim to have high protein drinks, shakes, or soups which are smooth (with no lumps) regularly throughout the day. The liquids should be able to run off the back of a spoon e.g. thin yoghurts, tinned soups, or runny custard.  

• Portion sizes are approximately 100 to 300ml. 
• Take small mouthfuls one at a time and give yourself a break in between mouthfuls so you can recognise the early signs of fullness and stop.  
• If you feel pain, stop immediately.    
• You will need to drink other fluids (water, tea, squash) to get your 2 litres fluids per day.  
• It can be difficult to get enough nutrients while you are following a liquid diet. 
• Aim to include as many liquids with lots of protein as possible. Protein is important for your general health including maintaining your muscle mass while you are losing weight. This will help your overall weight loss.   
• Aim to have 60g protein.

High Protein Liquids

• ‘Fortified milk’ - 1 pint semi-skimmed or skimmed milk with 4 tablespoons of dried skimmed milk powder
• Smoothies – fruit or vegetables blended with fortified milk, natural yoghurt or protein powder. (Avoid shop bought smoothies as these are low in protein and high in sugar).
• Smooth Soup (homemade or tinned). Add 1-2 tablespoons of skimmed milk powder or protein powder
• Meritene or Complan shakes or soups – available in Supermarkets or pharmacies 
• Meal replacement shakes e.g. Slimfast, Tesco Slim, Asda Great Shape, Exante or Lighter Life
• High protein milkshakes e.g. UFit, Arla, For Goodness Shakes, Urban Active
• Protein Water e.g. Vieve, Upbeat or +PW
• Whey, soya or pea protein powders

Recipes

Gradually introduce foods which are soft in consistency – foods that fall apart easily with a fork. Foods which are naturally moist are good at this stage or add sauce/gravy to dishes. 

Start with a small portion e.g. 3 tablespoons as a meal and increase gradually depending on how you feel.

Menu plan

Example meals 

Breakfast

• Low fat, high protein yoghurt with soft fruit
• Weetabix or other cereal softened with milk
• Porridge or Ready Brek
• Soft, cooked egg (poached, scrambled) with a tinned tomato
• Homemade fruit smoothie (fruit blended with yoghurt or milk)

Main meals (two a day - lunch and evening)

• Crackers or crispbread with high protein topping (tinned fish, cottage cheese, hummus, mashed egg, low fat cheese)
• Omelette (1 to 2 eggs) with cheese
• Lasagne, ravioli or spaghetti Bolognese (soft pasta dish)
• Sheppard or cottage pie
• Fish cooked in sauce or fish pie with vegetables
• Tuna pasta bake
• Meat stew
• Chunky, high protein soup
• Curry

Tips

• Use healthy cooking methods and use herbs/spices to flavour foods.
• If using oil, measure out a small amount (1 to 2 tsp).
• Try 1 tbsp of a new food every 1 to 2 days. If you feel nauseated or bloated after eating, then you may not be ready for this food. Wait a few days before trying this food again.

You are now ready to progress onto your long-term healthy diet. 

This stage can be challenging as you learn how much you can eat of certain foods and the importance of paying attention to your body as you eat. Continue to add new foods in slowly. 

Aim to eat 3 small meals per day with 1 to 2 snacks as necessary. Focus each meal and snack on a protein-rich foods. Keep portions small by using a small plate. Aim to eat 60 to 80g protein per day. 

Menu plan

Snack ideas (100 calories - higher protein)

• Small handful of nuts*
• 2 Small handful nuts*
• 2 tbsp roasted pumpkin/ sunflower seeds*  
• Slice of smoked salmon or ham with cucumber sticks*    
• Slice smoked salmon with 1 teaspoon cream cheese*
• Trail mix of nuts/seeds with dark choc chips    
• Nice cream – frozen banana whizzed with peanut nutter
• 1 pot of high protein natural yoghurt* (Icelandic or low fat Greek style)     
• 1 pot of fruit flavoured high protein yoghurt 
• 1 pot Greek style soya yoghurt*    
• 2 tbsp low fat Greek yoghurt with handful of berries*
• 1 boiled* or devilled egg*
• 80g soya/edamame beans*
• 1 oatcake or rye crisp-bread with 1 tbsp cottage cheese or low fat cream cheese    
• 80g Spicy chickpeas – try roasting with cumin and smoked paprika
• 1 pack of chicken bites*
• Slice of ham with low fat cheese spread* or cottage cheese*
• 1 egg muffin*  
• 1 mini cheese or babybel * 
• Veg sticks with 1 tbsp of hummus or bean dip    
• 1 stalk of celery* or 2 to 3 slices of apple with 2 tsp of almond butter

Cooking tips

• Remove fat and skin from meat before cooking. 
• Use low fat cooking methods such as grilling, baking (wrap in foil to keep things moist), steaming or boiling.
• Limit oil or butter added to vegetables or salads. If you need extra flavour, add seasoning or a little bit of low-calorie dressing or vinegar. If you need to use oil to stop food from sticking, use a spray oil. 
• Add flavour using herbs, spices, seasonings, lemon juice, ginger, onions, and garlic.
• Aim to avoid adding oil or butter to carbohydrates.
• Choose high fibre (wholegrain) carbohydrate foods where possible e.g.  wholegrain bread, brown pasta, brown rice, wholegrain/seeded crackers or oatcakes and keep skins on potato.
   

It is common to suffer with constipation in the early days of these operations due to the limited amount of food and drink you are consuming. 

To help manage constipation:

• drink plenty of fluids – aim for 2 litres daily 
• add in a laxative such as docusate sodium
• add in some high fibre foods where able e.g. vegetables, wholegrain carbohydrates, beans and pulses 
• keep active as your body allows

Please contact the Bariatric Team or the Bariatric Clinical Nurse Specialist if the above does not work. 

If you experience any of the above symptoms, it may be for one of the following reasons: 

• eating too quickly 
• not chewing enough 
• eating too much 
• drinking with the meal or within half an hour after eating 
• lying down too soon after eating 

If you have symptoms such as shortness of breath, worsening abdominal pain, fever, limb swelling, unable to tolerate food/fluids, nausea and vomiting please go to the Emergency Department, or contact the Bariatric Team or GP.
 

It is quite common for people to feel tired and to have low energy levels in the early weeks after the procedure. This is usually due to the fact that it is difficult to consume adequate calories and protein, also the fact you are losing weight.

Aim to consume at least 60g protein and 800 kcal each day. If you are struggling to do this, it can be helpful to include protein shakes to help meet this target. 

Tiredness can also, but less commonly, be due to a vitamin or mineral deficiency, so please do ensure you take your multivitamin and mineral supplement twice daily.

In the first 6 to 9 months, it is common to experience some hair loss. Again, this is usually due to an inadequate intake of calories and protein. Once your weight loss has stopped, this problem is usually resolved.

After your procedure you will be eating significantly smaller portions of food and it can be hard to get all the vitamins and minerals your body needs. Please take the following vitamins and minerals. You can buy these in most supermarkets, chemists or online. 

• 1 x A-Z multivitamin tablet twice daily

For first 6 weeks the multivitamin supplement will need to be in a chewable form. Once you are on a normal textured diet you can take a tablet form.
 

Dumping syndrome happens when the lower end of the small intestine (the jejunum) fills too quickly with undigested food from the stomach. There are two types of dumping: 

Early dumping - can occur during or right after a meal. Symptoms of early dumping include nausea, vomiting, bloating, cramping, diarrhoea, dizziness and fatigue 

Late dumping - can happen 1 to 3 hours after eating and is usually due to a low blood sugar. Symptoms of late dumping include weakness, sweating and dizziness 

Management of dumping syndrome: 

Early dumping syndrome: Lie down as soon as you experience these symptoms, you are likely to feel better after around 30 minutes. 

Late dumping syndrome: Have a snack that includes both carbohydrate and protein such as a cracker with soft cheese. If you feel very unwell you may need a small glass of orange juice before the cracker to bring your blood sugar back to normal. 

• To avoid experiencing dumping symptoms: 
• avoid chocolate, biscuits, cakes, sweets, desserts, high sugar drinks, high glycaemic index (GI) carbohydrates such as white bread
• aim to eat at least 3 times per day (rather than 1 big meal)  
• avoid eating and drinking at the same time – wait 20 minutes

Losing weight can increase fertility but we strongly recommend that you do not become pregnant for 2 years following the procedure. Weight loss may have effects on the unborn child. If you do get pregnant following bariatric surgery then it is important to let your GP, obstetrician, midwife, and Bariatric Unit know as soon as possible. You may require extra monitoring during the pregnancy to ensure that you and the baby get enough nutrients to keep healthy.

1. Focus on protein-rich foods every time you eat. Include vegetables, salads, wholegrain carbohydrates, unsalted nuts and fruit. 
2. Eat three meals daily and choose healthy snacks if you are hungry in between meals. 
3. Think PVC – protein first, then vegetables, then carbohydrates.
4. Limit foods high in fat, saturated fat and sugar such as biscuits, cakes, muffins, sweets, confectionary, chocolate and crisps 
5. Aim to follow the ‘Rule of 20’: 
   • cut your food up to the size of a 20 pence piece size 
   • chew 20 times  
   • wait for 20 seconds after swallowing before taking a second mouthful 
   • stop eating after 20 minutes (if you haven’t already stopped) 
   • avoid drinking 20 minutes before and after eatinh
6. Sip fluids often throughout the day; aim for 2 litres daily  
7. Avoid carbonated and sugary drinks. 
8. Avoid alcohol for the first 3 to 6 months, after this we advise caution when    drinking alcohol as your body will absorb at a faster rate and you will feel theeffects stronger.
9. Monitor your weight and food intake if you find this helps you keep on track.
10. Move your body in ways that your body allows, and you enjoy such as dancing in the kitchen or walking around the block  
11. Take your vitamin and mineral supplements. 

You will have Specialist Dietician support for 2 years following the procedure. Your first review will be approximately 3 months after your operation.

Protein is essential for growth and repair of the body, the basic building blocks for the body to help maintain good health. Following bariatric surgery, it is really important to include lean and low-fat sources of protein with each meal, aiming for 60 to 80g daily.

Below are some sources of protein (please be mindful whilst on the progressive textured plan 4 to 6 weeks after surgery):

• animal sources: lean red meat, lean poultry, fish and other seafood, eggs
• dairy sources: milk, yoghurts, cheese
• plant sources: soya, beans, pulses, lentils, tofu, nuts

Aim to eat the protein rich food of your meal first:

• eat first: protein (meat, fish, poultry, eggs, beans, pulses)
• eat second: vegetables and salad
• eat last: carbohydrates (bread, rice, potato, pasta, grains)

Top Tips:

• Plan your menu in advance; base your meals and snacks around foods that are high in protein.
• Choose low-fat varieties or lean meat; cut any visible fat off. Avoid adding fat when cooking these foods.
• Chew meat, chicken and fish well before you swallow to avoid it getting stuck.
• Eat slowly, use the ‘rule of 20’.
• You may find roasted meats more difficult to tolerate. If this is the case, you may find alternative ways to cook meats which may be easier, for example, stewed meats, casseroled meats, slow cooked meat, minced meat, and wafer thin meats.
   

The amount you will be able to eat is likely to change over the first year. The average portion of a meal in the first 3 to 6 months following your surgery is 3 to 6 tablespoons in total. By a year, most people can manage a child’s portion.

How much you eat will depend upon:

• type of food 
• how quickly you eat
• how much you have had to drink prior to a meal

During the initial time period after surgery (4 to 6 weeks) all medications will be in crushed or liquid form.

• Supplements after surgery
  • Iron - liquid ferrous fumarate for 4 to 6 weeks after surgery then continue in tablet form
  • A-Z multivitamin - chewable for 4 to 6 weeks twice daily and then continue in tablet form
  • Calcium and vitamin D - calcium and D3 one tablet twice daily
  • Vitamin B12 - injection by GP practice every 3 months
• Proton Pump Inhibitor (PPI)
  • Lansoprazole - or 1 year after surgery
  • Enoxaparin or fondaparinux  - for 2 weeks after surgery
• Constipation
  • Docusate sodium - if bowels have not open (pooed) for 3 or more days
     

Follow-up after surgery will be a mixture of face to face and phone appointments.

• Bariatric practitioner: 7 to 10 days
• Consulatant: 6 to 8 weeks
• Dietician: 3, 6, 9, 12, 18, and 24 months
   

• Bariatric Surgery Practitioner 0117 414 2085 or 07557 312784
• Bariatric Waiting List Coordinator 0117 414 8826
• Bariatric Coordinators 0117 414 0855 or 0117 414 0854