Your new anatomy after WLS

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Gastric Bypass

This page is a copy from sabariatric.

by Dr. M Selinkoff, Dr. Pilcher, Dr. Dana Reiss, and Dr.

Terive Duperier is based in San , Texas

Your new anatomy

The Roux-en-Y gastric bypass uses a staple line to partition the

stomach into two parts, with a very small " pouch " above the staple

line. This tiny pouch can hold about 2 ounces, about the size of a

double shot glass. The pouch is then hooked up to a segment of small

intestine in a way which should make the patient sick if he/she eats

a lot of sugar or other enriched food. The small pouch makes it

difficult to eat a large amount of solid food, but provides very

little barrier to liquids taken slowly.

Ghrelin is a hormone made in the stomach stimulates food intake. A

new study shows dieting increases Ghrelin (makes you hungrier) while

Gastric Bypass suppresses Ghrelin, explaining some of it's

effectiveness.

While the tissues of your surgically-altered stomach are healing,

you will be instructed to minimize the stress on these " raw " tissues

by never forcing food. This means that your main intake will be

(zero calorie) liquids and you will only eat small amounts of food

that is mostly soft. When you are doing well with soft food you

should transition to more solid food like chicken or fish.

Diet progression in the hospital

During the operation, a tube is placed through your nose into your

new stomach. On the first night after surgery, you may drink sips of

fluids regularly, and this tube will suck the fluids out, preventing

excess pressure on your new stomach pouch. When the stomach tube is

removed (usually the morning after surgery) you will be offered

sugar free clear liquids. You should sip on these liquids gradually,

and begin to learn how to sense fullness of the new stomach pouch.

It will always be important to avoid high calorie liquids such as

fruit juices and sugared soft drinks. When you are tolerating clear

liquids (usually one or two weeks), the soft diet is started. Your

surgeon will not expect you to eat all of the food provided, but

this will serve as an example of the type of diet you will be on for

your first week or so at home.

Focus on Fluids

One of the main challenges for a gastric bypass patient over time is

to maintain hydration. Your body needs just as much fluid after the

surgery as it did before surgery, yet you are limited by the stomach

pouch to intake of 1-2 ounces at a time. Maintenance of fluid intake

may also be difficult because of the necessity to take in food or

fluids, and not both at once. You must compensate for this by taking

small amounts of fluid on a near-constant basis. Usually this means

that you should carry your fluid source (a small bottle, or " sippy

jug " , or something similar) with you at all times. Icannot

overemphasize that the liquid must be a calorie-free liquid such as

water, Crystal Light, diet Kool-aid, or other diet products.

Patients who use fruit juice or other calorie-containing liquids for

hydration may experience inadequate weight loss because of the

calories in these fluids.

Fluids should be consumed on a near-constant basis, but not during

meals and not soon following food. If you drink during your meal,

you will tend to wash the food out of the stomach pouch, and consume

more food than is desirable. It may seem strange at first to eat

without drinking but it works fine. A good tip here is to actually

not have any fluid on the table while you are eating. In addition to

reducing your overall food intake, this new habit will encourage you

to chew more thoroughly before swallowing, because you will not

count on the fluid to wash down half-chewed food. Also note that

soup is kind of like drinking liquids with food – soup is not an

absolute " no-no " but recognize that it should not be a regular part

of your diet.

Liquids should not be consumed for about an hour after eating. This

is because the food actually forms a plug that blocks the outlet

from the pouch until it has all passed through. If you drink liquids

on top of this plug it will create a very uncomfortable sensation

and may also force food downstream more quickly than it should go.

A brief review on coordinating liquids and food:

Sip liquids constantly, even just before eating.

Don't drink liquids while eating.

Don't drink liquids until about one hour after completing your

meal. When the stomach pouch is mature (six months or more after

surgery) it is useful to wait two or three hours after eating before

consuming liquid.

If you must choose between liquids and food (frequently true in the

first months after gastric bypass) – choose liquids!

The Soft diet after Gastric Bypass

After a couple of weeks following your surgery, you can eat foods

which are high in protein and yet are " soft and mushy, " or foods

which are " crispy. " Foods which are " mushy " can be put into one of

four categories:

MUSHY FOODS:

Eggs - scrambled, soft boiled, and in the form of egg salad. The

whites of fried eggs are usually too rubbery to be eaten this soon

after surgery. Remember: egg whites have the protein, the yolks are

mainly fat.

Dairy products - although these are high in saturated fats, they are

also high in protein and will go down easily. Soft cheeses, low fat

yogurt, (flavorings optional), low fat frozen yogurt, and skim milk

are the best dairy products for weight reduction. Hard cheese may be

taken in moderation. Avoid: whole milk, cream, ice cream, whipped

cream, and ice milk.

Eggs and cheese are excellent sources of protein, but they also

contain a fair amount of fat. Eggbeaters (or just egg whites), low-

fat cottage cheese, and low-fat cheeses will give greater weight

loss, but are not 100% essential to have a decent weight-loss

result.

Legumes - this includes beans, lentils, and peas. All should be in a

mushy form which will pass through the pouch easily. Good examples

would be: split pea soup, bean soups, refried beans. Do not try

fresh or frozen green beans yet, because they are too fibrous to

digest easily. Canned green beans can be tried only if they're very

soft. Peanut butter should be used only in small amounts as a

substitute for butter or margarine. Peanut butter is very high in

fat, so use sparingly. A good choice for beans would be " fat-free

refried beans. "

Animal protein - examples of this would be tuna salad, chicken

salad, deviled ham, potted meats, pates, and liverwurst. Avoid any

gristly meats (including Spam) at this time because gristle tends to

get stuck in the pouch. Spam must be chewed very well. " Potted

meats " include any soft meats that you can spread on a cracker.

You may use real mayonnaise, light mayonnaise, or non-fat mayo....

the only difference to you will be how quickly you want to lose

weight. The same applies to your choice of tuna packed in water, or

packed in oil: If you choose " in water, " you will take in less fat,

and consequently, lose weight faster. It is up to you.

CRISPY FOODS:

" Crispy foods " are: foods that will disintegrate if you place them

in a glass of water. Examples of crispy foods would be: Melba toast,

crackers, well-toasted bread, tortilla chips, or very crispy bacon.

You can eat tortilla chips that are baked or fried. Again, if you

always choose " baked tortilla chips, " you will lose weight faster

because you are taking in less fat. Foods that must be chewed well

in order to be swallowed are crispy. Example: very crispy bacon, or

crackers.

You may put any spread on your crispy toast. However, if you put

regular butter on your crispy toast, you will lose weight more

slowly than if you select low-fat butter or margarine. The same

principle applies to regular cream cheese vs. low fat, or non-fat

cream cheese. If you want to lose weight faster, make the lower fat

choices. To avoid all fat on toast, eat it very toasted and dry, or

add just jam or jelly on top. There's no fat in jams, but there is a

small amount of sugar.

You can combine any " mushy " food on top of any " crispy " food.

Examples: tuna fish on crackers, or refried beans on tortilla chips,

or egg salad on crispy toast.

On the other hand, fried salty snacks such as potato chips, Cheetos,

Dorito's, etc. are ABSOLUTELY FORBIDDEN. If you get the urge for a

salty snack, Irecommend beef (or other meat) jerky. This fills your

mouth, you get to chew it a long time, and it is high in protein as

well.

NOTE: " Crispy foods " are not the same as crunchy foods. Raw

vegetables are the best example of crunchy foods. During this soft

diet, do not eat any raw vegetables because they are too fibrous and

can get tangled in the outlet. Example: do not put any celery in

your tuna salad or chicken salad. Canned vegetables can be eaten for

variety, because they are more mushy. By the second week after

surgery, you may start adding more of a variety of foods to your

diet if you are not having any difficulty tolerating the mushy

foods – if you are not sure ask the dietician or your surgeon.

Transition from Soft diet to Regular Gastric Bypass diet

As the weeks go by after surgery, additional foods may be added such

as ground meats, spices, and well-cooked vegetables. Patients vary

on the timing, so it is appropriate for individuals to adjust their

own progress depending on how they feel. When you are able to

routinely handle mushy food, you may begin adding new more solid

foods to your diet. In the long run you are permitted to eat

anything that is low in sugar and fat. As you expand your diet try

very small amounts of the new food, in case it doesn't " sit well. "

If you experience a problem with a particular food item, that

doesn't mean you can't ever have that thing again, but you should

wait awhile.

By the second week, you may try peeled fruits (apples, pears).

Remember to take small bites and chew well before swallowing.

Grapefruit may be tried by the fourth week. Note that fruits do

contain natural sugar, which can cause dumping syndrome if consumed

in large amounts. Usually dumping is not a problem because the fruit

also takes up space in your pouch and you don't get a large load of

sugar. Also, the natural fiber in the fruits seems to slow the

absorption of the sugar and reduce the chance of dumping. Note that

fruit juices (especially orange juice and grape juice) are rather

likely to cause dumping syndrome because they contain natural sugar

and go down easily in significant quantity.

It is best to wait until at least the third week following your

surgery before trying to add regular meats to your diet.

Weight loss and maintenance diet after Gastric Bypass

About four to five weeks after surgery, the patient should have

transitioned to a diet totally different from the above Soft Diet.

The main purpose now should be weight loss. To maximize weight loss

and to maintain nutrition, solid foods should be taken almost

exclusively. This means that soups, yogurt, and other healthy but

soft calories should be minimized.

You should now begin eating the same foods as the rest of the

family, only in much smaller amounts (e.g. a chicken wing might

constitute an entire lunch). The best foods here are meats and

salads. Since the quantity of your intake is very limited, it is

very important that you eat highly nutritious foods and don't waste

valuable space in your new " stomach pouch " with empty calorie, junk

foods. This is a great incentive to " eat healthy. "

All meats can now be eaten. The two most important things to

remember when eating meats are:

To cut up each piece of meat to the size of the eraser on a wooden

pencil.

To chew up each piece of meat individually, before swallowing.

These two new habits may take you several weeks to work on before

you feel comfortable doing them every time. Keep trying, even though

at first, it may seem very strange on your plate and in your mouth!

Each patient has certain foods which " don't agree with me. " It is

important to recognize that these are usually the very foods which

fill up the pouch the fastest! If a bite of a hamburger fills up

your pouch and makes further eating impossible, often it isn't

because " the hamburger doesn't agree with me " , but rather, because

that small amount of hamburger was enough to fill up your pouch!

STOP eating right then and there! To have that " second bite " is

often to overeat. Your new restricted stomach can't handle it – even

one more bite will distend the pouch and make you feel miserable.

When you have an experience like this (all patients do) use it to

learn how much of different kinds of food it takes to feel full. Try

to train yourself to recognize an adequate amount of food while it

is still sitting on the plate, and avoid that " painful full " feeling

altogether.

This is a new concept and it will take time to adjust to it. So, go

easy on this new eating pattern in the first few months until you

know what that new " feeling of fullness " is like. Eating such small

amounts of foods seems strange, but it is all you need to be healthy

and will promote maximum weight loss.

Remember: when you go to eat out in a restaurant bring your doctor's

card so you may be entitled to get the " child's plate. "