DALLAS BARIATRIC CENTER

MEDICATIONS TO AVOID BEFORE SURGERY

When preparing for surgery please review all your medications both over the counter and prescription drugs with Dr.Jayaseelan. We must be aware of what you are taking and all prescriptions should be documented in your medical record. It is important to stop anticoagulants also known as “blood thinners”. If you are taking a blood thinner such as Warfarin (brand name Coumadin), Apixaban (brand name Eliquis), Edoxaban (brand name Savaysa), Rivaroxaban (brand name Xarelto), Dabigatran (brand name Pradaxa), Clopidogrel (brand name Plavix) or high-dose Aspirin, please inform the prescribing physician about your upcoming procedure ASAP. There are general guidelines for anticoagulant management and the time frame to stop the medication can range from 3-5 days or 7-10 days, based on the medication you take. You should talk to your doctor about your anticoagulation management at least 14 days prior to surgery. Your doctor will instruct you when to stop your medication and work with you to manage your anticoagulation therapy.

Do not take any NSAIDs (Non-Steroidal Anti-Inflammatory) 2 weeks prior to surgery; this includes Ibuprofen, Advil, Motrin, Aleve, Excedrin, Mobic, Celebrex, Naproxen, Ketorolac, Diclofenac, Bufferin, Alka-Seltzer (these are the most common, this is not an all inclusive list so make sure to check label). TYLENOL is the only pain medication you may take. Stop taking ALL natural products, herbal medicines, vitamin E, Fish oil, and Turmeric. If you are taking GLP-1 medication, Phentermine or other appetite suppressants, these must also be discontinued 2 weeks prior to surgery. If you take medication daily and are unsure on whether to stop or continue to take medications please check with your prescribing physician for instructions.

No smoking 6 weeks before and after surgery. This includes but is not limited to cigarettes, pipes, cigars, electronic cigarettes, vapor cigarettes, marijuana. Nicotine constricts blood vessels and will delay your body's ability to heal after surgery.

No alcoholic beverages 2 weeks before surgery. Alcohol can negatively impact your surgery and recovery process.

When to begin your pre-operative liquid diet

Your pre-operative liquid diet will consist of SUGAR FREE, LOW CALORIE, CLEAR LIQUIDS, WITH THE EXCEPTION OF PROTEIN SHAKES. Following this diet will not only jump start weight loss but will also help reduce the size of your liver making the procedure easier and safer to perform. If you do not fully adhere to this diet, Dr. Jayaseelan may elect to postpone your surgery until you have complied with the liquid diet. If your BMI is greater than 50 you will need to do a 2 week pre-operative liquid diet with the exception of 1 sensible meal allowed during the first week and strictly liquids 1 week prior to surgery.

During this time it is important to include a protein shake as your meal replacement. You must drink one for breakfast, lunch, dinner, and snack to help ensure good nutritional status prior to surgery. Aim for a goal of 60-120 grams of protein per day obtained from your protein shake & 64oz of clear liquids. Dr.Jayaseelan also recommends to begin Thiamine 250mg twice a day (also known as vitamin B1) to help prevent nausea post-surgery. 

The list below provides recommended CLEAR LIQUIDS PRIOR TO SURGERY & POST SURGERY FOR 3 WEEKS. These liquids are considered acceptable during pre-op diet and post-op diet. Please avoid adding sugar to your drinks.

CLEAR LIQUIDS

• Water/ ice chips
• Tea
• Coffee
• Crystal Light
• Spark energy drink (1 per day) 
• Diet Snapple, Sugar free Kool-aid or Tang, Gatorade Zero, Powerade Zero, Vitaminwater Zero, or generic equivalant.
• Mild clear juices (fruit or vegetable), must dilute with water 
• Skim milk, unsweetened light soy, unsweetened almond, unsweetened coconut, or lactose free milk
• Sugar free popsicles or jello
• Low sodium broths
• Amazing Grass Fizzy Green Tablets: Superfood 1 full serving of greens & veggies plus 100% DV Vitamins B1, B12, C, E, Drop one tab into 8-10 fl oz of water
• Amazing Greens Blend Detox & Digest Clean Greens: Convenient Powder, simply add to water or smoothie, promotoes detox, 24 cleasing ingredients, supports digestive health, 1 billion CFU probiotic, supposts immunity, 1 full serveing of fruits & veggies +7 nutritious greens 

PROTEIN SHAKES

• Advocare
• Premier Protein
• Ensure Max
• Fairlife 
• Whey Protein Isolate
• Isopure
• Muscle Milk
• UNJURY
• Organic Plant Based Protein
• Bariatric Advantage

You can also purchase protein powder and mix with 8oz-12oz of water or unsweetened milk. Protein shakes will be your meal replacements and you’re allowed up to 4 per day (breakfast, lunch, dinner, and snack), even though they’re considered a “full liquid” we allow you to have them during your clear liquid diet. They must be high in protein low in sugar (sugar cannot exceed protein). Protein shakes will give you the energy you need and help you feel full longer.

SAMPLE MEAL PLAN

6: 00 AM One cup water

7:00 AM One 8 ounce cup of coffee with splash of unsweetened milk if preferred

8:00 AM One protein shake

9:00 AM One cup water

10:00 AM One cup diluted clear juice (fruit or vegetable) add scoop of Amazing Greens Poweder Blend Detox & Digest Clean Greens

11:00 AM One Spark energy drink

12:00 PM One protein shake

1:00 PM One cup water with Amazing Grass Fizzy Green Tablet

2:00 PM One cup sugar free jello

3:00 PM One protein shake

4:00 PM One cup Powerade Zero

5:00 PM One cup broth

6:00 PM One protein shake

7:00 PM One cup water

8:00 PM Two sugar free popsicles or sugar free jello

9:00 PM One cup water

10:00 PM One cup water

*This plan does not need to be followed precisely. You can adjust the times based on your own schedule. For patients that are required to do 2 week liquid diet, during the first week you may add 1 sensible meal (lean protien & produce) during the time of your choice. Keep in mind starting one week prior to surgery it’s strictly liquids.

Preparing for surgery 

1 week prior to surgery begin Thiamine (vitamin B1) 250mg twice a day or 500mg once daily. This will help prevent nausea post-operatively.

(FOR GASTROJEJUNOSTOMY PROCEDURE ONLY) Day before surgery you are required to do bowel prep OTC MiraLax 17.9oz. You can drink this as early as noon, but no later than 6pm. Make sure to mix the entire 17.9oz powder with 2 bottles of Gatorade zero. Once started, you may only have clear liquids and nothing after midnight. You can expect frequent trips to the bathroom once you begin your bowel prep.

Shower the night before and morning of surgery with anti-bacterial soap (OTC Hibiclens or Dial soap).

The night before surgery apply Rx Transdermal Scopolamine Base Patch behind the ear (remove after 1 day), this will help prevent nausea.

The anesthesiologist will contact you the day before and instruct you if it's ok to take your other medications morning of surgery, if on any. 

Day of procedure shower with antibacterial soap. Brush your teeth. No makeup, face lotions, jewelry, or hair accessories with metal. If you wear contacts or glasses bring your case with you. Wear loose fitting clothing. Leave all your valuables at home; only bring your DL, insurance card, form of payment, and your CPAP machine if you use one.

When you arrive at the surgery center morning of surgery take Rx Aprepitant to prevent post operative nausea and vomiting.

Be assured that every effort is made on the part of the surgery center team to ensure your surgery begins at the scheduled time. However, your surgery may be delayed as a result of a hospital emergency, or because of commonly encountered variations in the length of certain procedures due to unanticipated findings. Please bring reading material or other things to help pass the time while you wait.

All patients are required to have an escort (relative or friend) drive you home after surgery. You will not be allowed to drive until you have stopped taking your pain medication.

STAGE 1: BARIATRIC CLEAR LIQUIDS

Discharge from hospital 1st week: you will continue to be on a clear liquid diet along with protein shakes for 3 WEEKS POST-OP. This is the most crucial time, if you attemempt to anything solid during this time frame it can be life threatening , so don't risk it. Your liquid protein intake should be 1-2 shakes per day (goal 40-60 grams daily) along with clear liquids 48oz minimum. All protein shakes must be low in sugar high in protein. To prevent dehydration make sure to keep in minimum of 48 oz. of fluid in daily, but STOP when you feel full!

Your liquid protein intake "meal" will equal about 2-4 oz or, or ¼ - ½ cup in volume (1 ounce= 2 Tbsp) Make sure your protein shakes are thin and runny. It may take all day to drink an entire protein shake and that's normal.

Drink small amounts, 1oz every 15min. Sip slowly and stop when you feel full or nauseated, don't force anything down. Don't drink out of a straw as it will trap in more air and more discomfort.

Begin chewable Gas-X (take as directed), Milk of Magnesium (2 tablespoons twice a day until bowel movement), and acid reducer Pepcid Complete Chewable (once daily for 3 months). You may also drink black coffee (as your last resort) to help with bowel movements.

NO CARBONATED BEVERAGES, sweetened drinks, and alcohol.

Start with very thin liquids and advance slowly to thicker liquids. Remember to walk, walk, walk! It is the key to faster recovery.

No vitamins recommended at this as they may cause nausea and vomiting. You can begin vitamins at week 6. 

STAGE 2: BARIATRIC FULL LIQUIDS WEEKS 2 & 3 POST-OP

For weeks 2 & 3 you may now add cream blended soups and drinkable yogurts (NO chunks or lumps, strain your soups).

Drink 2 protein shakes per day (goal 60-80 grams daily), minimum of 64oz of fluid daily. Small sips, don't gulp or drink too fast.

Continue acid reducer Pepcid Complete Chewable (once daily for 3 months).

Avoid sugar sweetened drinks, carbonation, caffeine, and alcohol.

STAGE 3: BARIATRIC SOFT WEEKS 4, 5, & 6 POST-OP

Week 4, 5, & 6 you may introduce soft foods to your diet.

GOAL: at least 80-100 grams of protein daily and exercise 20 minutes 5 times a week. Avoid strenuous exercise. 

Continue 64 oz of fluid daily.

Continue acid reducer Pepcid Complete Chewable (once daily for 3 months).

At week 6 you may introduce Multivitamin & B-12. You will take these vitamins once daily for lifetime. 

Avoid sugar sweetened drinks, carbonation, and alcohol.

SOFT FOOD DIET

• Thin cooked oatmeal, cream of wheat, grits.
• Mashed potatoes, mashed beans, softened tofu.
• Low fat cottage cheese or ricotta.
• Low fat or sugar free pudding or yogurt.
• Very softly scrambled eggs or plain liquid egg or egg whites.
• Canned chicken or tuna (must be moist).
• Flakey fish like tilapia or salmon.
• Vegetables (cooked, canned, or pureed, only if able to be mashed with fork).
• Fruits (cooked, canned, or pureed, only if able to be mashed with fork and only to be eaten sparingly for maximum weight loss).

Please note: You must be able to mash food with fork, otherwise it is not considered a soft food. NO pasta, bread, crackers, tortillas, rice or leafy vegetables during this phase.

STAGE: 4 BARIATRIC REGULAR week 7 and therafter 

You may now introduce ground beef and meats (moist cooking).

NO steak or raw vegetables until after 3 months post-op.

Continue all supplements multivitamin, B12, and protein. Depeding on your vitamin levels Dr.Jayaseelan will inform you if you require to take additional vitamins.

Continue acid reducer Pepcid Complete Chewable (once daily for 3 months).

You may continue to drink protein shakes if you’re unable to get 60grams of protein with regular diet.

Continue a minimum of 64oz of fluid daily.

GOAL: 80-100grams of protein daily. Exercise planned activity 20-30 minutes, 5 times weekly.

REGULAR DIET

• Low fat soups.
• Wild rice, angel hair pasta, whole wheat pasta.
• Meats: chicken, turkey, pork, beef, seafood. Cooking method must be moist.
• Cooked, canned or pureed vegetables.
• Cooked, canned or pureed fruits. Only to be eaten sparingly for maximum weight loss.

STAGE: 5 BARIATRIC REGULAR month 3 and thereafter 

You may now introduce lean beef and raw vegetables to your diet.

Continue all supplements multivitamin, B12, and protein.

GOAL: Protein and produce, 80-120grams of protein and 64oz of fluids daily. Exercise planned activity 45 minutes, 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 is considered outpatient unless told otherwise by Dr.Jayaseelan.

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 at your pre-op appointment and have it at home waiting for you.
• If pain medication is not working once you get home, call your surgeon’s office.
• 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. 

MEDICATIONS

• For 6 weeks post-surgery you will need to crush, open capsule, or have pharmacist convert your medication into liquid form; check with pharmacist about crushing pills and opening delayed released capsules. After six weeks, pills should be no larger than Aspirin size.
• No NSAIDs (Non-Steroidal Anti-Inflammatory) such as Advil, Aleve, Motrin, Excerderin, Ibuprofen or any aspirin unless if approved by Dr. Jayaseelan.
• Find out about resuming medications before leaving the hospital.
• Start chewable Acid Blocker as instructed, no vitamins until week 6.

POST-OPERATIVE INTRUCTIONS

• No lifting more than 25 pounds for 4 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. If you don't receive one at the sugery center, make sure to do at least "10 deep breaths" every hour while awake.
• Showers only. No submerging your incisions in water for 4 weeks (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). For Milk of Magnesia instructions take 2 tablespoons twice a day until you have bowel movement.
• Avoid nausea and vomiting. If nauseated, take prescribed medication Ondansetron. If that doesn’t help and it becomes difficult for you to tolerate liquids please call office.
• Take prescribed Hydrocodone-Acetaminophen as directed for pain.
• For revisional surgery IV fluids may be arranged to prevend dehydration.
• Call the office if: 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 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!
• 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 4-10 days (lifting restrictions applied in that time frame).
• 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 supplements liquid or chewable multivitamin and B12 daily, begin at week 6.
• Take Rx or OTC acid reducer (Omeprazole, Dexilant, Pepcid Complete chewable, Prilosec, or Prevacid) for 3 months after surgery.

THINGS TO HAVE WAITING AT HOME

• Chewable Gas-X & Milk of Magnesia for intestinal gas pain.
• Extra Strength Liquid Tylenol or generic equivalent.
• Pepcid Complete Chewable acid reducer.
• Protein shakes and clear liquids.
• Comfortable walking shoes.
• Help and support around the house for at least 1 to 2 days.

FOLLOW YOUR TREATMENT PLAN

• Week 1
• Week 2
• Week 3 
• Week 6
• Month 3
• Month 9 
• Year 1
• Month 18
• Year 2
• Year 3
• Year 4
• Year 5

These appointments can be virtual if preferred.

If you have any questions about your surgery, pre-operative instructions or preparations, please contact Yaneth at 972-331-1111 or email yaneth@dallasbariatriccenter.com