Frequently Asked Questions

There may be some reduction in the volume of your stools, which is normal after a decrease in food intake because you’ll get less fibre. This should not cause you severe problems. If difficulties do arise, let us know as soon as possible.

This should always be planned.

Gastric balloon: you should avoid conceiving while you have the balloon in place. As you will need to remove it in six months, it is usually not advisable to have anaesthetic while pregnant.

Gastric band: There is no contra-indication but it is recommended that you loss some weight before falling pregnant.

Gastric Sleeve and bypass: you should wait until your weight is stable before falling pregnant it is usually more than 1 year after surgery. This is to ensure you have enough nutrition during your pregnancy.

That is not always the case. As a rule, plastic surgery will not be considered for at least a year or two after the operation. Sometimes the skin will mold itself around the new body tissue. You should give the skin the time it needs to adjust before you decide to have more surgery.

Weight-loss results vary from patient to patient, and the amount of weight you may lose depends on several things. The band needs to be in the right position, and you need to be committed to your new lifestyle and eating habits. Obesity surgery is not a miracle cure, and the kilos won’t come off by themselves. It is very important to set achievable weight-loss goals from the beginning. A weight loss of 2 to 3 kilos a week in the first year after the operation is possible, but one pound a week is more likely. Twelve to eighteen months after the operation, weekly weight loss is usually less. Remember that you should lose weight gradually. Losing weight too fast creates a health risk and can lead to a number of problems. Your main goal is to have weight loss that prevents and resolves health problems connected with severe obesity.

You will meet with Dr. Tsang  for a detailed discussion about the history of your weight disorder, your current health issues, what your expectations are and what you would like to achieve, the surgical options, the bariatric operation that is best for you, the benefits and risks involved, the pre-operative preparation and insurance requirements, and to address any of your questions or concerns.

Our office will arrange for your initial labs, dietician/ nutritionist consult, Psychologist consult if deemed necessary and assist you in arranging any medical clearances if you have significant medical co-morbidities.

You may be required to obtain “clearance” for bariatric surgery from a Cardiologist, Pulmonologist (Lung disease specialist), or other specialist prior to surgery. The specialist may recommend certain tests, then will send our office the results of the tests and a letter stating that you are “cleared” to proceed with bariatric surgery. Generally, these clearances should be completed within a month.

Pre-op Diet

• If your BMI is 35 – 54, you will be on an opti-fast diet for 2 weeks.
• If your BMI is 55 or greater, you will be on a low calorie diet as directed by Dr Tsang for and few weeks followed by an opti-fast diet for 3 weeks
• The pre-op liquid diet is VERY important. This pre-op calorie restriction will cause the liver to shrink significantly, making it easier to retract in order to get a clear view and have good access to the upper part of the stomach and complete your surgery laparoscopically.

Do not eat or drink ANYTHING after midnight unless you have been instructed to take certain medications with a sip of water early the morning of surgery.

You may bring pyjamas, bathrobe, slippers, bathroom items.

You may bring cell phone, iPod, tablet, laptop, books, photographs, etc .

Do not wear jewellery other than wedding ring

Bring your Incentive Spirometer (Voludyne) that you were given at your pre-op visit with the
Respiratory Therapist.

If you have sleep apnea, bring your CPAP mask, tubing and machine.

Admitting

• Your first stop will be Hospital Registration
• Bring your insurance information
• You will be taken to the Pre-op holding area and your family will be shown where the surgery waiting room is located.

Pre-op

• In the pre-operative holding area, you will change into a hospital gown, be weighed, then lie in a hospital bed
• You will have an IV started and an antibiotic given through the IV
• If you are diabetic or pre-diabetic, an accucheck will be done
• Women may have a urine pregnancy test done
• You will be given a Heparin (a blood thinner) shot to reduce your chance of developing a blot clot in your leg veins during surgery
• You will have compression stockings placed on your lower legs
• You will void before going back to the Operating Room
• You will meet the anesthesiologist who may give you a sedative through the IV
• Dr. Tsang will see you before you go into to the OR

Operating Room

• There will be large ceiling lights and many machines
• You will transfer to the Operating Room table, lying flat on your back with your arms extended on armboards
• You will be covered with a blanket
• Heart monitors will be placed on your chest
• An oxygen monitor will be placed on your finger
• The anesthesiologist will place an oxygen mask on your face, then will give you your initial anesthetic drug through the IV and you will go to sleep
• Once you are asleep, he will place a breathing tube in your trachea (wind-pipe) through which you will receive oxygen and anesthetic gas throughout the operation. You will not feel this.
• Once you are asleep, the Doctor may insert a catheter in your bladder which will be removed at 6 am the day after surgery
• The anesthesiologist will give you pain and nausea medications right before you wake up
• When you wake up, the breathing tube will have been removed, an oxygen mask will be on your face, and you will be in the recovery unit.

Post-op Recovery Unit/ Post-Anesthesia Care Unit (PACU)

• You will be groggy, but breathing on your own
• If you have pain, the nurse will give you medication
• If you have nausea, the nurse will give you medication
• If you have sleep apnea, you will wear your CPAP in the PACU and each night in the hospital.
• After about one hour, you will be transferred to the Surgical Unit

Surgical Unit

• Your active participation is crucial to your recovery and will be expected of you.
• Your recovery will be aided greatly by remembering these three things:
• WALK: Walk in the halls at least every two hours beginning 6-8 hours after your surgery and each day from 6 am to midnight
• WATER: Drink and sip throughout the day
• WIND: Use your Incentive Spirometer (Triflow) 20 consecutive times every hour with the goal of reaching your pre-op level
• You will have a drain in your right side which will be removed the day you go home.
• You will have supplemental oxygen delivered through a nasal cannula which you must wear all night.
• You will have compression stockings on your lower legs. These must remain on your legs throughout your hospitalization.
• You may disconnect them from the machine ONLY when you walk.
• You will begin drinking ice chips and sips of water the afternoon/ evening of surgery.
• You will begin using your Incentive Spirometer (Triflow) 20 consecutive times every hour.
• You will begin walking every two hours the afternoon/ evening of surgery until midnight.
• If you have sleep apnea, you will wear your CPAP while sleeping each night.
• Your regular oral medications will be resumed.
• Dr. Tsang will see you every day while you are in the hospital.

Supporters and Visitors

• Spouse, significant other, parents, or a friend are encouraged to help you in your hospital recovery, by encouraging you, walking with you and helping you to remember to drink your water and use your incentive spirometer.
• One individual may be permitted to sleep in the hospital room with you.
• Visitors are not permitted to bring food into the hospital room.
• Do not bring family members or friends who are not supportive of your decision to have bariatric surgery.
• We do not encourage several or frequent visitors during your hospitalization. We want you to concentrate and participate in your recovery.

Discharge Instructions

• Most patients will be discharged two days after their surgery (Gastric Bypass or Sleeve Gastrectomy). Nearly all patients will be discharged within 3 days of the operation.
• The nurse will remove your IV and your drain.

The LAP-BAND System limits food intake. If you feel nauseated or sick on a regular basis, it may mean that you are not chewing your food well or that you are not following the diet rules properly. However, it could also mean that there is a problem with the placement of the band so you should contact us if this problem persists. Vomiting should be avoided as much as possible. It can cause the small stomach pouch to stretch. It can also lead to slippage of part of the stomach through the band, which would reduce the success of the operation. In some cases, another operation may be required.

If LAP-BAND surgery is performed laparoscopically, patients typically spend less than 24 hours in the hospital. It takes most patients about a week to return to work and a month to six weeks to resume exercising. In the case of open surgery or if there are complications, recovery may take longer.

You should focus on long-term weight loss and remember that it is important to lose weight gradually while reducing obesity-related risks and improving your health.

Check-ups are a normal and very important part of the LAP-BAND System follow-up.

LAP-BAND does not affect or hamper physical activity including aerobics, stretching, and strenuous exercise.

Adjustments are often carried out in the X-ray department. They are done there so the access port can be clearly seen. When X-rays are used, your reproductive organs should be shielded. Sometimes adjustments can be done in an outpatient clinic or office. Local anesthesia may or may not be needed. A fine needle is passed through the skin into the access port to add or subtract saline. This process usually takes only a few minutes. Most patients say it is nearly painless.

There are no restrictions based on the access port. It is placed under the skin in the abdominal wall, and once the incisions have healed it should not cause discomfort or limit your movements or any physical exercise. The only sensation you may have from the port is when you go in for adjustments. If you feel persistent discomfort in the port area, let us know as soon as possible.

Although the LAP-BAND System is not meant to be removed, it can be. In some cases this can be done laparoscopically. The stomach generally returns to its original shape once the band is removed. After the removal, though, you may soon go back up to your original weight or even gain more.

This is a fairly common feeling, especially for people with bands that are tight or just after an adjustment. During the day the water content in the body changes and this may cause the band to feel “tighter” some of the time. Some women have also noticed that the LAP-BAND feels tighter during menstruation.

The LAP-BAND makes you eat less and feel full in two ways – by reducing the capacity of your stomach and increasing the time it takes food to get through the digestive system. After a small meal, the amount of which varies from person to person, you should feel full. If you follow the nutrition guidelines when you choose your food and chew it well, you should not feel hungry or deprived. Remember that the LAP-BAND is a tool to help you change your eating habits.

One of the major advantages of the LAP-BAND System is that it can be adjusted. If your illness requires you to eat more, the band can be loosened by removing saline from it. When you have recovered from your illness and want to lose weight again, the band can be tightened by increasing the amount of saline. If the band cannot be loosened enough, it may have to be removed.

Post-op Diet after Gastric Bypass and Sleeve Gastrectomy

• ALWAYS AIM DRINK 2 to 2.5 L OF WATER EVERY DAY
• Our dietician will guild you through each phage of your diet. 
• Day 2 weeks: Fluid diet
• Day 2 to 4 weeks soft diet
• Day 4 to 6 close to normal diet

Long-term Dietary Requirements:

Avoid:

• High-simple carbohydrate, high-fat foods like sweets, chocolate, candy, cookies, desserts, ice cream – Liquid calories – soda pop, fruit juice, milk, alcohol
• Complex carbohydrates – potatoes, pasta, rice, bread & rolls
• Processed snack foods and fast foods
• Steak and pork are usually difficult to eat and can easily get “stuck”. Avoid ham and bacon – For any packaged food, always check the calorie content on the label

Initially after surgery, all you need to do is WALK, WALK, WALK every day. This is essential in order to avoid developing blood clots in your leg veins.

Avoid lying flat during your waking hours; sit in a chair or walk.

Beginning 6 weeks after surgery, you may begin to do exercises involving lifting.

Your return to work date will depend on the type of work you do and will be determined individually.

Diet

• The day after discharge, begin liquid protein supplement (50 g protein, low carb, low fat) daily
• Liquid diet for 2 weeks as per our dietician instruction, you will see her before you progress to the next phase of your diet.

Activity

• WALK, WALK, WALK
• You may go to bed and wake up whenever you like, but during your waking hours, YOU MUST WALK every 1- 2 hours
• to avoid developing blood clots in your leg veins. Do not lie flat during your waking hours.
• Do no lifting greater than 5kg for two weeks after surgery.
• You may not drive until you are no longer taking your narcotic pain medication.
• Do not sit in a car for extended periods without stopping at least every two hours to walk.

Wound Care

• You will have a clear, waterproof sealant over your incisions which will flake off over the next 10 days
• Your sutures are under the skin and will eventually dissolve
• You may shower, but not bathe in a tub or swim. The incisions must not be submerged until the scabs have completely disappeared, which usually takes several days to a few weeks.

What to Expect

• It is common for your left-sided incision to be the most painful
• Usually within the first week, the incisional pain will subside and you may transition from your prescription pain medication to Panadol
• During the first few weeks, you may feel tired. As you get more sleep, advance your diet, take your protein supplement and vitamins, you will feel less tired and will eventually have more energy
• Vomiting is NOT NORMAL and not to be expected after bariatric surgery if you are eating properly.
• Vomiting may occur if you eat improperly (eat too fast, do not chew enough, eat too large a bite, eat too much at one time). If you are eating properly and still are vomiting, call the office. If you are unable to drink liquids, call the office immediately.

Post-op Visit

• 2 weeks after surgery date
• Discuss any problems you may be having
• Wound examination
• Advance diet
• Continue Protein Supplements
• Start bariatric vitamins
• Discuss medications
• Discuss advancing activity
• Decide when to return to work

FOLLOW-UP

It is essential that you come to all your post-op visits. At each visit, we will be addressing the following: •

• Weight loss
• Improvement or remission of your comorbidities
• Dietary compliance and progression
• Protein supplement
• Vitamins
• Activity and exercise progression
• Medications
• Followup

1. 2 week visit
2. 3 month visit
3. 6 month visit
4. One year visit
5. Yearly visit

Alcohol has a high number of calories. It also breaks down vitamins. An occasional glass of wine or other alcoholic beverage, though, is not considered harmful to weight loss.

After your stomach has healed, you may eat most foods that don’t cause you discomfort. However, because you can only eat a little it is important to include foods full of important vitamins and nutrients such as those recommended and advised by your surgeon and/or dietitian.

You should avoid foods that contain lots of sugar and fat or drink liquids full of “empty” calories, such as milkshakes.

Sweats are the most common causes of weight gain.

Order only a small amount of food, such as an appetizer. Eat slowly. Finish at the same time as your table companions. You might want to let your host or hostess know in advance that you cannot eat very much.

You should be able to take prescribed medication. You may need to use capsules, break big tablets in half or dissolve them in water so they do not get stuck in your stomach and make you sick. You should always ask the doctor prescribing the drugs about this.

Existing Medications Summary:

• Anticoagulants will be addressed at your pre-op visit with Dr. Tsang
• Antidepressants, Anti-anxiety medications, and other psychologic/ psychiatric medications should be taken early the morning of surgery with a sip of water.
• Beta Blockers (see below) must be taken early the morning of surgery with a sip of water
• Aspirin should be discontinued 10 days before surgery and withhold for 2 weeks post surgery• Narcotic pain medications may be taken through the day before surgery
• Non-steroidal anti-inflammatory medications or NSAID’s (see below) should be discontinued 2 weeks the before surgery.
• Oral Contraceptive Drugs (Birth Control Pills), Hormone Replacement Therapy drugs, Testosterone, Oral steroids, and Anti-immune medications (see below) should all be discontinued one month before surgery
• All other existing medications should be taken through the day before surgery, but NOT the morning of surgery, unless specified by the surgeon.

There are specific instructions for these medications:

Anticoagulants (Blood “thinner” medications)

• These will be addressed at your pre-op visit with Dr. Tsang
• Aspirin 325 mg (Regular Aspirin) should be discontinued 10 days before surgery date, then not resumed until 2 weeks after surgery.

Coumadin:

• You will receive a schedule of specific instructions and a prescription for Clexane at your Pre-op visit with Dr. Tsang
• On the 7th day before the surgery date, take your last dose of Warfarin (Coumadin). DO NOT take Coumadin again until instructed by Dr. Tsang.
• On the 6th day before the surgery date, take clexane120 mg subcutaneously at 9:00 pm only (always give the shot below the level of the umbilicus).
• On the 5th day before the surgery date, start taking Clexane  120 mg twice daily at 9:00 am and 9:00 pm until the day before surgery.
• On the day before surgery, take Clexane 60 mg at 9:00 am ONLY. On the surgery day, do not take Clexane.

• After discharge from the hospital, continue clexane 120 mg subcutaneously twice daily at 9:00 am and 9:00 pm through the 3rd day after restarting your Coumadin.
• Coumadin will be restarted (at pre-op dose) when you return for your post-op visit in the office with Dr. Tsang (about 7 – 10 days after surgery) or when instructed by Dr. Tsang.

Plavix

• You will receive a schedule of specific instructions at your Pre-op visit with Dr. Tsang
• On the 7th day before the surgery date, take your last dose of Plavix. DO NOT take Plavix again until the 3rd day after surgery

Antidepressants, Anti-anxiety medications

• May be taken early the morning of surgery with a sip of water

Anti-immune medications

• Avara (leflunomide), Imuran (Azathioprine), Methotrexate, Plaquenil (hydroxychloroquine) • Discontinue at least one month before surgery date

Beta Blockers

• MUST be taken early the morning of surgery with a sip of water.

Oral Contraceptive Drugs (Birth Control Pills) or Hormone Replacement Therapy (HRT)

• Discontinue at least one month before surgery date

Psychologic/ Psychiatric medications (other than antidepressants or anti-anxiety medications listed )

Should be taken early the morning of surgery with a sip of water

• Abilify (Aripiprazole)
• Clozapine
  Clozaril (Clozapine)
• Fanapt (Clozapine)
• FazaClo (Clozapine)
• Geodon (Ziprasidone)
• Invega (Paliperidone)
• Latuda (Lurasidone)
• Olanzapine
  Quetiapine
  Risperdal (Risperidone)
• Risperidone
• Saphris (Asenapine)
• Seroquel (Quetiapine)
• Ziprasidone
  Zyprexa (Clanzapine)

Steroid Medications

• Celestone, Cortef, Cortisone, Flo-Pred, Hydrocortisone, Medrol, Methylprednisolone, Millipred, Orapred, Rayos, Prednisolone, Prednisone, Prelone, Veripred
• Discontinue at least one month before surgery date

Testosterone

• Discontinue at least one month before surgery date

You may. It’s possible you may not get enough vitamins from three small meals a day. At your regular check-ups, your specialist will evaluate whether you are getting enough vitamin B12, folic acid, and iron.

After Bariatric Surgery, you MUST take your vitamins properly EVERY DAY for the rest of your life. Vitamin deficiency can cause serious health problems. You may us any brand of vitamins

You may use any brand of low calorie liquid or powder protein supplement 50 grams per day.

Powder protein supplements are preferable because they generally have a higher protein / lower total calorie ratio.

With protein powders, you must check the label to determine how many grams of protein are in a SERVING and how many SCOOPS are in a serving in order to calculate the amount you need to use (the number of scoops) to obtain 50 g of protein per day.

You can drink your protein supplement throughout the day. Do not drink it all at once.

You may dilute the protein powder as much as you desire as long as you drink the entire amount in one day in order to receive the full 50 grams of protein daily.

Always use WATER to mix with powder protein supplements. DO NOT USE MILK.

The amount of water you use to mix with your protein supplement counts toward your 2-3L daily water requirement.

Begin the protein supplement at the same time as your pre-op diet and continue it after discharge from the hospital.