Procedures manual

THE INTERVIEW

• About 1h duration.
• Patient´s medical conditions are reviewed and anthropometry analysis performed (weight, height, BMI, overweight standarized for age and sex, waist, hip and % fat mass impedanciometry by the dietitian).
• A complete preoperative blood test is necessary, including blood count, coagulation, electrolytes, glucose, urea, creatinine, ions, AST-ALT, GGT, Alkaline P, iron, folic acid, B12, calcium, cholesterol and triglycerides and thyroid hormones. Glicated Hb and C peptide are also requested in case of Diabetes condition.
• Preoperative gastroscopy is advisable to check for oesophagitis or gastropathy and helicobacter pylori infection. Hepatobiliary ultrasound to rule out cholelithiasis is also requested.
• Psychological or psychiatric reports may be necessary in case of psychiatric condition history.
• The patient will be informed about the technical options and the objectives pursued.
• Hygienic and dietary intervention prior to surgery will be provided the same day by the Dietitian-Nutritionist. Relevant authorizations and informed consent will be requested and a consultation with the anesthesiologist will be ordered, which includes a chest X-ray and an electrocardiogram.

PREOPERATIVE REVIEW

• Blood tests, ultrasound and endoscopy are reviewed. If cholelithiasis is present a cholecistectomy will be associated in case of Gastric Bypass, even if it is asymptomatic. In case of Sleeve Gastrectomy only in case of symptoms. With the anesthesiologist positive revision the date of surgery will be set.
• All doubts regarding the procedure will be discussed.
• We will also review the response to preoperative diet.

THE INTERVENTION

• Duration, 1 to 2 hours depending on technique.
• The patient is admitted to hospital the same day of surgery.
•  In the room serums, antibiotics and prophylactic antithrombotic stockings are placed.
• Then the patient is tranferred to the OR where surgery takes place under general anesthesia.
• After extubation and postanesthetic recovery the patient is usually transferred back to his room. The patient may stay at the ICU in case is necessary.
• During the next 48 hours the patient will be monitored, checked to rule out leaks and under the care of Dr Sala and the Hospital Team. With good oral liquid tolerance the patient is discharged.
• Dietary instructions, antithromotic medication, PPIs and analgesia prescriptions will be provided by Dr. Sala and the Dietitian.

POSTSURGERY REVISIONS

• In order to ensure long-term weight loss success the follow-up after surgery is as important as the surgical technique itself.
• After the operation, the following steps are established:
  Step 1: elemental rich in protein liquid diet to ensure wound and anastomotic healing,
  Step 2: Gradually crushed and passed to a pasty diet.
  Step 3: After 3-4 weeks, start a soft diet varied according to individual patient tolerance.
• At postop day 7 wounds are reviewed (we use intradermal sutures, without staples, so no scars are visible). Late postoperative medical and dietary revisions are made at 2 weeks , and 1, 2, 3, 6 and 9 months, and annually thereafter.
• The levels of iron, ferritin, B12, folate, calcium and other trace elements, as well as the improvement or disappearance of comorbidities are also reviewed.
• Blood tests are performed at months 3, 6 and 12 after the procedure, and annually thereafter.
• In case of abdominal ptosis, hernias and/or symptomatic cholelithiasis appears an abdominoplasty with or without cholecystectomy and mesh repair should be considered one year after bariatric surgery.

POSTOPERATIVE INTERMEDIATE RECOVERY

• Sometimes, when the patient comes from abroad it is possible to coordinate with the Hospital a temporary familiar stay in a Hotel-Resort in the shore until recovery is enough to fly back home.

BACK TO NORMAL LIFE

• Social and professional reintegration depends mainly on the type of activity developed and the character of the patient. With laparoscopy, which is minimally invasive surgery and little pain, this happens in a couple of weeks. Because the patient enters a catabolic phase, two weeks are needed to perform jobs that do not require physical effort, and between one to two months to perform heavy labor or hard sport efforts.

• Do not compare yourself with other patients because food tolerance or weight loss is not the same in all patients.
• If you have to ask questions seek experts.
• Eat small amounts, well masticated, and in several doses throughout the day.
• Do not mix drinks with meals. If we fill the reservoir with a meal and we feel full, drinking a liquid addition, instead of helping pass the solid will provoke vomiting.
• As a general rule, drink liquids half an hour before or two hours after meals.
• Perform aerobic exercise adapted to the conditions and personal circumstances of each patient. Our body behaves like a balance, that is, if we eat a lot and spend little (little exercise) we will not lose much weight. If you eat little and spend  a lot of energy you will lose much more weight. We know it is difficult to incorporate regular physical exercise for some patients who have never done sport, but in these cases it may success to make a sporting life, guided by some individual advice.
• Treatment should be individualized for each case, as each patient is different. This is also truth in the case of obesity surgery, where it is difficult to find a common pattern of behavior and adapt to this new way of eating and digesting.