There is no consensus regarding optimal perioperative care in bariatric surgery. However, there need to be guidelines and protocols based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

Pre-operaive preparation

Before any surgery, you should be prepared both physically and psychologically for the procedure and its outcomes. Detailed instructions will be given to you for the days before surgery as well as the day of the surgery. You will be given specific instructions such as:

• Try to control your weight by exercising and following a healthy diet
• Consult with a dietician and psychologist prior to surgery
• Wash your body with an antimicrobial solution for about 4 days prior to surgery to avoid infections
• Stay on a complete liquid diet for two days prior to the surgery
• Avoid food the night prior to surgery

The steps involved in pre-operative preparations are:

• Providing detailed information regarding the procedure
• Creating awareness of the risks involved in the procedure
• Collection of your complete medical history and performing physical examinations
• Collection of diet history, eating habits and eating tendencies
• Discussing the medications that you can and should not take
• Performing tests such as BMI, colonoscopy or endoscopy just prior to the surgery
• Giving bowel prep to cleanse your bowel

Patients well-prepared for a surgical procedure tend to have better outcomes.

Intra-operative period

When the patient is asleep in the operating room, a catheter is passed in to the bladder to collect urine. The catheter will stay in until the day after your surgery or possibly longer. Patient may have a sore throat from the tube in their nose and the breathing tube used during surgery. This soreness will usually go away in a day or two. Occasionally, a tube may be placed through the nose into the stomach at the end of surgery. The tube removes secretions from the upper portion of the stomach and helps prevent distention of the upper pouch. In many programs, a nasogastric tube is rarely used and is reserved for only complicated situations.

Some surgeons may also choose to place a tube through your skin into the operated part of your stomach. This tube is called a drain tube and are not routinely placed, but may be necessary to check for bleeding and leak in to the abdomen from the surgical site. If the patient have had stomach surgery in the past, they are more likely to need a drain-tube. Drain-tubes are often used for patients who are having revisional surgery.

Hospital Course Following Surgery

When you wake up from surgery, you will either be in the recovery room or you will go there shortly. Once your breathing is normal and vital signs are stable, which usually takes several hours, you will be taken to a monitored hospital room. If all goes well and the oxygen levels in your blood are okay, you will move to a regular hospital room the same day or the next day depending on hospital policy.

Pain Management After Surgery

Continues intravenous analgesia / Patient Controlled Analgesia (PCA) are the method of pain management used for bariatric surgery patients. Medication will be given through an IV or an epidural, and the dosage is controlled by the patient within pre-set limits. PCA allows the patient to receive small doses of pain medicine frequently, which provides steady pain relief. Patient will be very sore for the first couple of days, with the soreness rapidly decreasing over the next few days.

Tests After Surgery

The patient will receive nothing by mouth following surgery. This allows time for return of GI function and helps reduce the possibility of leaks. Patients may have an upper gastrointestinal fluoroscopy / X-ray test." For this procedure, they will drink special liquids and X-rays will be taken. This test lets us know that a leak has not developed from the small stomach pouch. Other tests for comorbidities depending on the type of disease will be ordered to help during the immediate post operative period.

Nutrition After Surgery

Every patient will receive thorough nutrition counselling by the clinical dietician. Patients will need to learn to take small bites and swallow slowly.

Post surgery, patient’s diet will be as follows:

Day of surgery: No food or drink

Day 1 after surgery and for rest of the hospital stay: May be progressed to clear liquids and water if no signs of a leak and after approval from surgeon. Then 1-2 ounces every 20 minutes while awake.

First week after discharge: Full liquids including 2 high protein drinks daily. Sugar-free pudding and fat free/light yogurt may be consumed during this diet stage. Drink/eat one to two ounces no more frequently than every 20 minutes while awake.

Second and third week after discharge: Pureed food with an emphasis on those high in protein plus one high protein drink daily. To eat one to two ounces of a pureed food every three hours. Patients should stop drinking 15 minutes before eating and should not drink for 30 minutes after they have finished eating. They should try to drink four ounces every 30 minutes between meals.

The next stage of their diet will be discussed at the first follow-up appointment with the dietician.

Activity and Circulation After Surgery

Activity is a very important part of your recovery and weight loss. Activity helps to prevent pneumonia, blood clots, and constipation, and it increases weight loss. For these reasons, patient’s exercise program will start while they are in the hospital. Most patients will be assisted out of bed on the evening of surgery. They will start walking in the hall the day after surgery. Compression stockings are plastic sleeves that will be wrapped around their legs during surgery and while in bed after surgery. They gently squeeze the legs and help blood circulate in legs and feet. These hose will help prevent blood clots from forming in the veins of their legs. The compression stockings will be worn for the first 2-3 days while in bed.

Breathing Exercises After Surgery

The patients will be provided with an "Incentive Spirometer" after surgery. It is very important to take about ten deep breaths into the spirometer every hour to help prevent pneumonia, lung collapse and other breathing problems. Coughing and deep breathing will also help to prevent breathing problems. If the patient have been diagnosed with sleep apnea through a sleep study, they will remain on breathing monitors overnight or until they are breathing well on your own. If they use a C-PAP machine at home, they will need to bring it with them to use in the hospital.

Post-operative follow-up

Patient’s follow-up visits are also necessary to help the team recognize vitamin, mineral and iron deficiencies in the early stages of weight loss so that appropriate treatment can be given. If patients miss your regularly scheduled follow-up visits and the required postoperative blood tests, they may eventually develop vitamin and mineral deficiencies.

Schedule of Postoperative Visits

First visit: Scheduled 1-2 weeks after bariatric surgery.

Second visit: Scheduled 4-6 weeks after bariatric surgery. A new solid diet is prescribed.

Quarterly visits: Scheduled at approximately 3 month intervals for the first year after the operation.

Annual / biannual visits: Scheduled at 6-12 month intervals after the first year. Follow-up will continue annually for an indefinite period of time.

Support Group Meetings

Learn from others. Most bariatric surgeons agree that ongoing support after bariatric surgery leads to the greatest level of success. Why? Because support groups give the patient a great opportunity to discuss personal or professional issues that arise from surgery or from a history of obesity. And they allow patients to surround themselves with people who understand and support their goals, which directly increases chances of long-term success. Support groups also help develop realistic expectations. That is, weight loss surgery will not immediately resolve existing emotional difficulties, or heal the years of damage caused by a lifetime of being overweight. Because support groups are so important, surgeons recommend ongoing support group meets before and after surgery for short-term questions and long-term camaraderie.