The Mini-Gastric Bypass Surgery

Discharge Instructions

Getting Ready to Leave the Hospital after the Mini-Gastric Bypass

Attention:

1. Please read all of these instructions carefully

2. Make Sure You Have Your Prescriptions (They are located in this packet)

3. Please Make a copy of these instructions and give them to your Doctor.

Emergencies

Remember: If you are sick and not feeling well go to the Emergency Room Right Away or Dial 911. You can

always come back.

If any problem arises at any time, we stand ready to do everything possible to try and fix it. If you are having

any problem at all, please, call and let us know to see if we can help. If you are sick and not feeling well go

to the Emergency Room or Dial 911.

Please email the office every day at DrR@clos.net between 12 noon and 5 p.m. leave a message that you

are doing well.

Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery are usually in church on

Sunday mornings and home with his family in the evenings. If possible please call during the day for routine

check in calls. For emergencies call the Emergency Department and or Dial 911. Also feel free to call Dr.

Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery at any time.

If you are having any problems talk to Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery.

Please use emails every day post op at DrR@clos.net to let us know how you are doing.

Contacting Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery

Call, Office Telephone or call the hospital and ask the operator to page your doctor or his staff.

In the event that Dr. Rutledge is unavailable call the Local Hospital Emergency Department

E-Mail: DrR@clos.net

Note: When calling for Dr. Rutledge, Please be patient and persistent, the paging system can take some

time and/or Dr. Rutledge might be involved in another case.

Warning: Never use email to contact Dr. Rutledge in an emergency or for any urgent communications.

Daily Contact for the First Week

After hospital discharge we ask that you take a moment every day and let Dr. Rutledge know how you are

doing. You can email Dr. Rutledge (DrR@clos.net). We want to know how you are doing. Make sure you

leave a message every day to let us know about your recovery.

Discharge Medicines

Warning: Please do not take any medicines other than those prescribed by Dr. Rutledge and the Surgeons

of the Centers for Laparoscopic Obesity Surgery unless you discuss them with Dr. Rutledge and the

Surgeons of the Centers for Laparoscopic Obesity Surgery first.

The Mini-Gastric Bypass can be expected to have a high likelihood of curing or improving your diabetes,

hypertension, gout, urinary incontinence, osteoarthritis and sleep apnea as well as many of the other

illnesses associated with morbid obesity. Because of this, many of the medicines that you were taking

before the operation will need to be stopped. Ask Dr. Rutledge and the Surgeons of the Centers for

Laparoscopic Obesity Surgery will discuss this with you.

Types of PostOp Medications

Type I: Required: These Medications are Required, You are to take them as written, they are Not Optional,

and Try not to miss a dose.

Type II: Not required, these medicines are Optional, You are to take them only if the need arises, they Are

Optional.

Required, Not Optional Type I: You are to take them as written, they are Not Optional, and try not to miss a

dose.

Prilosec OTC (omeprazole)

Dose: 20 mg. by mouth twice a day for the first 3-4 months after surgery. Then if you feel well it can be

stopped.

Note: “NEW: We now recommend 3-4 months of Prilosec OTC (omeprazole) following surgery.”

(About 10% of patients will develop "indigestion" type pains at the end of this time and will need another

month of the Prilosec OTC (omeprazole). In our experience in some cases the pain can be gastritis or an

ulcer causing bacteria called Helicobacter Pylori and will need a special mixture of medications.) Notes:

Prilosec OTC (omeprazole) is a medicine widely used to treat ulcers, heartburn and other conditions caused

by too much acid in the stomach. Prilosec OTC (omeprazole) works by reducing the secretion of stomach

acid. The production of stomach acid is reduced within 30 minutes to an hour. The new healing stomach

after Mini-Gastric Bypass is delicate and can be damaged by acid and bile. Prilosec OTC (omeprazole) is

designed to protect the healing stomach during the first 4 weeks after surgery. ) Prilosec OTC (omeprazole)

is a potent antacid medicine that is used to reduce the acid production from stomach designed to protect the

new stomach pouch from ulcers in the first 4 weeks after the operation. This medicine has been in use for

many years and is rather well tolerated. Oral tablets are used twice a day. Side effects: Prilosec OTC

(omeprazole) is a well-tolerated medicine and has very few side effects. Side effects that can occur include:

Abdominal pain, diarrhea, headache, nausea, vomiting. How to take: Swallow with a few sips of liquid or with

a spoonful of yogurt or oatmeal. Don't take with: Alcohol. Any other medicines, even over-the-counter drugs

such as cough and cold medicines, nose drops, diet pills, laxatives or caffeine, without consulting with Dr.

Rutledge and/or the Surgeons of the Centers for Laparoscopic Obesity Surgery.

Bismuth Subsalicylate (Pepto-Bismol):

Dose: 1 tablespoonful every 6 hours of the regular-strength suspension for 1-4 months following surgery.

Note: “NEW: We now recommend 3-4 months of Pepto-Bismol following surgery.”

Notes: Category: Antacid, Antidiarrheal, antisecretory, Antiulcer agent. Description: Bismuth subsalicylate

(BIS-muth sub-sa-LIS-a-late) is used to treat the symptoms of an upset stomach, such as heartburn,

indigestion, and nausea. This medicine is available without a prescription. Allergies: Not to be taken if you

have ever had an allergic reaction to bismuth subsalicylate or to other salicylates, such as aspirin, including

methyl salicylate (oil of wintergreen), or to any of the following medicines: Ibuprofen (e.g., Motrin) Naproxen

(e.g., Naprosyn) or other similar types of pain medications. Precautions While Using This Medicine: For

diabetic patients: False urine sugar test results may occur if you are regularly taking large amounts. Side

Effects: When this medicine is used occasionally or for short periods of time at low doses, side effects

usually are rare. However, check with your doctor immediately if any of the following side effects occur,

since they may indicate that too much medicine is being taken: Anxiety; any loss of hearing; confusion;

constipation (severe); diarrhea (severe or continuing); difficulty in speaking or slurred speech; dizziness or

lightheadedness; drowsiness (severe); fast or deep breathing; headache (severe or continuing); increased

sweating; increased thirst; mental depression; muscle spasms (especially of face, neck, and back); muscle

weakness; nausea or vomiting (severe or continuing); ringing or buzzing in ears (continuing); stomach pain

(severe or continuing); trembling; uncontrollable flapping movements of the hands (especially in elderly

patients) or other uncontrolled body movements; vision problems. In some patients bismuth subsalicylate

may cause dark tongue and/or grayish black stools. This is only temporary and will go away when you stop

taking this medicine.

Methylcellulose (Citrucel) Nonprescription

Dose: Dose 1 teaspoon or more twice a day in 2-3 oz. of any type of liquid, like Gatorade. Citrucel can also

be mixed with yogurt and taken that way as well. Notes: Fiber keeps your stools from becoming either too

loose, or dry and hard. Citrucel is a bulk forming dietary fiber, which has the ability to hold water and form

bulk. It also acts to coat the lining of the new stomach pouch and to normalize your bowel movements.

Cellulose, the fiber in Citrucel, has been shown to help the bowel become healthier, thicker and stronger.

Remember that ulcer is one of the long-term risks of this surgery over the long term. Low fiber intake has

been shown to be associated with the development of ulcers. Studies show that soluble fiber (like Citrucel)

from fruit and vegetables is protective against ulcer. On the other hand refined sugars (junk food) increase

the risk of developing an ulcer. Citrucel decreases episodes of diarrhea and helps to prevent or treat

constipation. Many studies have shown that increased fiber in the diet increases weight loss. Citrucel fiber

also increases the weight lost after surgery. TAKE YOUR CITRUCEL.

Note: The Citrucel is to be started as soon as you go home and continued for life.

(Note: See further information on fiber at the end of this section)

Calcium Carbonate / Titralac™, Tums™ ANTACID (Nonprescription)

Dose: Chew 1 or 2 tablets every 4-8 hours while awake. They can be taken with you other foods or liquids.

Notes: Calcium carbonate (Titralac™, Tums™) is an antacid that neutralizes or reduces stomach acids. It

relieves symptoms in patients with indigestion and heartburn. Calcium carbonate is also a dietary calcium

supplement. Tums can be started soon after the surgery and because of the risk of poor calcium absorption

after the Mini-Gastric Bypass; you should consider taking some form of calcium supplement for the rest of

your life. Generic calcium carbonate tablets are available. You should chew well, or crush the tablets

before swallowing; follow with a few sips of water, other fluids or yogurt. Antacids are usually taken after

meals and at bedtime. Take your doses at regular intervals.

Required, these are Not Optional, Type I: You are to take them as written;

they are Not Optional, Try Not to Miss a Dose.

(Note: Wait two weeks before starting the

Ursodiol (Actigall) and the Multivitamins)

Ursodiol (Actigall) (Do not start until 2 Weeks after Surgery.)

Dose: 300-mg. p.o. twice a day beginning two weeks after surgery. Ursodiol (Actigall) should then be taken

for the next 3-6 months after operation depending upon whether or not you have a gallbladder and how well

you are doing.

Notes: This medication helps to prevent the development of gallstone disease as you loose weight following

surgery. It can also help decrease the symptoms of any bile reflux that can occur after surgery. You should

take the Actigall as long as you are losing 10 lbs or more per month typically that is for 3-6 months.

Side Effects: This medication may cause diarrhea, stomach pains especially in the upper right side, nausea

or vomiting. If you experience any of these symptoms you can stop the Ursodiol (Actigall) and wait 5-10

days and then restart it slowly. Take 1 every other day and work up to the 2 a day. Always take it with food.

Other side effects include stomach upset, loss of appetite, gas, headache, tiredness, trouble sleeping, dry or

itchy skin, sweating, thinning of the hair, cough, runny nose, metal taste in the mouth, muscle pain,

nervousness or depression. These effects usually disappear as your body adjusts to the medication. If they

continue or become bothersome, inform Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery. PRECAUTIONS: Remember to discuss with Dr. Rutledge and the Surgeons of the Centers

for Laparoscopic Obesity Surgery any pre-existing liver disease or allergies. DRUG INTERACTIONS:

Discuss with Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery and the staff

any over-the-counter or prescription medication you may take especially estrogen hormones, birth control

pills, medication to reduce cholesterol levels such as cholestyramine, clofibrate or Colestipol or aluminum

antacids. STORAGE: Store at room temperature and keep away from moisture and sunlight. Do not store in

the bathroom

Multivitamins (Nonprescription),

Do not start the vitamins until 2 Weeks after Surgery.)

Dose: Take the multivitamin at three times the doe recommend by the label on the bottle of vitamins that you

have purchased. Do not start the vitamins until 2 Weeks after Surgery. Then, REMEMBER, you need to

take vitamins for the rest of your Life. Numerous vitamin brands are probably acceptable. You should

select one that includes IRON in the list of minerals. Vitamins have iron and can upset your stomach but

they are absolutely necessary. If they cause nausea, stop them for a day or two and then restart and begin

with one a day with meals and build up slowly to the three a day. Wal-Mart sells a brand called

"OneSource" Multivitamins. One of these three times a day is a good choice. Children's chewable vitamins

contain lower amounts of vitamins particularly B12 and they are not recommended.

Warning: The Gastric Bypass is very effective in causing weight loss because it causes malabsorption of fat

and calories, which is good for weight loss. But, the Gastric Bypass also causes malabsorption of some

vitamins and minerals, which is potentially dangerous to you.

Note: Most Drugs and Medications are NOT malabsorbed after Laparoscopic Mini-Gastric Bypass .

Remember: It is very important that you plan on taking high doses of multivitamins for the rest of your life

after Laparoscopic Mini-Gastric Bypass .

The Importance of Folate

Folate is included in the multivitamins that you should take every day. In several epidemiologic

investigations, folate intake has appeared to reduce the elevated risk of breast cancer.i A recent study

showed that Vertical Banded Gastroplasty patients' homocysteine levels increased. This is important

because homocysteine has been associated with the risk of hardening of the arteries. The study found that

the lower the patients' Folate level, the higher the level of the patients' homocysteine level (Bad). The best

recommendation is to make sure to take your vitamins including Folate.1 Severe obesity exposes one to an

increased risk of cardiovascular mortality. Gastroplasty has been shown to induce substantial weight loss

1 J Clin Endocrinol Metab 1999 Feb;84(2):541-5 Occurrence of hyperhomocysteinemia 1 year after gastroplasty for

severe obesity. Borson-Chazot F, Harthe C, Teboul F, Labrousse F, Gaume C, Guadagnino L, Claustrat B, Berthezene

F, Moulin P Service d'Endocrinologie, Hopital de l'Antiquaille, Lyon, France.

and to improve the atherogenic profile of severely obese subjects. However, vitamin deficiencies after

gastroplasty have been reported. Because hyperhomocysteinemia, an independent risk factor for increased

cardiovascular disease, is influenced by nutritional status (and especially by Folate intake), this study

hypothesized that a Folate deficiency induced by gastroplasty could promote hyperhomocysteinemia. They

found that plasma homocysteine concentrations increased, on an average, from 9.9 +/- 0.4 to 12.8 +/- 0.6

micromol/L (P < 0.0001). This increase in homocysteine levels was observed in two thirds of the subjects,

leading to clear-cut hyperhomocysteinemia (>15 micromol/L) in 32%. The changes in homocysteine

concentrations were correlated to weight loss (P < 0.001) and to decrease in plasma Folate concentrations

(P < 0.01). Whereas gastroplasty induced a mean 32-kg weight loss and a striking improvement in

conventional risk factors, the occurrence of iatrogenic hyperhomocysteinemia might hamper the benefit of

surgery on cardiovascular risk in most of the patients. They supported the use of a systematic efficient

Folate supplementation after gastroplasty.

Drugs that are NOT Required, They are Optional-Type II:

You are to take them ONLY if the need arises,

they ARE Optional.

Non-Prescription Pain Medication for Mild to Moderate Pain: Tylenol®

(Acetaminophen) Elixir.

Dose: Tylenol® (Acetaminophen) Elixir (160 mg/ 5 ml) 1-3 tsp (160-480mg) every 4-6 hours as needed for

pain. If your pain gets worse call your surgeon, the hospital or the Centers for Laparoscopic Obesity

Surgery.

This is a potentially dangerous pain medication. Be careful about using this and all medicines, follow the

instructions and do not allow others to use this medicine. You should take Tylenol cautiously and according

to the instructions, as you would take any medication. Side effects cannot be anticipated. If any develop or

change in intensity, call us at the Centers for Laparoscopic Obesity Surgery as soon as possible.

Acetaminophen has been shown to induce hematologic changes and liver and renal dysfunction. The dose

selected here is intentionally lower than usual to help avoid liver damage. You can purchase this at most any

drug store.

Anti-nausea Medicine for Mild to Moderate Nausea: Promethazine

(Phenergan®)

Dose: 25mg to 50mg as needed every 4-6 hours for nausea. Phenergan is effective in the relief of nausea,

and vomiting. It produces marked sedation in most patients. In general, gastrointestinal side effects are

minimal. It is stronger than the Diphenhydramine (Benadryl). You will receive 20 tablets from the druggist

and you may have 3 refills.

Anti-nausea Medicine for Mild to Moderate Nausea: Metaclopromide (Reglan)

Reglan increases the movements or contractions of the stomach and intestines. Metaclopromide relieves

symptoms such as nausea, vomiting, and continued feeling of fullness after meals, and loss of appetite.

Metaclopromide is also used, for a short time, to treat symptoms such as heartburn in patients who suffer

esophageal injury from reflux of gastric acid into the esophagus. Dose: 10 mg 30 minutes by mouth before

meals and at bedtime. Your prescription will be for 120 tablets (one month) you may have 3 refills. This

medicine will add to the effects of alcohol and other CNS depressants (medicines that cause drowsiness).

Some examples of CNS depressants are antihistamines or medicine for hay fever, other allergies, or colds;

sedatives, tranquilizers, or sleeping medicine; prescription pain medicine or narcotics; barbiturates; medicine

for seizures; muscle relaxants; or anesthetics, including some dental anesthetics. Check with your doctor

before taking any of the above while you are using this medicine. This medicine may cause some people to

become dizzy, lightheaded, drowsy, or less alert than they are normally. Make sure you know how you react

to this medicine before you drive, use machines, or do anything else that could be dangerous if you are

dizzy or are not alert. Possible Side Effects: Rare: Chills; difficulty in speaking or swallowing; dizziness or

fainting; fast or irregular heartbeat; fever; general feeling of tiredness or weakness; headache (severe or

continuing); inability to move eyes; increase in blood pressure; lip smacking or puckering; loss of balance

control; mask-like face; muscle spasms of face, neck, and back; puffing of cheeks; rapid or worm-like

movements of tongue; shuffling walk; sore throat; stiffness of arms or legs; trembling and shaking of hands

and fingers; tic-like or twitching movements; twisting movements of body; uncontrolled chewing movements;

uncontrolled movements of arms and legs; weakness of arms and legs. Beware of Confusion; convulsions

(seizures); drowsiness (severe). Other side effects may occur that usually do not need medical attention.

These side effects may go away during treatment as your body adjusts to the medicine. More common:

Diarrhea—with high doses; drowsiness; restlessness, Less common or rare: Breast tenderness and

swelling; changes in menstruation; constipation; increased flow of breast milk; mental depression; nausea;

skin rash; trouble in sleeping; unusual dryness of mouth; unusual irritability.

Mylanta and Maalox are antacids (Nonprescription)

Dose: Take 1 teaspoon every 2 hours as needed if you develop indigestion or burning chest pains like

indigestion. You should take antacids to relieve the discomfort of indigestion. If you have to take more than

a few doses call Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery to discuss

this issue with him.

Supplements

Supplements are an addition to your diet that may be advantageous in your recovery and in the

maintenance of your long-term good health. It is important to note that you do not have to take these

supplements. They might be of some help but they are not necessary for your recovery. They may be

started as soon as you like after surgery.

Supplements to consider:

Whey Protein

Whey protein has been shown to have numerous positive effects on wound healing, increased immune

function and increased strength and stamina. Recommended Dosage: Add one to three tablespoons to

yogurt once or twice a day.

Creatine

Creatine is a naturally occurring substance made from amino acids. It has established itself as a useful

sports supplement. Creatine is effective in increasing muscle mass and also has compiled a truly enviable

safety record. After creatine supplementation, individuals notice that they have greater strength and/or

endurance. These immediate "gains" will subside if you stop taking creatine. The long-term gains associated

with creatine supplementation come from the increases in exercise ability. In other words, creatine promotes

growth by allowing you to do more. Skeletal muscle function is decreased in obese men and women.

Studies have shown that ATP, creatine, glycogen, and lactate are decreased in obese patients. Creatine is

a naturally occurring compound found in muscle. It is made from three amino acids - arginine, glycine and

methionine. It has been shown that Creatine supplementation can increase muscle energy, stamina, and

strength, muscle mass and fat loss. Creatine supplementation enhances maintenance of fat-free mass

(muscle) and the progress of muscle strength during training in sedentary females. Recommended Dosage:

Creatine Monohydrate is taken 7,500 mg of the powder mixed in liquid 1-3 times daily, depending on how

much you can tolerate.

European J Applied Physiology Occup Physiology 1998 Jun; 78(1): 83-92 Effect of creatine supplementation

during rapid body mass reduction on metabolism and isokinetic muscle performance capacity. Oopik V,

Paasuke M, Timpmann S, Medijainen L, Ereline J, Smirnova T. Subjects studied before and after losing a 3-

4% of their body weight has shown that muscle strength could be maintained or even enhanced by dietary

creatine supplementation.ii The results indicated that creatine supplementation in comparison with placebo

treatment during rapid weight loss may help to maintain muscle mass.

Creatine has been shown to prevent muscle fatigue and improve strength. A recent study also shows that it

can also prevent mental fatigue as well. Creatine is abundant in muscles and in the brain and is used as an

energy source. Using a double-blind placebo-controlled design dietary supplementation with creatine was

shown to reduce mental fatigue when subjects repeatedly performed a mathematical calculation.iii

Glutamine

Glutamine is the most abundant amino acid in the body. Overall nutrition has a profound effect on the gut;

there are specific nutrients that influence the gut lining (epithelium). In the small intestine, glutamine has the

most important effects and this amino acid is now considered conditionally essential. Animal studies have

shown that there is enhanced growth of the lining of the gut with the administration of glutamine or a fibercontaining

diet. Exposure to various types of stress, such as starvation, infection and exercise, can severely

deplete glutamine stores, resulting in a spectrum of problems, including inhibition of muscle protein

synthesis and decreased immune function. Supplementation with glutamine can help supply your muscles

this important amino acid. Instead of taking glutamine from muscle storage during starvation, your body can

rely on the supplemental glutamine you're taking to deal with the additional demands placed on your body.

New research strongly suggests that the lining of your gut can be damaged easily. Chemicals, starvation

and stress can produce irritation and inflammation of the lining of the gut. Supplemental glutamine may to

counter these negative effects. Continuing supplementation is crucial since the average diet contains

relatively little glutamine. Glutamine is the principal fuel for the cells that line the stomach and the gut.

Studies have shown that Glutamine can decrease damage of jejunum (small bowel) and aid in healing.

Glutamine is safe and easy to take and can be a valuable supplement for a sound nutritional program.

Research has shown that an increased amount of glutamine can help to protect and heal the digestive tract,

strengthen the immune system and improve muscle mass. Glutamine plays a key role within the intestinal

tract. Glutamine supplementation can promote intestinal health and help to alleviate symptoms. Glutamine

is a primary source of energy for the cells of the gastrointestinal tract. The cells that line the intestine get

replaced with new cells every 72 hours. Glutamine plays a key role in the process of intestinal renewal as

well as healing and repair of damaged cells. Conversely, it has been proven that a lack of adequate

glutamine can result in diarrhea and damage to the intestinal tract. Glutamine supplementation has been

shown to promote the healing of diseased or damaged intestinal tract and enhance intestinal regeneration

following surgery. Recommended Dosage: 1-5 grams mixed in yogurt 2-4 times per day.

Studies have sown that 14 grams of glutamine per day helped AIDS patients keep on muscle and not gain

fat. The study also demonstrated improved immune function in AIDS patients receiving supplemental

glutamine.

GI Disease

Byrne et al, A new treatment for patients with short bowel syndrome, growth hormone, glutamine, and a

modified diet, Annals of Surgery 22 (3) 243-255, 1995. In the long-term study, 40% of the group remained

off TPN and an additional 40% have reduced their TPN requirements. After 28 days of therapy the patients

were discharged on only GLN + DIET.

Zoli et al, Effect of oral glutamine on intestinal permeability and nutritional status in Crohn's disease,

Gastroenterology, 108 (4): A766, 1995. Oral glutamine supplementation may decrease disease activity and

intestinal permeability while improving nutritional status.

Van der Hulst et al, Glutamine and the preservation of gut integrity, Lancet, 34:1363-1365 1993. The

addition of glutamine to parenteral nutrition prevents deterioration of gut permeability and preserves mucosal

structure.

Fish Oil/Flax Oil Tablets:

Recommended Dose: 1-2 tablets 1-3 times a day. There are many fatty acids, but only two are essential,

meaning they cannot be made by the body and must be obtained through diet or supplementation. Linoleic

(an omega6 fatty acid) and linolenic (an omega-3 fatty acid) are polyunsaturated fatty acids, whose primary

sources are vegetable oils and certain types of fish. EFAs have many important physiological roles in the

body and are critical for health, growth hormone production, mental functions, healing and recovery. EFAs

are useful because they help do so many things in the body and because, after surgery your new low fat diet

means that you’re not getting nearly enough of them, especially omega-3s. Some of the things they're

intimately involved in: increasing insulin sensitivity and insulin binding to receptors in skeletal muscle,

increasing binding of IGF-I (insulin-like growth factor-1) to skeletal muscle, decreasing cholesterol and

triglyceride levels, moderating the release of cortisol, stimulating the release of growth hormone, promoting

fat mobilization and inhibiting body fat synthesis and storage. There's also evidence that EFAs ameliorate

depression, improve mental function and support joint function. And that's just a sampling. Omega-3 fatty

acids are found in soybean, canola, walnut and, especially, flaxseed and linseed oils, as well as in some

fatty fish. The two most important omega-3s are eicosapentaenoic acid (EPA) and docosahexaenoic acid

(DHA). While your body can manufacture these, they are made from linolenic acid, which your body can't

make. You can also get EPA and DHA directly by eating certain fish, especially sardines, mackerel, herring,

salmon and lake trout, or by taking fish oil capsules. You can try a tablespoon or two of premium flaxseed oil

every day (one tablespoon per 100 pounds of bodyweight is good). If eating fish is not your thing, take fish

oil capsules, downing 3-4 g daily. Information: Several studies suggest that not all fats are the same and

that indeed some fats be good for you and treat and reverse different types of disease. Recent studies of the

so-called Mediterranean diet suggest that relatively high amounts fat as olive oil actually improved survival.

In another study addition of the omega 3 fatty acids (olive oil) improved the outcome of patients with bipolar

(manic depressive) disease. Fish and fish oil, rich sources of omega-3 fatty acids, have sparked intense

interest studies, which suggest a favorable effect on Heart Disease and other studies, which show a striking

improvement in lipid profiles in hyperlipidemic patients. Patients after gastric bypass malabsorb fat and

calories in part leading to the weight loss. One concern is the possible deficiency of essential fatty acids. It

may be a good idea to take a fatty acid supplement of fish or flax seed oil. It also may be advantageous to

use olive oil when possible. Corn and safflower oils on the other hand may not be good choices.

Zinc l-Monomethionine Zinc/Magnesium Aspartate

(TwinLab ZMA Fuel available at Wal-Mart and GNC Stores). Recommended Dose: 3 capsules for men and

2 capsules for women taken on an empty stomach 30-60 minutes before bedtime. Healing, recovery, tissue

repair, and muscle growth are maximized during sleep when growth hormone is released by the pituitary

gland. Zinc and magnesium may potentiate this healing effect of growth hormones during sleep.

Information: In a recent double-blind placebo study conducted with NCAA college football players,

researchers at Western Washington University found that eight weeks of nightly supplementation with ZMA:

Increased plasma zinc levels 29%, while placebo levels decreased 4.4%---a 33.5% difference. Increased

plasma magnesium levels 6.2% while placebo levels decreased 9.2%--a 15.4% difference. Increased total

testosterone levels 32.4% while placebo levels decreased 10.5%--a 42.9% difference. Increased free

testosterone levels 33.5% while placebo levels decreased 10.2%--a 43.6% difference. Increased Insulin-like

Growth Factor (IGF-1) levels 3.6% while placebo levels decreased 21.5%--a 25.1% difference. Increased

muscle strength 11.6% while placebo strength increased only 4.6%--a 2.5-fold difference. Other reported

benefits of ZMA include increased physical endurance; a decrease in muscle cramps and strains, faster

healing from injuries, improved mental concentration and alertness, decreased water retention, and deeper,

more restful sleep.

Bran Tablets:

Recommended Dose: 1-2 500 mg. tablets 1-3 times per day. Start slow and build up. Information: Fiber

has been shown to have a variety of positive effects. Bran has been shown in hundreds of studies to

decrease fat absorption, protect the lining of the gut and improve the bowel function.

Eating more fiber rich foods relieved abdominal pain and bloating for one out of four Irritable Bowel

Syndrome (IBS) sufferers in a recent University of Pittsburgh study. Even better when the rest added the

antidepressant paroxetine (Paxil), another two out of three reported that their discomfort faded away (Amer

Jour. of Gastroenterology, Sept 2002).

"Start by adding at least 25 g of fiber and six glasses of water a day. IBS is a problem that waxes and

wanes. So bear with it for 6 weeks," says researcher George L. Arnold, MD. Still uncomfortable, Keep up the

fiber, and ask your doctor about paroxetine. Paxil, which is gaining attention as a promising IBS treatment,

boosts the levels of serotonin available to nerve cells throughout the body (not just in your brain). "Serotonin

acts on the nerves in the gastrointestinal tract to cut some of the pain and spasms and restore more normal

contractions," Dr. Arnold says.

Activity

You may have heard after other types of surgery that you should beware of vigorous exercise or heavy lifting

after surgery. This is not the case with laparoscopic surgery. Vigorous exercise can be started immediately

after surgery if you wish. You do not have to start exercising immediately after surgery, but you can if you

want to. Exercise does not put your stomach pouch at risk. Walking soon after operation is very helpful in

your recovery. You can start water aerobics or swimming within seven days after operation. Weight lifting

and sit-ups are fine and are encouraged. Take it easy if your have not done this type of exercise before.

Your white "TED" hose are elastic stockings designed to compress the veins in your legs and help protect

you from Deep Vein Thrombosis (clots in your legs) and from Pulmonary Embolus (clots going to your

lungs.) You should continue to wear you stockings after you go home until you are back to normal levels of

activity.

Bandages and Wounds

Try to get the tape and bandages off of your wounds as soon as possible. The tape can pull the skin and

scar and damage your skin. If your bandages get wet or stained, then you should change or remove them.

BRUISING OR BLEEDING is common after surgery. Bandages often become stained with blood on the day

of surgery. And later if the wound bleeds during the first 24 hours after surgery, press on the area with a

clean gauze pad, tissue or cloth for 10 minutes. Bruising often worsens several days after surgery. Bruising

or bleeding is usually not a source for concern unless accompanied by steady foul smelling drainage,

worsening pain, tenderness, redness or progressive swelling. You may shower or wash the incision gently

with mild unscented soap. Between baths, keep the wound dry with a bandage for the first 2 to 3 days after

surgery. If a bandage gets wet, change it as soon as convenient. After the first 3 days you can leave the

wounds open to air or cover them with a band-aid type bandage if you like.

Patient Instructions for the "Paint" on your abdomen used for the skin sterilization at the time of surgery: We

use the 3M DuraPrep Surgical Solution, a bacteria killing skin preparation that acts fast and lasts long. It is

recommended that this film remain on the skin after the procedure because it continues to kill bacteria for up

to 12 hours and maintains low bacteria counts under dressings for up to 3 days. The film will gradually wear

away. If, however, early removal is desired: Soak gauze with 70% isopropyl alcohol and place on the

prepped area for at least 40 seconds. Lightly scrub to remove the solution.

Showering after Surgery

It is OK to shower and get your incision wet 1-2 days after the operation but do not soak in a bathtub for a

week or 10 days. If the incision becomes red or starts to drain, you should immediately contact Dr. Rutledge

and the Surgeons of the Centers for Laparoscopic Obesity Surgery.

Your Diet

There are three stages in the diet that you should eat after surgery.

Stage I:

Stage I is from the moment that the operation is completed until 10-14 days after surgery. During this period

the surgical wounds are healing and the new connection between the stomach and the small bowel is

repairing itself. This is your most dangerous time. It is during the first 10 to 14 days when you are the

greatest risk of leakage at this new connection. During stage I, the titanium staples initially hold the stomach

and the small bowel together. They are rapidly replaced by the body’s own connection based upon the

protein called collagen. The titanium staples are only effective for a few days and then the body must heal

the stapled areas or they will fall apart. During this period the new “plumbing”, the new connections in the

gastro-intestinal tract are most at risk of coming undone. If this happens a leak of gastro-intestinal contents

and bacteria occur that is very serious and can be lethal.

Because of this fragile connection, during the period of Stage I we ask that you be extremely careful about

what and how much you eat.

Your postoperative diet in Stage I should consist mainly of fruit and vegetable juices, Gatorade and different

types of light soups. Well-chewed Saltine crackers are also a good choice. Thin soups and Yogurt are also

very good for you at this point.

Orange, grapefruit, tomato, V8, grape and other juices are all good choices. Juices are a good choice

because of their high potassium content and the fact that they also contain other vitamins and minerals.

Gatorade is also a good choice because it is light and it contains sodium and potassium. Occasionally the

sweet juices can be too sweet and cause the “Dumping Syndrome.” You may need to dilute the juices with

water.

Coffee, tea, sodas are not good choices because of their low potassium and vitamin content.

You should get some saltine crackers and nibble on them in the days right after surgery. They are packed

with sodium and my experience has shown that they will help you avoid dehydration.

Yogurt: Yogurt is a very valuable part of your postoperative diet. You should eat nonfat yogurt at the very

least once a day. Yogurt is a good source of protein and calcium, it coats the lining of the new stomach and

it provides healthy bacteria to the gut.

"Ensure" and other similar commercial supplements contain fat and may lead to dumping syndrome and

should probably be avoided.

Chicken Noodle Soup: Salty soups, such as chicken noodle soup, are good choices early after surgery.

Cream soups may cause dumping and probably should be avoided.

Eat Frequently: The effects of meal frequency on body composition during weight loss has shown that eating

six or more times meals day leads to better retention of lean body mass (muscle.) These studies show that

lower frequency of eating intake leads to greater muscle loss even if the same diet is consumed. So eat

every few minutes through out the day.

The Myth of 8 Glasses of Water a Day: Many people have heard that drinking lots of water helps with

weight loss. This wrong and is dangerous right after your Laparoscopic Mini-Gastric Bypass . You can have

a little water to drink after surgery but Gatorade, V8, juices and chicken noodle soup are much better

choices because they contain some sodium and potassium.

It is important to emphasize that you should take only small amounts of liquids at each feeding during stage

I. (No more than 2 - 3 table spoons at a time). Then wait for approximately 10-15 minutes before taking any

more. This is done to avoid distending the new small stomach pouch and potentially disruption the new

staple.

Stage II

Stage II in the healing of the stomach after surgery is from 10-24 days following surgery to the time in which

you return to a modified regular diet. This can last anywhere from a few days to two months. During this

time juices and liquids should continue to be a mainstay of your diet. If you choose you can move quickly

through this stage to an almost regular diet. It has been our experience that those patients who work

hardest to stay mostly on juices for up to two months have the greatest weight loss. During this time soups

are very useful in providing variety to your diet. Other types of very soft foods that would fit through a

strainer are also useful and healthful. Examples are applesauce mashed potatoes and “runny” cereals

especially oatmeal.

Stage III

Stage III is the period when you return to essentially a normal diet. Most anything is really OK if you tolerate

it. At this point most patients report that red meat (beef) is often difficult to eat. Bread can be a problem as

well. Many patients say that they ”crave” fruits and vegetables. Most patients find that they must eat

frequently and eat about 20-30% of what they used to eat for a meal. They find that sweets, junk foods and

fatty foods are not as enjoyable as they once were and are more often left out of their diet except for in small

quantities.

The “Dumping Syndrome”

The dumping syndrome consists of mild, moderate or severe abdominal pains and cramping, occasionally

causes diarrhea, lightheadedness, sweating, and palpitations. A concern after all types of gastric bypass

surgery is condition called "dumping syndrome" in which there is discomfort following eating or drinking. This

may include mild moderate or severe cramping, full feeling, rapid pulse, weakness, cold sweating, dizziness,

and nausea and vomiting can even follow. In simple terms, the rapid movement of food into the small

intestine causes this syndrome from the stomach. When there is liquid with the dry/solid foods, it causes a

faster movement into the small intestine, sometimes precipitating the dumping syndrome. Thus the

recommendation to not have liquids with solid foods or close to eating times.

Other recommendations to help prevent dumping include:

-Six or eight very small meals throughout the day

-Inclusion of protein and fat with carbohydrates, and may even want a relatively low carbohydrate

content to decrease the chance of dumping

-Avoid sugar, sweets, and desserts (again, simple carbohydrates digest fastest and move quickest

through the system)

-Avoid alcohol and sweet carbonated drinks

The Dumping Syndrome can be caused by sugary foods, fatty foods, too much food or liquid at one time and

other foods in individual patients. Changing what you eat and how much you eat can treat the dumping

syndrome. Remember that you must eat several small “meals” throughout the day, to be careful of liquids

and foods that contain sugar, and to eat foods high in protein (like nonfat yogurt). To reduce the amount of

fluid that enters the small intestine, patients are usually encouraged not to drink more than a very small

amount at a time. Medicine also can help control the dumping syndrome. The symptoms usually disappear

in 3 weeks to 3 months.

Anti-dumping/Mini-Gastric Bypass diet is for persons with the Mini-Gastric Bypass for morbid obesity usually

doesn’t tolerate:

· (Remember you are on Liquids for the first several weeks, this stuff is for later☺)

· Tough meat, especially beef

· Fried or fatty foods

· Concentrated sweets

· Milk and dairy products are some times problems (yogurt seems to work best.)

· Bread, especially when fresh or fluffy can form a ball and be a problem (remember to chew your

food very, very carefully)

· Citrus juices and fruits can be too sweet (mix them with water if they bother you)

Also drinking fluids with meals displaces nutrient dense foods and tends to make the person feel bloated

and sick even if flat (fizz gone) carbonated beverages are drunk.

What happens is because of the smaller gastric pouch; the simple sugars aren't broken down prior to being

dumped into the intestines. The sugars ferment and cause bloating or sometimes vomiting.

Nausea, vomiting, bloating indigestion or heartburn can also be caused by: Eating or drinking too quickly,

Not chewing food adequately especially beef, bread, Eating too much, Eating fatty, rich or sweet foods,

Eating gas producing foods or drinking carbonated beverages, Eating foods that usually cause gastric

discomfort to the individual.

Consider resting or lying down with your head elevated for 15 minutes after a meal to decrease movement

of food from the stomach to the small intestine. This can decrease the severity of symptoms in some

patients. You may want to avoid very hot or cold foods or liquids, which may increase symptoms in some

patients. The best advice is to go very, very slowly on taking any liquids or foods as you begin to adjust to

the Mini-Gastric Bypass.

Protein

The gastric bypass decreases the absorption and digestion of some foods after surgery. There is a risk of

malnutrition and so attention to a good balanced healthy diet after surgery is important. We DO recommend

some additional protein after the Mini-Gastric Bypass SM. Some additional protein is probably a good idea

but very high levels of protein are probably not a good idea. High levels of protein in the diet have well

recognized risks. Recent studies suggest that kidney stones can be associated with high levels of animal

proteins.

Protein and Kidney Stones

Kidney stone patients are often told to limit their dietary intake of calcium. But new research suggests that

restricting animal protein and salt may be a better way to prevent kidney stones from recurring.

In a study, 20% of men on a low-animal protein, low-salt diet that contained normal amounts of calcium had

recurrent stones after 5 years, compared with 38% of men on a low-calcium diet.

The results point to a dietary association kidney stones and restricted intake of animal protein and salt. A

restricted animal protein diet combined with a normal calcium intake provides greater protection than the

traditional low-calcium diet,'' the authors write in the January 10th issue of The New England Journal of

Medicine.

A diet that restricts animal protein and salt is thought to reduce the urinary excretion of oxalate, a compound

that combines with calcium and other compounds to form kidney stones, the researchers explain. Lowcalcium

diets, on the other hand, may reduce urinary excretion of calcium but they also cause levels of

oxalate in urine to rise, research has shown.

You may also be well advised to limit oxalate-containing foods such as walnuts, spinach, rhubarb, parsley

and chocolate, and to consume 2 to 3 liters (quarts) of liquid daily.

After 5 years, the diet restricting animal protein and salt patients were significantly less likely to have

recurrent stones, the report indicates. Urinary levels of oxalate increased in the men on the low-calcium diet

but decreased in men on the other diet. Urinary calcium levels declined in both groups.

Kidney stones, which are often extremely painful to excrete, cost billions of dollars each year in medical care

and lost productivity. Roughly 10% of Americans develop a kidney stone at some point in their lives.

SOURCE: The New England Journal of Medicine 2002;346:74-75, 77-84, 124-

Bile Reflux

Bile is a complex fluid containing water, electrolytes and a battery of organic molecules including bile acids,

cholesterol, phospholipids and bilirubin that flows through the biliary tract into the small intestine. There are

two fundamentally important functions of bile in all species: Bile contains bile acids, which are critical for

digestion and absorption of fats and fat-soluble vitamins in the small intestine. Many waste products are

eliminated from the body by secretion into bile and elimination in feces. Adult humans produce 400 to 800 ml

(1/2 to 1 quart) of bile daily. Bile is composed of bile acids and salts, cholesterol, pigments, water, and

electrolyte chemicals that keep the total solution slightly acidic (with a pH of about 5 to 6). Gallstones, most

of which are composed predominantly of cholesterol, result from processes that allow cholesterol to

precipitate from solution in bile. Bile acids are derivatives of cholesterol synthesized in the liver cells.

Cholesterol, ingested as part of the diet or derived from hepatic synthesis is converted into the bile acids

cholic and chenodeoxycholic acids, which are then conjugated to an amino acid (glycine or taurine) to yield

the conjugated form that is actively secreted into the gut. Large amounts of bile acids are secreted into the

intestine every day, but only relatively small quantities are lost from the body. This is because approximately

95% of the bile acids delivered to the duodenum are absorbed back into blood within the ileum.

After your surgery with the new connection between the stomach and the bowel new connection it is

common to have bile reflux into the new stomach. This is usually worst in the first few weeks after the

surgery and improves over time. Rarely it can be so severe that you can have unpleasant episodes of

nausea and vomiting. This can be worst at night when you lie down. It is often made worse by eating late at

night or just prior to going to bed. It can usually be made better by sleeping in a near sitting position for a

few days and avoiding meals late at night. Taking your Prilosec OTC (omeprazole), Pepto-Bismol and

Citrucel in the evening prior to bedtime can also be helpful. The supplemental Bran Tablets have also been

shown to be helpful as well.

If you do have an episode of vomiting bile soda pop (Sprite, 7-up or Mineral Waters like Perrier) can be

helpful in washing the taste out of your mouth and throat. Soda pop is a weak acid. Stomach acid (HCl)

hydrochloric acid is a relatively strong acid. Baking soda, sodium hydrogen carbonate (NaHCO3) is a weak

base. It is the phosphoric acid that is deliberately added to soft drinks to give them a sharper flavor that can

help neutralize the bile. Soda pop is acid from the phosphoric acid and not from the carbonic acid from the

dissolved CO2 (the bubbles), the pH (how acid it is) of fresh (bubbly) and flat soda pop are about the same.

The pH of regular and diet pops ranges from 2.5-3.4. Phosphoric and citric acids contribute to the acidity of

pop. The phosphoric acid in soda is “corrosive.” Drinking carbonated soft drinks regularly can contribute to

the erosion of tooth enamel surfaces. Soft drinks, which contain sticky sugars that break down into acids,

adhere easily to tooth surfaces. These acids can soften tooth substance and promote formation of plaque,

which erodes the enamel.

Fruit juices and drinks are also tart, but they don't use phosphoric acid as a flavor additive. These beverages

get their tang from citric acid, a substance found in oranges, limes, lemons and grapefruits. You can

purchase some over the counter anti-nausea syrups that have many of the same ingredients as soda pop.

An anti-nausea liquid syrup product made by Valu-Rite lists the active ingredients as: phosphoric acid,

dextrose (glucose), levulose (fructose), with a few inactive ingredients like glycerin and food coloring. These

ingredients aren’t much different than the corn syrup and phosphoric acid in carbonated sodas. Mild nausea

caused by stomach irritation is often treated with a 'phosphorylated carbohydrate syrup'. The composition of

these syrups is very similar to soda pop. There are a few differences:

The bubbles in carbonated drinks can be a source of stomach irritation, so you may want to let the pop go

flat before using it for this purpose. The syrup probably does a better job of coating the stomach than the

pop would. The syrup doesn't contain caffeine, while some pop does. Additional acid contributes to irritation.

So why doesn't the phosphoric acid irritate the stomach? At high concentrations, it's nasty stuff. The

phosphoric acid in the syrup and in soda pop is very dilute, and it is not fully protonated (if the syrup has a

pH of around 2.5-3, it's mostly H2PO4- with a smaller amount of H3PO4). The phosphoric acid can buffer as

H3PO4/H2PO4- around a pH of 2.1. The pH of normal stomach contents is typically lower than this (about

1.6 to 1.8). So the phosphoric acid in the syrup won't lower stomach pH by dissociating. So you can try flat

soda pop, non-acidic fruit juices, and Popsicles as means to prevent the nausea!

A concern raised by some, is the potential association of the Billroth II (BII) type connection used in the

Mini-Gastric Bypass SM with stomach (gastric) cancer. There are some medical studies that seem to raise

concerns about the relation between the Billroth II type connection and gastric cancer. A careful review

shows that this is not a reasonable concern. A good and very well done study looking at this question was

published in the New England Journal by Schafer et al In this study performed by the Mayo Clinic studied

residents of Minnesota, who had surgery for ulcers between 1935 to 1959. These patients were followed for

over 5,635 person-years. They found gastric cancer in only two of the patients in the surgical group, as

compared with an expected rate of 3 people. That is, they found that the rate of gastric cancer in the

surgery patients was actually lower than that seen in unoperated patients. Many other studies of Billroth II

patients have found no evidence of an increased incidence of gastric cancer.

In a recent study by Bassily the records of 569 patients who had a partial gastrectomy for ulcer disease were

analyzed. Five hundred and seven patients (83.5%) had a Billroth II. They showed that "the risk of gastric

cancer was not increased after Billroth II partial gastrectomy."

In a study from Finland the risk of gastric cancer after gastric surgery for ulcer was reported. Six of the

285 patients developed gastric cancer after the operation. The risk of contracting gastric cancer in the rest of

the population (individuals who had no operation) of equal size and age during a similar follow-up period

was 8 cases. That is to say, the operated patients had a lower risk of gastric cancer than the nonoperated

patients. This study, as well as many others, shows that the risk of gastric cancer does not significantly

increase after partial gastrectomy for benign peptic ulcer.

It is true that there are some studies that appear to show an increased risk of gastric stump cancer as

compared to the general population. But these studies are seriously flawed. All of the studies that show

slight increases in the rate of gastric cancer following Billroth II include patients that have had the surgery for

ulcer disease. The problem with this kind of study design is the fact that gastric ulcer is associated with an

increased risk of gastric cancer.

For example, in a study by Molloy and Sonnenberg the association between ulcer and gastric cancer was

demonstrated in patients from the US Department of Veterans Affairs. 3,078 subjects with gastric cancer

were compared with 89,082 people without gastric cancer. This study showed that gastric ulcer patients had

an increased rate of gastric cancer (relative risk 1.53, note that this increased risk is similar in magnitude to

the increased risk reported in the studies showing an increased risk of gastric cancer in Billroth II surgical

patients.) Many other studies confirm these findings that ulcer patients have an increased risk of gastric

cancer.

In a study by Hansson published in the New England Journal of Medicine the risk of stomach cancer in

57,936 patients was analyzed. The rate of gastric cancer among patients with gastric ulcers was increased

1.8 times. Again, this value is very similar to that reported for the increase seen in some studies of postgastrectomy

patients. They concluded that gastric ulcer disease and gastric cancer have causative factors in

common.

Thus the studies that find small increased rates of gastric cancer in post gastrectomy patients may simply be

identifying gastric ulcer patients that are prone to develop gastric cancer regardless of any surgery they may

have had.

The incidence of gastric cancer in the United States has decreased four-fold since 1930 to approximately 7

cases per 100,000 people. It is important to look at the actual size of the reported possible increased risk of

stomach cancer in the series that appear to find an increased risk of stomach cancer in post gastrectomy

patients.

In other words, how much of an increased risk are we talking about and how does that compare to other

factors involved in the development of gastric cancer. As described above the many studies find no

increased risk of gastric cancer in Billroth II patients, but in the studies that do find an increase in risk, how

much of an increase is seen and how does this compare to other factors involved in the development of

gastric cancer? Analysis of these issues can put these studies reporting an increased risk of gastric cancer

into proper perspective.

What causes cancer of the stomach?

No single cause for stomach cancer has been identified but a number of important risk factors are known.

Diets rich in salted or smoked foods have been associated with increased cancer risk in many studies.

Similarly, some foods contain nitrites and these chemicals can be converted to more harmful compounds

(carcinogens) by bacteria in the stomach. Lack of vitamin C, fruit and vegetables may be important.

Stomach cancer is more common in smokers and in those with heavy alcohol intake.

Helicobacter Pylori

Helicobacter Pylori (H. Pylori) is being increasingly recognized as an important and potentially causative

agent in a variety of serious medical illnesses including stomach ulcers and cancer. In recent years studies

have reported that infection with Helicobacter pylori (HP) can increase the risk of gastric cancer three to six

fold. This data has come from large population studies comparing the rates of HP infection in patients with

gastric cancer compared with patients who do not. It has been estimated that HP infection may actually be

responsible for approximately 60% of all cases of stomach cancer. At present, there is no general

recommendation that antibiotic therapy should be offered to people with the H. Pylori infection. Studies

clearly show that H Pylori not gastrectomy appears to be the risk factor associated with gastric cancer and

physicians who feel this is of concern can provide treatment to patients to eradicate H. Pylori.

The risk of stomach cancer is higher in close relatives of patients with the disease. Hundreds of articles

have looked at factors that affect the development of gastric cancer. These studies of stomach cancer

indicate that salted, smoked, pickled, and preserved foods (rich in salt, nitrite, and preformed N-nitroso

compounds) are associated with an increased risk of gastric cancer. There is good evidence that the high

eating fresh fruit and raw vegetables and a high intake of antioxidants are associated with reduced risks

of gastric cancer.

Now with all of these factors know to affect the risk of gastric cancer, where is post-gastrectomy positioned

as a risk factor? Extensive research shows that gastric cancer has an environmental cause, of which diet

appears to be the most important component. Studies show that there is an approximately a threefold

increased risk of gastric cancer for frequent consumption of fresh and processed meats (relative risk 3.1 and

3.2). Gastric cancer risk rises with increasing intake of smoked and pickled foods (relative risk 3.7.) All of

these factors that increase the risk of gastric cancer are as much as twice as high as that seen with the

studies showing an effect of gastrectomy on gastric cancer risk. Many studies also show a decreasing risk of

stomach cancer with increasing frequency of vegetable consumption. Increased intake of citrus fruits (risk

0.47) and raw-green vegetables (risk 0.56) appear to be protective. Consumption of salty snacks more than

twice per month has been associated with an 80 percent increased risk. These findings are consistent with

many studies around the world that indicate important roles for salt, processed meats, and vegetable

consumption in the risk of gastric cancer.

There are dozens more articles like these but we can summarize these findings as follows:

The incidence of gastric cancer in the United States has decreased four-fold since 1930 to approximately 7

cases per 100,000 people. This is in the range of the risk of being struck by lightning.

Billroth II post gastrectomy patients are at little or no increased risk of gastric cancer.

If either they or their physicians are concerned about gastric cancer it appears that very simple dietary

modifications (i.e. avoiding processed meats, smoked and pickled foods while increasing one's intake of

fresh fruits and vegetables, with or without supplementation with additional antioxidant vitamins) can have a

much greater impact on the patient's lifetime risk of gastric cancer than that of the Mini-Gastric Bypass SM.

Another way to put this is to say that a regular diet of bologna sandwiches appears to be of greater risk to a

patient for the development of gastric cancer than the Billroth II.

It may also be of value to point out that thousands of general surgeons routinely perform the Billroth II

anastomoses on a daily basis. Tens of thousands of patients undergo Billroth II type gastrojejunostomy on a

yearly basis and there is no ground swell effort being generated against the risk of the Billroth II type

anastomoses.

The Causes of Stomach Cancer

Following are questions that will help you determine if you're at high risk for developing stomach cancer:

Do you have an existing stomach ulcer? (Stomach ulcers don't necessarily cause stomach cancer, but

stomach cancer often originates in people with a stomach ulcer.)

Are you a heavy eater of food that's been smoked, pickled, barbecued, and salted?

Have you been exposed to aflatoxins, carcinogenic byproducts of a fungus that grows on seeds, nuts, corn,

and other dried foods?

Do you smoke or drink alcohol heavily?

Is it possible that you could be suffering from a long-term helicobacter pylori infection? (It causes stomach

irritation and ulcers and might contribute to the formation of some cancers.)

Do you have a personal history of gastritis, pernicious anemia, and gastric polyps?

Are you involved in an occupation such as coal mining or metal mining?

Do you live or work in an environment where you inhale dust and fumes?

Are you male? (Stomach cancer occurs twice as often in men as in woman.)

Are you African American?

Low dose aspirin bleeding risk: Aspirin “thins” the blood

Even low doses of aspirin can cause internal bleeding in the stomach and intestine, researchers have found.

Many doctors recommend that their patients take aspirin to reduce their risk of heart problems. The drug

thins the blood, and reduces the risk of clots forming in key blood vessels. “Aspirin treatment should be used

only when there is good reason to do so.” said Dr Yoon Kong Loke, Radcliffe Infirmary It is well known that

doses of 300mg a day, which were prescribed in the past, carry a risk of gastrointestinal bleeding. Some

experts thought, however, that low doses of aspirin, such as 75mg a day, that is “baby aspirin” carry little risk

of side effects. But this theory has been debunked by scientists at the Radcliffe Infirmary in Oxford, who

found that long-term use of the drug, even at low doses, does have potentially harmful side effects. They

also found no evidence that using expensive "modified release" formulations of aspirin reduces the risk of

bleeding. The researchers analyzed 24 previous studies of aspirin, involving almost 66,000 patients. They

found that, on average, bleeding occurred in 2.5% of patients taking aspirin compared with 1.4% who were

not. Writing in British Medical Journal, the researchers warn that their findings have important implications

for everyday practice as the use of aspirin to prevent heart problems is very common. Patients and doctors

need to consider the trade-off between the benefits and harms of long term treatment with aspirin, they say.

Researcher Dr Yoon Kong Loke said: "There is no doubt that aspirin is an effective drug. "Because of this

problem with gut bleeding though, aspirin treatment should be used only when there is good reason to do

so." In an accompanying editorial, Dr Martin Tramer, of Geneva University Hospitals, Switzerland, argues

that it is unclear who should be given what dose of aspirin and for how long. Doctors have been treating

their patients with low dose aspirin on the understanding that they did more good than harm, he says.

But it was wrong to make such an assumption until further research was carried out. A study by researchers

at the Wolfson Institute of Preventive Medicine in London published earlier this year found aspirin was linked

to a risk of serious bleeding in men with high blood pressure.

To estimate the risk for upper gastrointestinal (UGI) bleeding in patients taking low-dose aspirin,

investigators in Spain reviewed charts of and interviewed 903 consecutive hospitalized patients who were

diagnosed with cardiovascular disease and who were treated with low-dose aspirin (75-325 mg/day).

During a mean follow-up of 45 months, 41 patients (4.5%) required hospitalization for UGI bleeding

(annualized rate, 1.2 events per 100 patient-years). The hospitalization rate remained constant throughout

the study. In multivariate analysis, factors that increased the risk for a UGI bleeding event were history of

peptic ulcer disease or UGI bleeding (relative risk, 3.1) and aspirin dose above 100 mg/day (RR, 1.8).

Factors associated with a decreased risk for UGI bleeding were use of acid antisecretory agents (RR, 0.22)

and use of nitrates (RR, 0.73). The authors concluded that the risk for UGI bleeding in patients taking lowdose

aspirin is significant and higher than risks documented in prior clinical trials.

These results confirm that low-dose aspirin therapy carries a small, but significant, risk for UGI bleeding and

that the lowest aspirin dose is the safest. The increased risk for UGI bleeding in patients with peptic ulcer

disease reported in this study is similar in magnitude to the reported risk for UGI bleeding associated with

NSAIDs. If UGI bleeding risk in patients with peptic ulcer disease is partially mitigated by acid reduction,

then this study may underestimate this risk because nearly 40% of patients on antisecretory therapy were

taking proton-pump inhibitors, which are more likely to confer protection against UGI bleeding than are H-2

receptor antagonists. This study did not include enough patients who had Helicobacter pylori infection or

who were taking nonaspirin NSAIDs to determine their association with UGI bleeding in low-dose aspirin

users.

Ulcers, Gastrointestinal Tract Bleeding and the use of

Antidepressants

Ulcers, upset stomach and gastritis are some of the most common problems and complaints after Roux-en-

Y and MGB surgery. It is very important to be aware of this risk and actively avoid things that increase the

risks of gastric irritation and damage where possible and remember to do the things that can help protect the

lining of the stomach. Recently several studies have documented the fact that the use of selective serotonin

reuptake inhibitors (SSRI's) increases the risk of upper gastrointestinal tract bleeding by 2-400%. Some

prominent SSRIs include Celexa (Citalopram), Luvox (Fluvoxamine), Paxil (Paroxetine), Prozac (Fluoxetine),

Zoloft (Sertraline). In a recent study from the Archives of Internal Medicine "Use of Selective Serotonin

Reuptake Inhibitors and Risk of Upper Gastrointestinal Tract Bleeding: A Population-Based Cohort Study"iv

the risk of upper gastrointestinal tract (GI) bleeding with use of antidepressant medication was evaluated in

all users of antidepressants in Denmark. During periods of SSRI use without use of other drugs associated

with upper GI bleeding, we observed 55 upper GI bleeding episodes, which was 360% more than expected.

Combined use of an SSRI and nonsteroidal anti-inflammatory drugs or low-dose aspirin increased the risk to

1220% and 520% respectively. Antidepressants without action on the serotonin receptor had no significant

effect on the risk of upper GI bleeding. The risk with SSRI use returned to normal after termination of SSRI

use.

They concluded that selective serotonin reuptake inhibitors increase the risk of upper GI bleeding, and this

effect is potentiated by concurrent use of nonsteroidal anti-inflammatory drugs or low-dose aspirin, whereas

an increased risk of upper GI bleeding could not be found with other types of antidepressants.

What you should expect after you leave the hospital

You should be alert and oriented. You should understand what day it is, where you are and what is going on

around you. In summary you should feel that you are almost back to normal.

You should be able to stand, walk and move about steadily and without dizziness or lightheadedness. You

should be up and walking very often during the day. You should not have undue amounts of pain. You

should be able and encouraged to go up and down steps and to be reasonably active during the day and to

be able sleep well at night. It is recommended that you alternate periods of rest and activity. You may do

normal daily activities, light housework, and walking as tolerated. You will tire more easily for a while after

surgery, but gradually the periods of activity will get longer before you need to rest.

You should NOT have high fevers, night sweats or shaking chills at home. You temperature should be less

than 101.5.

You should be able to breathe comfortably without pain or shortness of breath. You should not be coughing

up sputum or blood. You are encouraged to breath deeply, to cough and clear your lungs to open the lungs

and help them recover from the operation.

You Should Have a Normal Pulse Rate: After the surgery one of the best indicators that something is wrong

is a rapid pulse rate. Often this shows up as the first sign of an important problem. In the first week after

surgery get in the habit of taking your pulse several times per day. The more often that you do it the better

you will be at it. Your pulse after resting for 10 minutes should be under 100 beats per minute. It is very

worrisome if it is over 120 beats per minute. If your pulse is over fast or if you do not feel well call Dr.

Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery immediately.

You should be able to drink fluids without nausea or vomiting. Remember you have a new and very small

stomach. Drink slowly and drink only a small amount at one time. Sip your juices. Don't rush it. Sometimes it

may help to dilute your juices with water half and half.

You may have diarrhea for several days after the surgery. This can be severe for a few days and if you are

not near a bathroom can lead to accidents in some cases. In every patient so far this problem has resolved

in the first week or 10 days following the operation as the body begins to adjust to the new bypass.

You may have constipation: The Sucralfate (Carafate) and other factors can lead to constipation after the

operation. Usually this resolves in the first week after the operation. If you are having problems with mild

constipation you may try stopping the Sucralfate (Carafate) and taking a small dose of Milk of Magnesia. If

you do not feel well remember to call Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery.

You should be able to pass your urine without difficulty. You should not have burning pain, bleeding or

hesitancy when you pass you urine.

You may have some clear or bloody drainage from the wounds. If you do, you can change your bandages

whenever necessary. The drainage should not be purulent or foul smelling. There may be some bruising

around the port site wounds but they should not turn red or swell or become more painful.

You can take a shower. Treat the wounds with care, but they can get wet. You can cover them with a Band-

Aid, if you wish.

CAUTIONS - "What to Look Out For"

Nausea: Nausea is common for the first several days after surgery. In unusual cases the nausea can be so

severe that prevent patients from taking in an adequate amount of liquids. If this happens you need to come

back to the hospital to receive intravenous fluids. Rarely this can last as long as several weeks. In every

single case so far this has always resolved. For nausea that occurs in the first days after surgery

medications such as the Scopolamine patch, Phenergan and benadryl are often helpful.

Nausea and Estrogen Levels: Nausea is common in the first several months of pregnancy. It is felt that the

nausea of pregnancy may in part be related to changing hormone levels. We have seen that nausea can

occur after Laparoscopic Mini-Gastric Bypass and that this nausea can sometimes be reversed by a low

dose estrogen patch, Climara 0.05 mg/day. Climara is indicated for the treatment of menopausal symptoms,

hypoestrogenism and the prevention of osteoporosis. Estrogens should not be used by patients with known

or suspected pregnancy, breast cancer, estrogen-dependent neoplasia, undiagnosed abnormal genital

bleeding, active thrombophlebitis or thromboembolic disorders. Estrogens have been reported to increase

the risk of endometrial carcinoma.

Constipation:

Infection: Watch for signs and symptoms of infection. These are: a rapid pulse rate of over 100 beats per

minute that does not slow down, a fever greater than 101.5 degrees, chills, increased redness or pus

draining from the incision sites. Look for increasing abdominal pain, nausea, vomiting or shortness of breath.

If you experience any of these please CALL Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery immediately.

Pneumonia:

Depression: Our experience has shown us that in the period of stress, starvation and weight loss that occurs

following Mini-Gastric Bypass SM mild to severe depression is common. You and your family should look for

the signs of depression: Persistent sad, anxious, or "empty" mood, · Loss of interest or pleasure in activities,

including sex, Restlessness, irritability, or excessive crying, Feelings of guilt, worthlessness, helplessness,

hopelessness, Sleeping too much or too little, early-morning awakening, Decreased energy, fatigue, feeling

"slowed down", Thoughts of death or suicide, Difficulty concentrating, remembering, or making decisions,

Persistent physical symptoms that do not respond to usual treatment. Effective drug and psychological

treatments for depression are available. With treatment patients can improve and return to normal quickly.

Unfortunately, most depressed persons do not recognize their depression. You and your family need to be

aware of the risk of depression in the recovery period and if present we need to discuss possible treatment.

Estrogen and Depression

A recent paper by Soares and colleaguesv points out that previous studies have suggested that estrogen

improves depressive symptoms experienced by perimenopausal women. They studied the effect of Climara

17beta-estradiol patch for the treatment of clinically significant depressive disorders in perimenopausal

women. Women (aged 40-55 years), with major depressive disorder, dysthymic disorder, or minor

depressive disorder were randomized to receive transdermal patches of 17beta-estradiol (100 microgram) or

placebo in a 12-week, double-blind, placebo-controlled study.

Remission of depression was observed in 17 (68%) women treated with 17beta-estradiol compared with 5

(20%) in the placebo group (P =.001).

Patients treated with estradiol sustained antidepressant benefit of treatment after the 4-week washout

period, although somatic complaints increased in frequency and intensity. Treatment was well tolerated and

adverse events were rare in both groups. They concluded that the transdermal estradiol replacement is an

effective treatment of depression for perimenopausal women.

Our experience has been that with the rapid decline in estrogen that results from the starvation and weight

loss following surgery, there is a significant incidence of depression, anxiety and irritability that is often

relieved by short term estrogen patch supplementation. We have had very good results with CLIMARA®

(estradiol transdermal system.) This is the leading transdermal (patch) form of estrogen replacement. The

CLIMARA® system delivers estrogen directly into the blood stream in the same manner as when it is

naturally produced in a woman's body.

The patch is a major drug and has risks as well as benefits:

WHO SHOULD NOT USE ESTROGENS

Estrogens should not be used:

• During pregnancy (see Boxed Warning).

If you think you may be pregnant, do not use any form of estrogen-containing drug. Using estrogens while

you are pregnant may cause your unborn child to have birth defects. Estrogens do not prevent miscarriage.

• If you have unusual vaginal bleeding which has not been evaluated by your doctor (see Boxed Warning).

Unusual vaginal bleeding can be a warning sign of cancer of the uterus, especially if it happens after

menopause. Your doctor must find out the cause of the bleeding so that he or she can recommend the

proper treatment. Taking estrogens without visiting your doctor can cause you serious harm if your vaginal

bleeding is caused by cancer of the uterus.

• If you have had cancer.

Since estrogens increase the risk of certain types of cancer, you should not use estrogens if you have ever

had cancer of the breast or uterus, unless your doctor recommends that the drug may help in the cancer

treatment. (For certain patients with breast or prostate cancer, estrogens may help).

• If you have any circulation problems.

Estrogen drugs should not be used except in unusually special situations in which your doctor judges that

you need estrogen therapy so much that the risks are acceptable. Men and women with abnormal blood

clotting conditions should avoid estrogen use (see RISKS OF ESTROGENS, below).

• When they do not work.

During menopause, some women develop nervous symptoms or depression. Estrogens do not relieve these

symptoms. You may have heard that taking estrogens for years after menopause will keep your skin soft

and supple and keep you feeling young. There is no evidence for these claims and such long-term estrogen

use may have serious risks.

Some of the “RISKS OF ESTROGENS”

• Cancer of the uterus.

• Cancer of the breast.

• Gallbladder disease.

• Abnormal blood clotting.

You are cautioned to discuss very carefully with your doctor or health care provider all the possible risks and

benefits of long-term estrogen and progestin treatment as they affect you personally.

These issues are much less of a concern in our post MGB patients because the surgery itself markedly

decreases the patients’ estrogen levels and the patch only acts as a short term bridge to the new life of

lower estrogen levels. Taking a short course of the estrogen patch is akin to taking a nicotine patch when

someone is quitting smoking. Over the long term one of the greatest advantages of the MGB and weight

loss is lower systemic estrogen levels and lower risk of cancer from high estrogen levels.

SIDE EFFECTS

In addition to the risks listed above, the following side effects have been reported with estrogen use:

– Nausea and vomiting.

– Breast tenderness or enlargement.

– Enlargement of benign tumors (“fibroids”) of the uterus.

– Retention of excess fluid. This may make some conditions worsen, such as asthma, epilepsy, migraine,

heart disease, or kidney disease.

– A spotty darkening of the skin, particularly on the face.

Sample comments from our patients on short term supplementation with the Climara estrogen patch:

I have had to wear the patch for about 4-5 days the last two months the week before my period. I just get

edgy and very bitchy about everything. It helps within an hour or two. I'd probably wear the patch for the

whole 7 days, but it doesn't stick well and taping it to my arm is really annoying. This month I plan to "patch"

early so I don't get all crabby. It is a temporary fix until things settle down with estrogen level. Don't think of

it as permanent, but just one of the things you need to do to be yourself.

Karen McG.

I got grumpy post op and my hubby put the patch on my behind. I felt so much better after that. I used what

was in the box (they are good for a week each) and have not needed any since. Every one is different. Try

it you might like the way you feel. Don't feel like if you put it on you will have to use it forever. Good luck.

Sandy B.

Covey, you need the patch!!!!!!! I used the patch for one month and it really helped keep me on an even

keel. Call the CLOS offices and/or your PCP/Gyn for a prescription. You and your fiancé will be so glad that

you did!!!!! Good luck,

Alisha

Covey,

You may need to switch to the Estrogen Patch... Which seems to work better for new post ops than pills

do...? At least that has been the experience of other MGBer’s, rely on their experience! Btw, when I took

birth control pills it made me, depressed and bitchier! Couldn't handle the mix....

Hugs, LyndaV Cushing Oklahoma USA

I used DepoProvera for a while - for birth control and then for hormone control. I know Shelley that you don't

have any problems but I HATED IT and SO DID MY HUSBAND. I was a raving witch with a capital B, had

no interest in sex, etc. My OB/GYN even hates it - will use it if a patient requests but doesn't "recommend"

it. It also "supposedly" can make you resistant to losing weight - even though Shelley you obviously haven't

had problems in that area either.

Julie in GA

Lisa,

Mean just doesn't quiet describe how bad I get when I need my hormones. Death wish for individuals who

cross me is more like. Minimal dose. It's like having a back massage, chocolate and a hot shower all at the

same time....I don't miss my estrogen unless it's by accident or they post warnings of possible terrorist

activity in our area!

Valerie in SC

The patch can cause problems:

Peggy, I had surgery may 01 2002 and last month I had a period for the whole month. This month (21 days

later) I started again and thought I was going to bleed to death I was on the estrogen patch and the Dr. took

me off that and put me on progestin and the bleeding slowed down immediately and almost stopped by 2

days. I go back for check up tomorrow. Prayers for you.

Bonnie

Do Not Drive for two weeks or until you are completely back too normal.

NO SMOKING!

Smoking has been shown to be a risk factor for wound infection in surgery. When compared to nonsmoking,

smoking was significantly associated with wound infection after all types of surgery. Other risk

factors associated with complications were diabetes, obesity, alcohol, NSAIDs, duration of surgery, and

surgical experience. I know you've heard this before, but it really is an important part of your recovery.

Smoking causes narrowing of your blood vessels that in turn decreases circulation. If you smoke you will

need to stop as soon as possible. Ask your nurse or Dr. Rutledge and the Surgeons of the Centers for

Laparoscopic Obesity Surgery for information on smoking cessation drugs and programs.

Post Op: Vaginal Yeast Infections

Vaginal yeast infections are caused by a fungus called Candida albicans. Yeast infections can be very

uncomfortable, but are usually not serious. Symptoms include the following:

Itching and burning in the vagina and around the outside of the vagina (the vulva, the edge of skin that

surround your vagina)

A white vaginal discharge that may look like cottage cheese

Swelling

Yeast infections are so common that ¾ of women will have one at some time in their lives. Half of all women

have more than one infection in their lives. If you have symptoms of a yeast infection, you can call Dr.

Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery or speak with your doctor

about your symptoms.

What causes vaginal yeast infections?

Yeast are tiny organisms that normally live in small numbers on the skin and inside the vagina. The acidic

environment of the vagina helps keep yeast from growing. If the vagina becomes less acidic, too many yeast

can grow and cause a vaginal infection. The acidic balance of the vagina can be changed by your period

(menstruation), pregnancy, diabetes, certain antibiotics, birth control pills and steroids. Moisture and irritation

of the vagina also seem to encourage yeast to grow.

How are these infections treated?

Yeast infections are usually treated with a vaginal medication or with a pill form that you take by mouth.

Should I see my doctor every time I have a yeast infection?

Be sure to see your own medical doctor the first time you have symptoms of a yeast infection. It's important

to make sure you have a yeast infection before you start taking medicine. The symptoms of a yeast infection

can sometimes be the symptoms of something else. If you have often been diagnosed with yeast infections,

talk to your medical doctor about using a medicine you can buy without a prescription.

How can I avoid getting another infection?

Here are things you can do to help prevent another yeast infection:

Don't wear tight-fitting or synthetic-fiber clothes.

Wear cotton underwear.

Don't wear pantyhose or leotards every day.

Use your hair dryer on a low, cool setting to help dry your genital area after you bathe or shower and before

getting dressed.

Wipe from front to back after using the toilet. This may help prevent the bacteria that normally live in your

rectum from getting into your vagina.

Change out of wet swimsuits or other damp clothes as soon as you can.

Don't douche or use feminine hygiene sprays, deodorant sanitary pads or tampons, or bubble bath, and

avoid using colored or perfumed toilet paper. These items seem to affect the balance of acidity of the vagina

and can lead to symptoms of a yeast infection.

Antifungal Medications

Prescription Drugs Now Available as Over-the-Counter Products

Product class: Antifungal

medications

Active

ingredients/availability

Brand

name(s) OTC indications Usual dosage Cost*

Clotrimazole 1%, 100-mg

vaginal tablet or

applicator full of cream

Gyne-

Lotrimin

Treatment of

recurrent vaginal

yeast infection in

persons age 12

years and over

One vaginal tablet

or one applicator full

of cream vaginally

once daily

$12.00 per

seven-day

treatment

regimen

Clotrimazole 1%, 200-mg

vaginal tablet

Gyne-

Lotrimin 3

Treatment of

recurrent vaginal

yeast infection in

persons age 12

years and over

One vaginal tablet

once daily

$7.00 per

three-day

treatment

regimen

Butoconazole 1% cream Femstat 3 Treatment of

recurrent vaginal

yeast infection in

persons age 12

years and over

One applicator full

of cream vaginally

once daily

$17.00 per

three-day

treatment

regimen

Miconazole nitrate 1%,

100-mg vaginal

suppository or applicator

full of cream

Monistat 7 Treatment of

recurrent vaginal

yeast infection in

persons age 12

years and over

One vaginal

suppository or one

applicator full of

cream vaginally

once daily

$13.00 per

seven-day

treatment

regimen

Miconazole nitrate 1%,

200-mg vaginal

suppository

Monistat 3 Treatment of

recurrent vaginal

yeast infection in

persons age 12

years and over

One vaginal

suppository once

daily

$13.00 per

three-day

treatment

regimen

Post Op: Thrush

Thrush: Fungal infection of the oral cavity, Zegarelli DJ. Otolaryngol Clin North Am 1993 Dec;26(6):1069-89

Columbia University College of Physicians and Surgeons, New York, New York. Candida is the most

commonly encountered oral fungal infection. Candida albicans is present in as many as 40% to 65% of

healthy adults. Oral candidal infection almost always involves a compromised host. The compromise may

be local or systemic. Local factors include decreased salivation and the weaning of dentures. Systemic

factors include diabetes mellitus, pernicious anemia, and AIDS. Some have even implicated advanced age

and the female gender as being mild predisposing factors. Numerous medications exist for the treatment of

oral candidiasis. They include the antibiotic nystatin as well as clotrimazole, ketoconazole, and fluconazole.

Nystatin is safe and is used as a topical agent in rinse or pastille forms. Clotrimazole is used as a topical

agent in lozenge form; it is highly effective but can cause liver enzyme changes. Ketoconazole, which is

usually prescribed systemically, is highly effective but also capable of causing adverse liver changes.

Chlorhexidine can be used as an oral rinse or as a disinfectant for dentures.

Frequently Asked Questions

What is Thrush?

Candidiasis of the mouth and throat, also known as a "thrush" or oropharyngeal candidiasis (Thrush), is a

fungal infection that occurs when there is overgrowth of fungus called Candida. Candida is normally found

on skin or mucous membranes. However, if the environment inside the mouth or throat becomes

imbalanced, Candida can multiply. When this happens, symptoms of thrush appear.

How common is Thrush and who can get it?

Thrush can affect normal newborns, but it occurs more frequently and more severely in people with

weakened immune systems, particularly in persons with AIDS.

What are the symptoms of Thrush?

People with Thrush infection usually have painless, white patches in the mouth. Symptoms of Thrush in the

esophagus may include pain and difficulty swallowing.

How do I get Thrush?

Most cases of Thrush are caused by the person’s own Candida organisms which normally live in the mouth

or digestive tract. A person has symptoms when overgrowth of Candida organisms occurs.

How is Thrush diagnosed?

Thrush is diagnosed in two ways. A doctor may take a swab or sample of infected tissue and look at it under

a microscope. If there is evidence of Candida infection, the sample will be cultured to confirm the diagnosis.

How is Thrush treated?

Prescription treatments such as, Oral fluconazole, clotrimazole troches, or Nystatin suspension usually

provide effective treatment for Thrush.

What will happen if a person does not seek treatment for a Thrush?

Symptoms, which may be uncomfortable, may persist. In rare cases, invasive candidiasis may occur.

Can Candida-causing Thrush become resistant to treatment?

Overuse of antifungal medications can increase the chance that they will eventually not work (the fungus

develops resistance to medications). Therefore, it is important to be sure of the diagnosis from before

treating with over-the-counter or other antifungal medications.

Future Appointment

Follow up consists of an initial postoperative clinic visit approximately 7 days following surgery. Warning:

You must agree to return to clinic for follow up and evaluation and further education on the week following

your operation and then to return to my clinic at 1, 3 and 6 months following surgery and every year

thereafter for evaluation and further education. Only in extraordinary circumstances should miss your clinic

visit with Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery. In the unusual

event that you cannot return to Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity

Surgery’s clinic, you must arrange to see your referring physician. Please understand that this is only to be

done in unusual circumstances and we expect that your will return to your scheduled clinic visits with Dr.

Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery. If you do see you own Doctor

for some reason, we ask that you or your Doctor please make certain that a record of the clinic visit and any

laboratory work please be forwarded to Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery. You are expected to return to Dr. Rutledge and the Surgeons of the Centers for

Laparoscopic Obesity Surgery’s clinic for follow up and you must understand that it is only in unusual circum

stances that you should miss these appointments. http://clos.net/forms/clinic_appointment_form.htm

In most cases, your appointment will be made for you prior to your departure.

Follow Up

The Laparoscopic Mini-Gastric Bypass program includes a very extensive commitment to follow up care.

From the first patient contact through long term follow up attention is constantly paid to careful and

continuous follow up of patients following surgery.

The patient must recognize that an operation upon the stomach and upper digestive tract is a serious

undertaking with both known and unknown long-term risks that are described by Dr. Rutledge and the

Surgeons of the Centers for Laparoscopic Obesity Surgery and others. These include but are not limited to,

ulcers, reflux, inadequate or excessive weight loss, hair loss, serious vitamin and mineral deficiencies and

many other known and unknown problems detailed here and elsewhere. As a result patients must make a

firm and legal commitment to fulfilling Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery’s instructions for long term follow up. You must agree to make every effort to follow up

closely with the office and to follow post op directions to protect yourself from these and other problems

associated with the bypass.

Following surgery patients must agree to not leave the area following surgery for 7 days after surgery and

until you have been seen in Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity

Surgery’s clinic and have been approved for discharge from the area.

Patients must agree preoperatively to return to Dr. Rutledge and the Surgeons of the Centers for

Laparoscopic Obesity Surgery’s clinic at 1, 3 and 6 months following surgery and every year thereafter for

evaluation and further education.

In only the most extraordinary circumstances when patients cannot under any circumstances reach Dr.

Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery’s clinic patients may try to

make arrangements to have an appointment with their local medical Doctor’s clinic and with his/her approval

complete that follow up visit with your local medical doctor.

In that unusual event patients must agree to make certain that the medical doctor forwards copies of their

clinic visit to Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery.

Patients must understand and agree that Dr. Rutledge and the Surgeons of the Centers for Laparoscopic

Obesity Surgery expects them to return to his clinic for follow up and it is only in the most unusual circum

stances that patients will miss these appointments.

Patients must also promise to go to Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity

Surgery’s web site at http://clos.net/ff2-hosp.htm and complete the “Patient Follow up Form” monthly after surgery.

Patients must agree to alert Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity

Surgery’s office of any changes in my address, telephone numbers, and email address or health status.

When to come back to clinic: You can come back to see Dr. Rutledge and the Surgeons of the Centers for

Laparoscopic Obesity Surgery at any time.

When to get your staples out: You staples should be removed between 5-10 days after you date of surgery.

When to see Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery: Usually you

should plan to see Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity Surgery on the

clinic that falls closest to 7 days after your date of surgery.

WARNING: it is very important for you to stay in contact with Dr. Rutledge and the Surgeons of the Centers

for Laparoscopic Obesity Surgery.

Also yearly follow up with Dr. Rutledge and the Surgeons of the Centers for Laparoscopic Obesity

Surgery are required after the first year.

Recommended One Year Follow Up Blood Tests:

Vitamin B-12 level , Folate level , Calcium / Magnesium / Phosphorus levels, Total Protein / Albumin , Iron

/TIBC, Ferritin, Transferrin , CBC (Complete Blood Count) Hemoglobin and Hematocrit , Chem. 7

(Electrolytes and Glucose) , Liver Panel: SGOT/SGPT Alk Phos, T/D Bilirubin , Cholesterol Triglyceride

Level , Serum immunoreactive parathyroid hormone Hemoglobin A1c level , Vitamin E and A levels ,

Pyridoxal phosphate (Vitamin B-6) level , DHEA-s, Zinc

Also, please go to: The Online Follow Up Form to complete your monthly follow up form.

i J Natl Cancer Inst. 2003 Mar 5;95(5):373-80. Plasma folate, vitamin B6, vitamin B12, homocysteine, and risk of breast cancer. Zhang SM, Willett WC, Selhub J, Hunter DJ, Giovannucci EL,

Holmes MD, Colditz GA, Hankinson SE.

iii Neurosci Res 2002 Apr;42(4):279-85 Effects of creatine on mental fatigue and cerebral hemoglobin oxygenation. Watanabe A, Kato N, Kato T.

iv Use of Selective Serotonin Reuptake Inhibitors and Risk of Upper Gastrointestinal Tract Bleeding: A Population-Based Cohort Study (Archives of Internal Medicine 2003;163:59-64) Susanne

Oksbjerg Dalton et al. Correspondence: Susanne Oksbjerg Dalton, Institute of Cancer Epidemiology, Danish Cancer Society, Strandboulevarden 49, DK-2100 Copenhagen, Denmark (e-mail:

sanne©cancer.dk).

v Arch Gen Psychiatry 2001 Jun;58(6):529-34 Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial.Soares

CN, Almeida OP, Joffe H, Cohen LS.Perinatal and Reproductive Psychiatry Clinical Research Program, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WACC 812,

Boston, MA 02114, USA. csoares@partners.org