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