Bariatric Inpatient Preparation Group Specialist Bariatric Surgery Dietitians: Laura Carstairs Cleverly Fong Bariatric Nurse Specialist: Tamara Ramkalawan Cecilia Jones Bariatric physiotherapist: Al Myers

Objectives Inpatient experience Length of stay & operation Medications Pregnancy Before surgery and after diets Breathing & circulation exercises Importance of early post-op mobility Introduction to physical activities

The surgery Usually done as keyhole surgery Quicker recovery time Length of stay in hospital –1 to 2 days for Gastric Banding, surgery time 1- 2hrs – 3 to 4 days for the other surgeries, surgery time 1.5 – 4hrs

Day of surgery Omit diabetes tablets, blood pressure tablets, insulin, and other regular tablets morning of surgery unless instructed specifically to do otherwise Warfarin and aspirin – to follow your consultant’s instruction Bring all meds and CPAP Bring personal clothing and toiletries for use on ward Arrange transport to come into and discharge from hospital Walk to theatre and onto the operating table

Ward experience Surgical ward after recovery IV Fluids, Flowtron and TEDS, Nursed upright, Oxygen therapy, Drains Regular observations Sips of water to clear fluids MRSA screening Nebulizers, CPAP to start 48hrs post surgery Clexane (you may get some bruising) and early mobilisation

What will you feel like after surgery? Pain ( wind or bloating) – painkiller will be given Nausea and vomiting – anti-sickness will be given

When to alert staff Short of breath, anxiety and chest or calf pain Severe onset of abdominal pain Racing heart beat Vomiting Wounds bleeding

Discharge Medication – Clexane, Fastabs, Multivits, Adcal, painkillers, laxatives (no whole tablets, liquid, soluble, chewable or crushed meds using a pill crusher or spoons for 4 wks post surgery) G.P.- get repeat prescriptions & return sharps bin Practice nurse – wound dressings, Blood sugar and BP to be checked regularly Appointments with nurse, dietitian and surgeon. Band fills 4-6 wks post op Contact team if any problems

Pregnancy Weight loss can increase fertility Pregnancy is not advised during the first 18 months after surgery as it can be very risky for both mother and baby. - Potential for maternal and fetal malnutrition - Gestational diabetes - Preeclampsia ( High blood pressure in pregnancy) - More likely to need cesarean delivery - Blood clots after giving birth - Increased blood loss during delivery - Increased risk of miscarriage, pre-term birth, stillbirth - Increased risks of congenital anomalies, growth abnormalities, etc.

Pre op liver shrinkage diet Follow for 2-4 weeks pre surgery –4 weeks if BMI over 50 3 options –Food based diet –Milk diet –Slimfast diet All 1000kcal, low carbohydrate Caution with diabetic control Follow one diet only- do not mix and match

Post surgery liquids in hospital Water Tea/coffee Milk No added sugar squash Clear soup Build up soup tomato flavour (ask the staff!) You should not be having yoghurt, jelly, ice cream or liquids with bits or lumps at this stage

Post-surgery: Stage Diet Stage 1: Liquid Diet 2 weeks Except after Sleeve Gastrectomy: 3 weeks Stage 2: Puree Diet 2 weeks Stage 3: Soft Textured Diet 2 weeks Stage 4: Normal Diet Long term

Physiotherapy in the Ward You will be seen the day after your surgery. Your respiratory system and movement will be checked. You will be advised on breathing and circulation exercises. You will be encouraged to sit out of bed as much as possible and to walk around the ward lots.

Why is early mobility important? Early mobility restores normality to your body’s systems by; 1.Speeding up your recovery from the anaesthetic. 2.Reducing your risk of developing blood clots. 3.Making the lungs work more effectively and reducing the risk of chest infections. 4.Moves trapped wind from your abdomen.

Can I reduce the risk of blood clots? Early mobility! Practice circulatory exercises of your ankles; point the feet down all the way then pull up and perform clockwise/anti-clockwise circles. Repeat roughly 5 times in each direction hourly throughout the day. Remember spelling the alphabet with your toes.

Could I get a chest infection after the operation? The anaesthetic used in the operation reduces lung function. You can feel pain in your abdomen - making deep breathing and coughing painful. This can cause mucus/phlegm to gather in your lungs and can cause a chest infection. If you are a smoker, you are already at a higher risk of chest infections as the lungs tend to contain more mucus.

How can I reduce the risk of chest infections? Early mobilisation! Sitting out of bed (make the lungs more upright). If you smoke, please look to stopping; contact the NHS Stop Smoking Helpline on or access information online at smokefree.nhs.uk.

How can I reduce the risk of chest infections? Contd. Tell ward staff if your pain stops you doing breathing exercises, perform an effective cough or mobilise. Support your abdomen with your hands, a towel or pillow when coughing to reduce pain. Practice breathing exercises twice an hour to keep the chest as clear as you can - less phlegm, less risk of infection

Breathing exercises? The Active Cycle of Breathing Technique (ACBT) exercises. To start-get comfortable; sit up in bed or sitting upright in a chair. Breath in through your nose and out through your mouth if possible.

Lets Practice The Cycle Deep Breaths (3-4) Breathing Control (6-8) Deep Breaths (3 or 4) Breathing Control (6-8) Huff (1-2) Supported Cough if required Breathing Control (6-8)

What Breathing Exercises can I do? Contd. 1. Breathing Control – Normal, relaxed breathing as you would do, do 6-8 breaths. 2. Deep Breaths – Breathe in slowly and deeply, breathe out without forcing it, repeat 3 or 4 times. 3.The Huff – Take a medium sized breath in, breathe out forcefully for a short time, keep your mouth open and use your stomach muscles. “Imagine you are steaming up a mirror with your breath”. Practice the cycle every hour-stop if you feel your cough the dry and unproductive.

Physical Activity In the ward we will discuss; *benefits of physical activity *the government recommendations *check your current physical activity levels *help set shared goals *exercise initiatives local to you Regular physical activity is essential to the lifestyle change required to get the most from this procedure in the long-term General rules for activity after surgery - avoid heavy lifting until you feel comfortable and swimming until your wounds have healed. If you drive, contact your insurance provider to ensure they are happy with coverage – also make sure you can comfortably perform an emergency stop.

The PACE Class If you can get to the Hospital and commit to the twelve weekly classes you can join the Physical Activity Circuit and Education (PACE) class. Exclusively for patients who have had bariatric surgery at the Homerton University Hospital. You will take part in education sessions combined with physical activity circuits. Its aim is to introduce, support and motivate for increasing your physical activity levels. Classes run every Tuesday evening from pm and Wednesday afternoons from 3pm-4.30pm. The classes last for 12 weeks.

Questions? Thanks for listening and good luck! Any questions for the team? YOU ALL NEED TO ATTEND PRE ADMISSION IN THE SURGICAL CENTRE TODAY