Roux-en-Y Gastric ByPass Procedure

Gastric bypass surgery makes the stomach smaller and allows food to bypass part of the small intestine. You will feel full more quickly. Bypassing part of the intestine also results in fewer calories being absorbed.
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Is the Gastric ByPass right for me?

Most people who have gastric bypass surgery quickly begin to lose weight and continue to lose weight for up to 12 months. One study noted that people lost about one-third of their excess weight (the weight above what is considered healthy) in 1 to 4 years. Some of the lost weight may be regained.
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Gastric Bypass is a restrictive and malabsorptive procedure that has been performed worldwide for over 35 years. Gastric bypass involves cutting and stapling a small piece of the stomach so that it becomes separate from the other portion.

This area acts as a new, smaller stomach with the rest being restricted permanently. The top of the small intestine is then severed completely with the stapling device with the ends of the intestine routed to the smaller stomach pouch. The other end is attached to the small intestine so that the digestive liquids from the liver, gallbladder, duodenum and pancreas can process food.

Gastric bypass surgery makes the stomach smaller and allows food to bypass part of the small intestine. You will feel full more quickly than when your stomach was its original size, which reduces the amount of food you eat and thus the calories consumed. Bypassing part of the intestine also results in fewer calories being absorbed. This leads to weight loss.

• Average excess weight loss is usually higher than with purely restrictive procedures.
• One year after surgery, weight loss can average 77% of excess body weight. After 10 to 14 years, some patients have maintained 50-60% of excess body weight loss.
• 96% of certain associated health conditions (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved according to a 2000 study of 500 patients.
  

• "Dumping syndrome." When stomach contents are literally "dumped" rapidly into the small intestine. Sometimes triggered by too much sugar or large amounts of food. Dumping syndrome doesn't pose a health risk, but its symptoms aren't fun: nausea, weakness, sweating, faintness, and diarrhea. Some patients can prevent dumping syndrome by avoiding sweets after surgery.
• Up to 20% of patients need follow-up operations to correct problems like hernias.
• Up to 30% of patients develop gallstones after losing weight. You can reduce the risk of gallstones by taking bile salts for 6 months following surgery.
• Leakage of the connection between the pouch and the intestine. This is very rare, but potentially dangerous.
• Diminished effectiveness. The success of the procedure can be reduced if the stomach pouch is stretched and/or left larger than 15-30cc (1/2 to one ounce).
• Poor views of internal organs. The bypassed portion of the stomach, duodenum, and segments of the small intestine are difficult to see using X-ray or endoscopy. This only becomes a problem if the patient develops ulcers, bleeding, or malignancy. Gastric bypass does not cause cancer.
• Nutrient deficiencies. Almost a third of patients develop nutritional deficiencies because the duodenum is bypassed in this procedure. So the body doesn't absorb iron, calcium and other nutrients efficiently after surgery. Fortunately, these deficiencies can usually be controlled with proper diet and vitamin supplements. Nutrient deficiencies can lead to:
• Iron deficiency anemia. Because the duodenum is bypassed in this procedure, the body doesn't absorb iron and calcium very well after surgery, which can lead to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during menstruation or from bleeding hemorrhoids.
• Osteoporosis. Because the body doesn't absorb calcium properly after surgery, there is a greater risk of developing osteoporosis.
• Metabolic bone disease. Also caused by bypassing the duodenum, some patients experience bone pain, loss of height, humped back and fractures of the ribs and hip bones.
• Chronic anemia. A type of anemia caused by a deficiency of vitamin B12. Can usually be managed with pills or injections.

Although guidelines vary, surgery is generally considered when your body mass index is 40 or higher or you have a life-threatening or disabling condition related to your weight.

Your doctor may only consider doing gastric bypass surgery if you have not been able to lose weight with other treatments.

The following conditions may also be required or are at least considered:

• You have been obese for at least 5 years.
• You do not have an ongoing problem with alcohol.
• You do not have untreated depression or another major psychiatric disorder.
• You are between 18 and 65 years of age.

All surgeries have risk, and it is important for you and your health professional to discuss your treatment options to decide what is best for your situation.

1. What happens during the procedure?
2. How is the surgery done?
3. Why is it called a Roux-en-Y?
4. Can my surgery be done laparoscopically if I have had a previous open abdominal surgery?
5. I have a high Body Mass Index (BMI).  Can I still have a have a laparoscopic gastric bypass?
6. What can I expect during my hospital stay?
7. How long will I stay in the hospital?
8. What should I do to prepare for the surgery?
9. What should I take to the Hospital?
10. What can I buy before my surgery to help my recovery at home?
11. What happens to the distal stomach? Does it shrink?
12. What are the risks of the Gastric Bypass Procedure?
13. Will I need to take vitamin supplementation after this procedure?
14. What is Symptomatic Dumping Syndrome?
15. Why do some people experience diarrhea after this surgery?
16. What if I see blood in the stool after Gastric Bypass Surgery?
17. Why is there hair loss after Gastric Bypass Surgery?
18. What is the risk of infection and what can I do about it?
19. How much weight can I expect to lose?
20. Can I get pregnant after Gastric Bypass Surgery?
21. How much help will I need at home?
22. What can I eat right after surgery?
23. How many calories should I be eating after surgery?
24. Why do some people complain of nausea and frothing after the surgery?
25. Why is it sometimes necessary to vomit?
26. Is it possible to fail to lose weight with this surgery?
27. What is the ‘Window of Opportunity’?

1.What happens during the procedure?
Bariatric surgery is an advanced surgical procedure designed to promote weight loss and reduce the complications associated with morbid obesity.  This procedure will transect (cut) your stomach, dividing the stomach into two parts.  The surgically created small stomach pouch will receive the food you eat.  The remaining segment of your stomach continues to produce stomach acid and digestive juices, but does not receive any food.  The surgeon creates a new connection from your stomach pouch to your small intestine, and bypasses a segment that is equivalent to about one-third of your small bowel.
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2.How is the surgery done?
The surgery is performed either through an incision that runs from your breastbone to your navel (called a laparotomy, referring to the open gastric bypass procedure) or through six, small, half-inch incisions (laparoscopic surgery). During laparoscopic surgical instruments, including a small camera, are placed through tubes inside these incisions, called ports. The abdominal wall is lifted off the intestines by putting air into the abdomen, a process called insufflation.  Both types of gastric bypass surgery are equally effective, and change the internal structure of the digestive system in exactly the same way, through two different approaches.
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3.Why is it called a Roux-en-Y?
It refers to the ‘Y’ shape of the small bowel connection.  During the operation, the small bowel is transected (divided) and then reattached at one end to the newly created pouch (the new stomach) where it will now receive food that has been chewed and swallowed.  None of the bowel is removedduring the surgery.  The new connection between the stomach pouch and the small bowel is called the gastro-enterostomal anastomosis, and is sized into an exact, narrow opening to help restrict the passage of food moving from the pouch into this piece of small bowel, called the Roux limb (after a French surgeon, Roux.)  The Roux limb is called the “Alimentary Limb.” Alimentation refers to food intake, so you can think of this as your personal ‘food channel.’  The Roux limb is the right arm of the “Y.”  The left arm of the “Y” is the part of the bowel still connected to the excluded stomach.  This arm is called the “Bileopancreatic Limb.”  It carries the acids produced in the distal (excluded) stomach, the digestive juices produced by the liver and pancreas, including insulin, and some juices produced by the small bowel itself.  The two arms of the “Y” connect again.  Foods and digestive juices now meet each other for the first time, later than in the normal digestive process, in what is known as the ‘common channel.’
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4.Can my surgery be done laparoscopically if I have had a previous open abdominal surgery?
Your surgeon will evaluate you on an individual basis.  It is possible to have a laparoscopic gastric bypass after having open abdominal surgery or other laparoscopic abdominal procedures.  Our surgeons believe that every patient has the right to be given the opportunity to choose minimally invasive surgery as an option.
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5.I have a high Body Mass Index (BMI).  Can I still have laparoscopic gastric bypass?
Our surgeons have successfully performed laparoscopic gastric bypass surgery on a patient with a BMI of 91.  High BMI and extreme physical parameters might prove too great a challenge to another, less experienced team of surgeons. We exclude no one as a laparoscopic surgical candidate based on BMI alone.  Your surgeon will evaluate you on an individual basis.  Evanston Northwestern Healthcare is proud to have one of the most experienced and professionally recognized teams of Bariatric and Minimally Invasive Surgeons in the Midwest.  Again, our surgeons believe that every patient has the right to be given the opportunity to choose minimally invasive surgery as an option.
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6.What can I expect during my hospital stay?
You will receive a call from the WLS Clinic on the day before your surgery telling you when to arrive at the hospital on the day of your surgery.

The Ambulatory Surgery Area will prepare you for surgery and make sure that you did not eat or drink anything after midnight.  Your family will keep your belongings during the operation.  There is nowhere in the Ambulatory Surgery Department to store your things.  You might wish to have a Public Safety Officer secure your belongings if you do not have family in attendance.  Your belongings will be delivered to you upon request once you reach your room after surgery.

You will be brought to the Holding Area in the Department of Surgery.  You will be greeted by your nurses and Anesthesiologist.  An IV may be started here, and relaxation medicine will be given to you, as well as one ounce of an antacid that you will drink.
 
You will be brought to the operating room and greeted by the surgical team.  Before you know it, surgery will be done; you will be awoken from the procedure and brought to the post-anesthesia care unit (PACU.)

You will be groggy as you awaken from anesthesia.  You may have an oxygen mask over your face or oxygen delivered through your nostrils.  IV fluids will be running, and you will have a catheter in your bladder draining your urine into a bag.  You may or may not have a tube in your nose to your new stomach to keep the pouch empty.  You will have an elastic binder around your abdomen…it will feel like a gentle hug.  You will have compression boots on your feet or compression sleeves on your lower legs, giving you a gentle massage: they are there to help prevent blood clots in your legs.

You will stay in PACU for one to two hours and then be released either to the Intensive Care Unit for overnight observation or to the medical-surgical floor that receives all of our patients.  The staff is specially trained to care for gastric bypass patients.  You will travel in your bed.

You will get out of bed and ambulate with assistance as soon as you are able.  You are required to walk on the day of your surgery if you have had the laparoscopic gastric bypass.  This helps you to recover faster and restore your bowel activity.  It helps fully expand your lungs, aids in preventing pneumonia, and in preventing blood clots.  Oddly enough, the more you walk, the more your abdominal wall relaxes, whether you have had an open or a laparoscopic procedure.  You will find that you have better pain control if you get up and walk.  Patients are always amazed to find out how well this works!

You may feel nauseated.  This is part of the surgical process itself.  Again, walking and sitting upright will help relieve some of this early nausea.

You will feel sleepy most of the time and need frequent naps.  You have had major surgery!
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7.How long will I stay in the hospital?
Most patients stay two after laparoscopic gastric bypass and up to four days after open gastric bypass.
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8.What should I do to prepare for the surgery?
Stop smoking completely.  This will make your post-operative recovery easier.

Increase your physical activity to the best of your ability.  This will make your post-operative recovery easier.

Stop taking any aspirin or aspirin type medication (for example: Motrin, Ibuprophen, Advil, Anaprox, and Lodine) at least 10 -14 days before your surgery date.  If you are unsure of what medication you are taking, ask your doctor.

Herbal medications that start with the letter “G” (garlic, glucosamine, ginko biloba, ginseng) and Vitamin E have been know to increase bleeding in the immediate post-operative period.  These medicines tend to thin the blood.  You may wish to stop taking these common over the counter remedies, too, in the weeks before your surgery.

You many take Tylenol for pain, if needed.

After midnight, the day of your surgery, do not eat or drink anything.  Do not eat or drink anything the morning of your surgery.  (Your surgery may need to be postponed or cancelled if you do eat or drink.)  Your surgeon will tell you which of your prescription medications to take the morning of surgery and which to hold.

Take a shower to wash your entire body the morning of or the night before surgery.

You may or may not perform a bowel preparation just before your surgery.  If your surgeon does require bowel preparation, take the day before surgery off of work and stay close to home.

Consider having your hair braided to keep it groomed and in control while you are in the hospital.  Avoid hairspray, which will just get hard and sticky and make it hard to comb.

You may keep your nails polished or keep artificial nails intact.
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9.What should I take to the Hospital?
Slippers which are easy to put on and take off and have a good non-slip tread on the bottom for walking.

You might want to bring a few personal toiletries, like toothpaste, your own hair items, moisturizing creams.  We have these items in the hospital, but sometimes having your own things is comforting.

Consider bringing hair bands and barrettes to keep your hair off your neck.  You will feel cooler and neater when your hair is groomed.

Lip balm

Your Sleep Apnea machine (CPAP/BiPAP) if you use one at home
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10.What can I buy before my surgery to help my recovery at home?
You may want to purchase some food and supplies before your surgery so that you can make your recovery less stressful.  You are going to experience some things unique to gastric bypass patients. One of the most important things to remember is that you will have a stomach pouch smaller than your mouth.  This can prove a challenge in your early post-op life.

You may be used to taking large bites or gulps or in not chewing your foods thoroughly.  Give yourself time to heal and to become familiar with the volume capacity of your pouch.  Do not rush your meals.  Sip your fluids and chew everything to the consistency of applesauce.   If you have trouble chewing, you might want to consider using a blender, potato masher, or food processor to bring the foods to a manageable consistency.

Supplies to purchase before surgery:

A ‘sippy’ cup can help you learn to take fluids slowly and to avoid gulping volumes.  You may or may not need this type of reminder.  It is safer than drinking through a straw, adding an amount of air into your pouch, which might cause the discomfort of overstretching.  You will need to drink enough fluids to keep you well hydrated.  The best way to determine this is by observing the color of your urine, which should be more yellow, less orange, but never brownish.  Hydration is important to help control nausea in the immediate post-op course.

Children’s Chewable Vitamins with Iron (for example: Flintstones with Iron, Bugs Bunny with Iron): you will start taking these as soon as you are taking semi-solid foods, like yogurt or oatmeal: one tablet, twice a day.

Tums or another chewable calcium supplement: calcium carbonate is not as absorbable as calcium citrate, but it will not irritate your new pouch as calcium citrate might in your early post-op period.  You will grow into adult strength vitamin and mineral supplementation after you have had time to physically recover from your surgery.  You will take these with your chewable vitamins: two tablets, twice a day (four tablets altogether.)

B-12 Supplement:  There are sublingual (under the tongue) and liquid varieties, as well as small pills available, but the sublingual and liquid varieties will absorb best of all.  You will be taking 1000 mcg once per week.

Measuring Cups and Spoons:   These will help you better understand your pouch capacity, until you are more familiar with your physical limitations.  Your pouch is only one to two ounces large when you are first out of surgery.  A cup equals eight ounces, a quarter cup equals two ounces, and an eighth of a cup is one ounce.  One ounce is 30cc, which equals two tablespoons.  Again, remember, you will have a stomach pouch smaller than your mouth.  It takes a little time and practice until that concept becomes a part of your daily life and your eating habits are automatic.

Two Rolls of Kerlix Gauze (bandage rolls):  What on earth is THAT for, you might be asking!   You can make a ‘bed ladder’ with the gauze to assist you in moving around and getting up from bed in your early recovery period.  If your bed has a frame, you can unroll the gauze and make a knotted loop through the foot of the bed frame.  Now make knots along the length of this big loop for hand grips.  Repeat this process with the second roll of gauze, putting the second loop next to the first.  When you are ready to get out of bed, grab the gauze loops to help sit up and turn yourself.  Place a chair next to your bedside to help you stand to you feet, and now you are on your way.  Walk your way to early recovery!
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11.What happens to the distal stomach?  Does it shrink?
The distal stomach gets smaller over time since it is no longer getting stretched with food and drink, but still serves an essential purpose in producing stomach acid and enzymes to help us digest our food.
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12.What are the risks of the Gastric Bypass Procedure?
All the risks of this procedure will be explained to you, in detail, by your surgeon. 
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13.Will I need to take vitamin supplementation after this procedure?
This procedure creates a selective malabsorption of certain foods (fats, especially) and nutrients that you eat.  Certain vitamins and minerals may not be absorbed well enough for you to meet the recommended US daily requirements.  This is especially true of Vitamins B6, B12, Folate, calcium and the mineral iron.  For this reason, we strongly recommend that you take a multivitamin with minerals and calcium daily, at minimum, and a dose of Vitamin B12 under your tongue weekly for the rest of your life.
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14.What is Symptomatic Dumping Syndrome?
Early and late dumping has been reported in patients after this procedure.  Dumping is caused by rapid passage of food from the pouch into the small intestine.  Before surgery, the stomach has a valve at the top and bottom, and serves as an acid-filled storage tank, breaking food intake down into small, component parts and passing it to the small bowel in increments.  After surgery, food passes directly into the small bowel, mixed only with saliva and amylase from the mouth, but no stomach acid.  The molecules (component parts) of the food remain fairly intact and therefore, large.  The small bowel responds by diluting what we eat through a process of ‘water recruitment’ into the bowel space.  The ‘richer’ the food, in terms of molecule size or sugar content, the more water will rush into the small bowel to dilute it.  This is referred to as ‘early dumping.’  Suddenly, the heart will pound and beat rapidly; you may feel dizzy, and overwhelmingly tired.  The bowels may gurgle and churn, and will feel bloated and gassy.  This might be followed by loose stools and even vomiting.  It is not dangerous, but it can be frightening to the uneducated patient. ‘Late dumping’ is caused by an insulin response to the ingested food.  One might feel flushed, sweaty, fatigued, and experience all the signs of hypoglycemia (low blood sugar).

You can avoid early and late dumping by avoiding the foods that cause dumping.  In other words: sugars, starches, fried foods, fats, and high glycemic foods.  The glycemic index refers to how swiftly the sugars from the food enter the bloodstream after eating.  Each person has a different tolerance, and you will discover what your personal safe foods might be throughout your post-operative life.  Person A might have no problem with bananas, Person B might dump every time one is eaten, and Person C might be able to do a rare banana, only if it is a little bit green.  You will learn what your own trigger foods might be.  Be aware that these may change over time, as your surgical tool matures.  What you tolerate in your early post-operative course you might not tolerate later, and vice versa.  Every body and everybody is different!
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15.Why do some people experience diarrhea after this surgery?
Diarrhea can occur immediately after surgery but usually subsides in the first week.  Any time the bowel is touched, third spacing can occur.  Third spacing means that water will fill the bowel space, and may pass as loose stool.  Sometimes, this extra water may be reabsorbed without causing diarrhea.  Chronic diarrhea that does not get better is not a common side effect of this procedure.  Examine what you are eating (see dumping, as listed above.)  Fruit juices, potatoes, high sugar and high starch foods will provoke diarrhea.  Read your labels!  If the diarrhea persists, and you have eliminated any offending foods, call your surgeon.
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16.What if I see blood in the stool after Gastric Bypass Surgery?
You can expect to see some blood in your stool for the first few bowel movements after surgery because the procedures to the stomach and intestine will have caused some trauma to the tissues and oozing of a small amount of blood is not unusual.  If this persists, or if the toilet water is not merely tinged with blood (looking like cranberry juice) but in fact appears to be purely blood (looking like tomato juice) call your surgeon.  If you feel weak or dizzy, proceed to the nearest emergency room.  Be sure to report to them that you have just had a gastric bypass, give the date of surgery and the name of the surgeon.
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17.Why is there hair loss after Gastric Bypass Surgery?
Some hair loss is unavoidable, usually starting in the third month after surgery, but is only temporary and fully resolved by the sixth to ninth month post-op.  With proper nutrition, it is rare for a patient to have thinner hair a year after surgery than the amount they had before surgery.  Some patients have fuller and healthier hair because the body’s hormone balance has improved with weight loss.  The medical term for hair loss is trichatrophia.   It occurs partly in response to having had a major surgery and exposure to anesthesia, as well as the sudden calorie and protein deprivation experienced just after surgery.  Hair follicles have a three month life cycle.  The hair follicles that were born on the day of your surgery inside your scalp, working their way outwards over three months, were born unhealthy and will fall out, leaving an empty socket until the next hair follicle emerges in the same spot.

Do not over eat protein calories thinking this will prevent hair loss.  It will not work, and you will be setting a bad precedent for yourself.  As pouch capacity increases, calorie intake increases.  At first, the capacity of the pouch is so small that a patient can lose weight no matter how often they eat during the day. By eating often and in ever increasing amounts, you may unwittingly increase your total calorie intake to the point where you exceed the number of calories you require for weight maintenance, let alone weight loss. Your long term weight loss might not proceed as far as it could have if you train yourself to eat frequently.  Hair loss is only temporary.  Bad eating habits can become permanent.

You can minimize hair loss by taking biotin (a vitamin supplement) or primrose and flaxseed oil capsules; using a mild, protein based shampoo; reducing the number of times you wash your hair per week to prevent drying your scalp, styling the hair to reduce tension and strain at the roots (perhaps going shorter to ease pulling); and having a short suspension of hair-coloring, braiding, weaving, and chemical processing to give the hair a rest.  Consider this as an opportunity to try something new!  By this point, given your weight loss at three months, it is a great time to try a new style that you might never have tried before when your face was fuller and your neck was heavier.  A whole new you can emerge!
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18.What is the risk of infection and what can I do about it?
While the incidence of infection is low, any time an incision is made into the skin and through the gastrointestinal tract, the risk of infection exists.  Shower daily with a good antibacterial soap to reduce surface bacteria, and always wash your incision first.  Wash you hands well and then apply soap and water to your incisions gently.  Please consider installing a hand-held shower in your bathroom to help you reach difficult places.  Your ability to twist and turn will be altered immediately after surgery.  Do not take a bath or swim until all your incisions are well-healed, without drainage and have formed closed scabs.
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19.How much weight can I expect to lose?
You are expected to lose a percentage of your excess weight, but only a few patients lose 100% of their excess weight and reach a number established on a weight chart, most of which have been developed by an Actuary (a statistics specialist) employed by a life insurance company.  That ideal weight might have little to do with your best weight, where you feel and function at peak health.  When you have been carrying  excess weight for a long time, your bone frame and muscle mass will have needed to increase, too, in order to support your excess weight.  The standard weight charts do not reflect this.  Most patients lose 60-70% of their excess weight in the first year after surgery.
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20.Can I get pregnant after Gastric Bypass Surgery?
If you are a woman of child-bearing age, it is strongly advised that you do not get pregnant for at least a year and a half after your surgery.  By delaying a post-operative pregnancy until this time, you are better assured that you will be able to get the proper nutrition for the health of your baby and yourself. Your hormone levels are going to change as you lose weight, and you may find yourself more fertile, with an increased chance of pregnancy.  Consult your Gynecologist to develop a contraceptive plan. If you do find yourself pregnant, please notify your Bariatric surgeon immediately, so that the team might help you modify your eating plan for the best possible outcome for yourself and your baby from the earliest stages of your pregnancy.
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21.How much help will I need at home?
Much depends on the demands of your daily life.  For example, you must avoid lifting more than 15-20 pounds for one month after your surgery.  If you have small children, this might require childcare assistance. You will have no restriction on walking or climbing stairs.  You will avoid driving for one week.  You will avoid vigorous physical activity.  If you need to go back to work or to drive immediately, consult your doctor.
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22.What can I eat right after surgery?
You will be given a comprehensive list of appropriate and acceptable food and drink at the time of your surgical consult.  Everyone has different tastes and tolerances, so you might notice that there is no cookbook detailing exactly what you should eat, at exactly what time, and in exactly which amount.  This is not a diet in the traditional sense of the word.  You must develop a new relationship to food and to eating that suits your tastes and cultural heritage, obeying just a few simple guidelines.

Rule Number One:  Read all your labels for SUGAR CONTENT.  The magic number is 16 grams of sugar, or sweet sixteen.  In other words, everything must have LESS THAN 16 grams of sugar per serving, as labeled.  Be careful to read the label of No Sugar Added Products-there might still be enough sugar to trigger dumping in your system, depending on your sensitivity.  Items sweetened with ‘sugar alcohol’ (maltilol, sorbitol, anything with an ‘-ol’ ending) can have a laxative effect.  In fact, maltilol is used as a baby laxative.

Rule Number Two:  Do not be concerned about fat content.  In exchange for fat the manufacturers add sugar.  You are not absorbing fats well and you need some to absorb your fat-soluble vitamins: A, D, E, and K, which are essential antioxidants, to name one of their gifts.

Rule Number Three:  Your taste tolerances are going to change rapidly.  This has a lot to do with your zinc levels, which drop after surgery and change your perception of sweet and sour. Resist the urge to buy things you like today in mass quantities, for tomorrow they might get scratched off your list.  Another thing that will change in the early post-operative period is your sense of smell.  You might not tolerate heavy perfumes or certain scents easily.  This is a temporary stage.
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23.How many calories should I be eating after surgery?
Eat at least 600 per day, which will be a struggle in the early days when you have no appetite and limited tolerance for food.  This number of calories might seem terribly low to you now, but you will discover that it is an effort to reach it on some days in your early post-operative life.
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24.Why do some people complain of nausea and frothing after the surgery?
This can be the most challenging aspect of early recovery.  Pay attention to your body’s signals of fullness and keep yourself hydrated.  Your pouch will instinctively protect itself when over-stimulated or over-dry by producing a white mucous liquid (referred to as Frothing) which may make you feel quite nauseated. The pouch is lubricating itself, sometimes in preparation to cause vomiting and release of whatever food is offending the pouch or stuck in the Roux limb. You might find that your nose feels full after you eat.  This is also part of the frothing process.  Some people combat frothing with a mildly acid liquid, sipped slowly, like milky tea or tea with lemon, lemon water, drops of apple cider vinegar in water, or even a few drops of pickle juice or sauerkraut juice.  The common feature in all of these is the acidity of the remedies.
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25.Why is it sometimes necessary to vomit?
Pay attention to your body’s signals of fullness.  One extra bite may cause pain and discomfort. Your pouch and Roux limb, the two parts of the gastric bypass tool, work like a slow moving sink drain.  There is no stopper at the bottom of the sink, but the narrowness of the connection between the pouch and the Roux limb restricts the passage of food out of the pouch and into the Roux limb.  The passage of food is greatly affected by the texture or consistency of the food: heavy, fibrous or dense food exits slowly; soups or liquids pass quickly.  Sometimes if a food gets stuck and will not pass into the Roux limb, the only solution is to cough out the offending food to release it from the pouch.  Vomiting is best avoided; it is rough on your tender pouch.  If you do vomit, go easy on the next meal or next few meals.  Consider going to a full liquid diet for the next meals to rest your pouch.

Ask yourself the following:

Am I eating too fast?
Am I chewing my food?
Am I eating too much?
Am I drinking with meals or too soon after eating?
Am I lying down too soon after eating?
Are the foods I'm trying to eat too advanced for my pouch and roux?
If you find yourself unable to keep even clear liquids down, repeatedly, call your surgeon.

26.Is it possible to fail to lose weight with this surgery?
This surgery changes your food tolerances and capacity, and will lead to behavioral changes, but only if you listen to your new anatomy, not your old habits.  The surgery does not fix you.  You must consciously and mindfully choose to live a healthier life, with healthier eating habits, that will lead to improved health overall.  Is it not automatic. You can choose to not change your relationship to food and to eating.  You can ‘out eat’ any surgery.  The moment the last instrument is removed and the last stitch is placed, you are responsible for your body's upkeep and maintenance.
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27.What is the ‘Window of Opportunity’?
The first 12 to 14 month time period is what surgeons call the ‘window of opportunity,’ during which time you have the highest degree of pouch restriction and malabsorption working together to your greatest advantage.  Do not squander this gift.  It is when your surgical tool is working at its maximum level of function.  The relative ease with which weight loss occurs in the first few months after surgery can lead some patients to the mistaken belief that their bowel has been made impervious to calories.  Even sloppy eating habits can lead to weight loss in the early post-operative course.  This stage does not last long. Your pouch will soften, your bowel will adapt, and the behavioral changes you make or fail to make in your early post-operative life will determine how well you succeed in the long-term with gastric bypass surgery.  Losing weight early on is a given, maintaining that loss takes work.
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