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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword
- •Preface
- •Acknowledgments by Salman Al-Sabah
- •Contents
- •Editors and Contributors
- •Introduction
- •Learning About the Laparoscopic Sleeve Gastrectomy (lSG) The Birth and Evolution of Laparoscopic Sleeve Gastrectomy
- •1 Introduction
- •2 Costing Methods
- •3 Costing Components
- •4 Cost of Obesity and Overweight: The Evidence
- •5 Overall Cost of Obesity
- •6.1 Ischaemic Heart Disease and Stroke
- •References
- •Obesity, a Costly Epidemic
- •6.2 Diabetes Mellitus
- •6.3 Osteoarthritis
- •6.4 Cancers
- •7 Conclusion
- •References
- •The Health Effects of Obesity
- •1 Obesity Reduces Life Expectancy
- •2 Obesity and Cardiovascular Disease
- •3 Obesity and Respiratory Disease
- •4 Obesity and Cancer
- •5 Other Obesity-Related Conditions
- •6 Health Effects of Obesity in Special Populations
- •6.1 Transplant Recipients
- •6.2 Orthopedic Surgery Patients
- •6.3 Pregnancy
- •6.4 Children and Adolescents
- •7 Conclusion
- •References
- •Obesity and Body Mass Index
- •2 Obesity and BMI
- •3 Percent Excess Weight Loss (%EWL)
- •4 Percent Excess BMI loss (%EBMIL)
- •5 Percent of Total Weight Loss (%TWL)
- •References
- •Dealing with Obesity: Patient Perspective
- •1 Considering the Psychology of Obesity
- •2 Education for Success
- •3 Understanding the Necessity of Mind Shift for Success
- •The Future of Bariatric Surgery and Genetics
- •1 Heritability and Obesity
- •2 Weight Loss Interventions and Genetics
- •3 Bariatric Surgery and Genetics
- •References
- •Sleeve Gastrectomy Registries
- •1 Introduction
- •3 The Value of Registries
- •7.1 Direct-Data Entry Only
- •7.2 Electronic Upload Only
- •8 Key Step 5—Create a Suitable Minimum Dataset
- •9 Key Step 6—Layer in GDPR Compliance
- •14 Conclusion
- •References
- •Weight Loss: Diet Options
- •1 Introduction
- •2 Principles in Dietary Therapies
- •3 Diet Options for Weight Loss
- •4 The Weight-Maintenance Diet
- •5 Summary
- •References
- •Candidates for Sleeve Gastrectomy
- •Eligibility Criteria for Sleeve Gastrectomy
- •1 Introduction
- •2 Current Eligibility Criteria for Bariatric Surgery
- •3 Age
- •4 BMI
- •5 Procedure Selection
- •6 Other Considerations in Decision-Making
- •7 Summary
- •References
- •The Sleeve and Pregnancy
- •1 Pre-pregnancy Weight Management
- •2 Pre-pregnancy Supplementation
- •3 Acceptable Weight Changes in Pregnancy
- •4 Care During Pregnancy
- •5 Gestational Diabetes
- •5.1 Screening
- •5.2 Treatment
- •5.3 Mode of Delivery
- •5.4 Postpartum
- •References
- •The Sleeve and Reproductive Potential
- •1 Introduction
- •2 Obesity and Female Reproduction
- •3 Obesity and Male Reproduction
- •4 Female Reproduction Following Bariatric Surgery
- •5 Male Reproduction Following Bariatric Surgery
- •6 Timing of Conception Following Bariatric Surgery
- •8 Conclusion
- •References
- •6 RYGB to SG
- •7 SG After Endoscopic Procedures
- •8 Conclusion
- •References
- •Converting Endoscopic Bariatric Procedures to LSG: POSE, Endosleeve, and Balloon
- •1 Introduction
- •The Sleeve as a Revisional Procedure
- •1 Introduction
- •2 General Considerations
- •3 Choice of Technique Based on Evidence
- •5 Sleeve Gastrectomy to Re-sleeve
- •2 The POSE Procedure
- •2.1 How the POSE is Performed
- •2.2 Converting a POSE to an LSG
- •3 The Endosleeve
- •3.1 How the Endosleeve is Performed
- •3.2 Converting Endosleeve to LSG
- •4 The Balloon
- •4.1 LSG Following Balloon Removal
- •5 Conclusion
- •References
- •The Sleeve Gastrectomy in Adolescents
- •1 Introduction
- •2 Eligibility
- •2.1 Who is Eligible?
- •3 Which Procedure is Right for Adolescents
- •4 Pre- and Post-operative Nutritional Care
- •5 Psychological Concern
- •6 The Outcomes of SG
- •References
- •2 Epidemiology
- •3 Risk Factors
- •4 Pathophysiology
- •5 Clinical Presentation
- •6 Diagnosis
- •7 Non-invasive Tests
- •7.1 Laboratory Investigations
- •7.2 Imaging
- •8 Scoring Systems
- •8.1 Invasive Measure
- •8.1.1 Liver Biopsy
- •9 Clinical Scores
- •10 Sleeve Gastrectomy in NAFLD and NASH
- •13 Sleeve Gastrectomy Pre-transplant
- •15 Sleeve Gastrectomy After Liver Transplantation
- •References
- •Sleeve Gastrectomy in Immunocompromised Patients
- •1 Introduction
- •2 Safety and Postoperative Morbidity
- •2.2 Perioperative Timing of Immunosuppressive Therapy
- •3 Outcomes of SG in Immunocomromised Patients
- •3.2 Changes to Rheumatoid and Autoimmune Conditions
- •4 Summary
- •References
- •Sleeve Gastrectomy and Cancer
- •1 Obesity and Cancer
- •2 Pathogenesis of Cancer in the Obese
- •3 Current Literature
- •4 Bariatric Surgery and Cancer Risk
- •5 Colorectal Cancer (CRC)
- •6 CRC in RYGB Versus SG and AGB
- •7 Breast and Endometrial Cancers
- •8 SG and Gastro-esophageal Cancer
- •9 Conclusion
- •References
- •Multidisciplinary Care Before and After Sleeve Gastrectomy
- •1 Introduction
- •2 Bariatric/Obesity Specialist
- •3 Bariatric Dietitian
- •4 Bariatric Clinical Psychologist
- •5 Bariatric Coordinator
- •6 Conclusion
- •References
- •Psychiatric Evaluation: Pre and Post Sleeve
- •1 Introduction
- •3 Depression
- •4 Eating Disorders
- •5 Anxiety
- •6 Substance Use Disorders
- •7 Self-harm and Suicidal Ideation
- •8 Psychotropic Medications
- •10 Mental Health Preoperative Assessment
- •11 Outline of Domains of the Evaluation
- •12 Psychiatric Contraindications for Bariatric Surgery
- •13 Conducting the Assessment
- •13.1 History of Weight Loss and Previous Attempts
- •13.2 Medical History
- •13.3 Pathological Eating Behavior
- •13.4 Psychiatric History and Screening of Substance Use
- •13.5 Support System
- •13.6 Psychiatric Medication
- •14 Psychiatric Assessment Conclusion
- •15 Special Populations
- •15.1 The Adolescent Patient
- •15.2 Limited Cognitive Function
- •16 The Impact of Bariatric Surgery on Mental Health
- •16.1 Quality of Life
- •16.2 Mental health status
- •16.3 Suicide
- •16.4 Addiction
- •16.5 Eating Disorders
- •16.6 Psychotropic Medication
- •16.7 Postoperative Pharmacological Considerations
- •17 Conclusion
- •References
- •Insurance, Self-Pay and Medical Tourism
- •How Much Does the Sleeve Cost
- •1.1 Economic Methodologies
- •1.2 Fixed Costs: Medical Devices
- •1.3 Fixed Costs: Personnel
- •1.4 Variable Costs: Reusable Instruments
- •1.5 Variable Costs: Disposables
- •2 Bariatric Surgery Costs
- •2.1 Methods for Identifying Cost Components
- •2.2 Methods for Valuing Cost Components
- •3 The Cost of the Sleeve Around the World
- •References
- •Analysis of LSG Competitors
- •1 Competition in the Industry
- •2 Potential of New Entrants into the Industry
- •3 Threat of Substitute Products
- •3.1 Anti-obesity Medications
- •3.2 Herbal and Alternative Medicine
- •3.3 Diet Program
- •3.4 Exercise
- •3.5 Acupuncture and Acupressure for Weight Loss
- •4 Power of Customers
- •5 Power of Suppliers
- •5.1 Strengths
- •5.2 Weaknesses
- •5.3 Weaknesses of Duodenal Switch Surgery
- •5.4 Opportunities
- •5.5 Threats
- •References
- •Medical Tourism: Global Bariatric Healthcare
- •1 Introduction
- •2 The Impetus Behind Global Healthcare
- •4 Conclusion
- •References
- •Sleeve Gastrectomy: Medicolegal Aspects
- •References
- •Laparoscopic Sleeve Gastrectomy 101
- •References
- •Robotic Sleeve Gastrectomy
- •1 Introduction
- •2 Robotic-Assisted Sleeve Gastrectomy
- •3 Cost of Robotic-Assisted Sleeve Gastrectomy
- •5 Operative Technique
- •6 Clinical Outcomes
- •7 Future Directions
- •8 Conclusion
- •References
- •Laparoscopic Sleeve Gastrectomy in Situs Inversus Totalis
- •1 Introduction
- •2 How to Perform the Procedure
- •3 Discussion
- •4 Conclusion
- •References
- •Banded Sleeves
- •1 Introduction
- •2 Procedure
- •3 Pre- Intra- and Post-Operative Management
- •4 Results
- •5 Band Complications
- •7 Conclusions
- •References
- •Buttressing the Sleeve
- •1 Introduction
- •2 Technical Aspects
- •3 Buttressing for Bleeding
- •4 Buttressing for Leaks
- •5 Results from the MBSAQIP
- •6 Previous Evidence
- •7 Conclusion
- •References
- •Sleeve and Ventral Hernias
- •1 Introduction
- •2 Prevalence, Incidence and Cost of Ventral Hernia
- •4 Primary Abdominal Wall Hernia
- •5 Incisional Hernia
- •5.1 Medial or Midline Zone
- •5.2 Lateral Hernias (Flank Hernias)
- •6 Size of the Hernia
- •7 Indication and Risks of Ventral Hernia Repair
- •8.1 Position of Trocar and Creation of Pneumoperitoneum
- •9 Principles of Adhesiolysis
- •10 Measurement of Hernia Defect
- •12 Technique of Open Ventral Hernia Repair [10, 25, 26]
- •13 Concurrent LSG with LVHR
- •14 LSG with Sequential LVHR
- •15 Conclusion
- •References
- •1 Introduction
- •5 Operative Concerns and Patient Selection
- •6 Preoperative Evaluation
- •7 Esophageal High-resolution Manometry
- •8 Surgical Technique
- •9 Discussion
- •References
- •Omentopexy in Laparoscopic Sleeve Gastrectomy
- •1 Background
- •3 Omentopexy in Sleeve Gastrectomy
- •3.2 Operative Technique
- •5 Effect on Gastric Emptying
- •6 Conclusion
- •References
- •Sleeve Gastrectomy and Gallstones Disease
- •1 Introduction
- •2 Obesity and the Risk of Gallstone
- •3 Rapid Weight Loss and the Risk of Gallstone
- •5 Incidence of Cholecystectomy in Sleeve Gastrectomy
- •6 Biliary Complications Post LSG
- •7 Cholecystectomy: When to Operate?
- •8 Prophylactic (Routine) Cholecystectomy
- •9 Elective (Selective) Cholecystectomy:
- •11 Ursodeoxycholic Acid (UDCA) Prophylaxis
- •12.1 Dose, Frequency
- •13 Disadvantages of UDCA
- •14 Summary
- •15 Conclusion
- •References
- •LSG Under Block Anesthesia (PVB)
- •1 Introduction
- •2 Review on General Anesthesia
- •2.1 General Overview
- •2.2 General Anesthesia in the Obese/bariatric Population
- •3 Review on Paravertebral Block (PVB)
- •4 Anatomy
- •4.1 Indication
- •4.2 Techniques
- •4.2.1 Blind Technique
- •4.2.2 Neurostimulation Technique
- •4.2.3 Ultrasound Guided Technique
- •4.3 Mechanism and Spread of Anesthetic
- •4.4 Anesthetic Drugs
- •4.5 Complications
- •4.6.1 Abdominal Surgeries
- •4.6.2 First Paravertebral Block in Sleeve Gastrectomy
- •References
- •Elderly High Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy
- •1 Scope of the Problem
- •1.1 Increasing of the Elderly Population
- •1.3 Risks of Surgery in the Elderly
- •1.3.1 Bariatric Surgery in Elderly
- •2 Sleeve Gastrectomy: Procedure of Choice
- •2.1 Intraoperative Difference in Elderly
- •3 Postoperative Care in the Elderly
- •4 Postoperative Mortality and Morbidity
- •5 Postoperative Outcomes
- •5.1 Excess Body Weight Loss
- •5.2 Comorbidities Improvement
- •5.3 Quality of Life Improvement
- •6 LSG in Septuagenarians and Elderly Super Obese
- •7 LSG Compared to Gastric Bypass in Elderly
- •8 Conclusions
- •References
- •Postoperative Diet Progression for Laparoscopic Sleeve Gastrectomy
- •1 Introduction
- •2 Diet Progression: Stages
- •3 Conclusion
- •References
- •How Laparoscopic Sleeve Gastrectomy May Cause Weight Loss
- •1 Ghrelin Effect
- •1.1 Other Gastrointestinal Hormone Secretion
- •1.2 Other Molecular Changes
- •1.3 Bile Acid Metabolism
- •1.4 Microbiome
- •1.5 Central Nervous System Changes
- •1.6 Conclusion
- •References
- •Expected Weight Loss After the Sleeve
- •1 Introduction
- •2 Preoperative Weight Loss
- •3 Short-Term and Mid-Term Outcomes
- •4 Long-Term Outcomes
- •6 Summary
- •References
- •1 Introduction
- •2 Set Point Theory
- •3 Weight Regulation and Weight Loss Maintenance
- •6 Neurohormonal Regulation of the Body Set Point
- •8 Conclusions
- •References
- •Quality of Life and Bariatric Surgery
- •1 Medical Outcomes Survey Short Form 36S (SF-36)
- •3 The Bariatric Quality of Life Index (BQL)
- •References
- •LSG: Risks and Considerations
- •Risks Associated with Sleeve Gastrectomy
- •References
- •Outcomes and Complications After Sleeve Gastrectomy
- •1 Introduction
- •2 Impact on Obesity
- •3 Impact on Diabetes
- •4 Impact on Hypertension
- •5 Impact on Dyslipidaemia
- •6 Complications
- •7 Non-Surgical Complications of Sleeve Gastrectomy
- •9 Early Complications of Sleeve Gastrectomy
- •10 Alteration to Bile Flow After Sleeve Gastrectomy
- •11 Anatomical Changes After Sleeve Gastrectomy
- •12 Vagus Nerve Modulation After Sleeve Gastrectomy
- •13 Cardiovascular Effects of Sleeve Gastrectomy
- •14 Effects on Microbiota After Sleeve Gastrectomy
- •15 Impact on Metabolism After Bariatric Surgery
- •16 Conclusion
- •References
- •How to Manage Sleeve Complications: Hemorrhage
- •1 Background
- •2 Bleeding Cascade, Patient and Surgeon Factor
- •3 Surgical Stapler Technology
- •4 Management and Prevention
- •4.1 Buttressing, Oversewing
- •5 Hemostats
- •6 Summary
- •References
- •Endoscopic Management of Leak and Abscess Following Laparoscopic Sleeve Gastrectomy
- •1 Introduction
- •3 Closure of the Leak Site
- •3.1 Self-Expanding Metal Stents
- •3.2 Types of SEMS
- •3.3 SEMS Insertion Procedure
- •3.4 Outcome of SEMS Placement
- •3.5 Over-The Scope Clip System
- •4 Internal Drainage
- •4.1 Endoscopic Internal Drainage
- •4.2 EID Procedure
- •4.3 Outcome of EID Procedure
- •4.4 Endoscopic Vacuum Therapy
- •5 Septotomy and Pneumatic Balloon Dilatation
- •6 Conclusion
- •References
- •How to Manage Sleeve Complications: Surgical Leak and Abscess
- •1 Introduction
- •2 Principles of Management
- •3 Endoscopy
- •4 Surgery
- •4.1 Control of Early Complications and Nutritional Status
- •4.2 The Leak Site
- •4.3 Roux en Y Fistulo-Jejunostomy
- •4.4 Literature Review of the Remaining Surgical Options
- •4.5 Discussion of the Surgical Approach
- •5 Conclusion
- •References
- •How to Manage Sleeve Complications Through Endoscopy: Strictures
- •1 Introduction
- •4 Signs and Symptoms
- •5 Diagnosis and Management
- •6 Bougie Dilation
- •8 Self-Expanding Metal Stent (SEMS) Placement
- •10 Strategies for Endoscopic Success
- •11 Conclusions
- •References
- •Sleeve Gastrectomy Stenosis: Surgical Treatment
- •1 Introduction
- •2 Diagnosis
- •3 Incidence
- •4 Prevention
- •5 Treatment
- •6 Conclusion
- •References
- •1 Introduction
- •2 Mechanisms of GERD Post-Sleeve Gastrectomy
- •3 Incidence of GERD After Sleeve Gastrectomy
- •4 Screening Recommendations
- •5 Role of Pharmacotherapy, Diagnosis, and Testing
- •7 Radiofrequency Ablation
- •8 Transoral Incisionless Fundoplication (TIF)
- •9 Conclusion
- •References
- •1 Background
- •2 Pathophysiology

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363

Postoperative Diet Progression for Laparoscopic Sleeve Gastrectomy
Dana AlTarrah
1 Introduction
Nutritional management and regular postoperative follow-up are vital for patients
undergoing bariatric surgery and has been found to impact weight loss and
long-term weight maintenance. Registered dietitians (RDs) and clinical nutritionists play an important role in establishing a bariatric dietary protocol to maximize
weight loss, meet postoperative nutritional requirements, manage food intolerances and prevent nutritional complications [1–3].
To date, evidence-based diet progression guidelines following bariatric surgery
are lacking, and although some guidelines have been published, there is no standardization for the postoperative nutritional management of bariatric patients [2–4].
Moreover, there is limited evidence on diet progression recommendations specifically for laparoscopic sleeve gastrectomy (LSG) patients, thus postoperative
dietary guidelines tailored for Roux-en-Y Gastric Bypass (RYGB) are likewise
recommended for LSG patients.
Dietary progression stages are highly patient-dependent and are predominantly
personalized to meet patient’s individual tolerance and nutritional requirements [4–6]. Hence, postoperative nutrition management protocols adopted by
RDs and surgeons are found to differ in relation to the duration a patient remains
at each diet stage and the type of fluids/foods offered [7].
Patients undergoing weight loss surgery including LSG must be prepared for
lifelong dietary, behavioral and lifestyle changes. Routine follow-up appointments
with RDs are crucial to ensure long-term postoperative success and reduce the risk
D. AlTarrah (*)
Faculty of Public Health, Kuwait University, Kuwait City, Kuwait
e-mail: danah.altarrah@ku.edu.kw
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_35
365

D. AlTarrah366
of potential postoperative complications [8, 9]. In agreement with postoperative
Center of Excellence recommendations, follow-up appointments should be scheduled 1 to 2 weeks following surgery, and continue regularly every month until
3 months, followed by a 6 month, 9 month and yearly follow up, thereafter [4, 10].
2 Diet Progression: Stages
Dietary progression stages following LSG are based on nutritional needs and a
gradual transition in food texture and consistency over a period of 1 to 2 months,
until regular textures and solids are reintroduced and well tolerated [2, 4].
Postoperatively, patients are advised to slowly and gradually begin introducing clear liquids (non-calorie, decaffeinated, sugar-free, non-carbonated) for
the first 1 to 2 days, and later advance to a full liquid diet (1 to 2 weeks) which
includes fluids rich in protein, carbohydrates and dietary nutrients. Approximately
14 days following surgery, patients are advanced to pureed and soft solids for 3 to
4 weeks, and lastly firmer regular foods are introduced as tolerated by the patient.
Suggested guidelines for the quantity and frequency of foods and/or fluids at each
stage are displayed in Table 1. However, as mentioned earlier the progression of
patients from one stage to the next, and the pace and duration spent at each diet
stage are highly patient-dependent, even among patients undergoing the same
weight loss procedure. In particular, due to the long surgical staple line and high
prevalence of nausea reported following LSG, a slow and gradual diet progression
plan is highly recommended for LSG patients [4–6]. Table 2 provides an in-depth
description of diet stages for LSG patients.
Food intolerances are commonly experienced by bariatric patients during the
early postoperative period. Although, food tolerances are found to vary widely
between LSG patients, intolerances are found to peak at 6 months, and progressively improve. Therefore, it is necessary that patients are advised to chew food
efficiently, and to provide patients with guidelines regarding foods that are frequently reported to increase intolerances, such as rice, milk, certain vegetables
and red meats [11, 12]. Frequent postoperative nutritional follow-up and support is
highly recommended to advise and educate patients about difficult foods and substitutions for such foods. For instance, rice may be replaced with potatoes, milk
with yoghurt, and tougher red meats with white tender meat (poultry and fish), to
ensure that patients consume a varied and nutritionally balanced diet from all food
groups as the patients gradually introduce solids [7].
During the early postoperative diet stages, many patients may particularly
develop an intolerance to protein-rich foods due to inadequate mastication, and
a decrease in hydrochloric acid and proteolytic enzymes (e.g. pepsinogen). As a
result, protein deficiency is a commonly reported macronutrient complication
associated with LSG [4, 13]. Although protein recommendations for LSG patients
remain unclear, patients are advised to include 60–80 g of protein in their
diet [14]. However, in the case that patients are unable to incorporate protein-rich
foods, protein supplementation (whey, whey isolate, or soy protein powder;

Postoperative Diet Progression …
Table 1 Diet stages postoperatively and suggested foods/fluids and quantities
Diet stage Postoperative
day
Clear liquid 1 to 2 days 1 to 2 days Water
Full liquid 2 to 16 days 10 to 14 days Water
Pureed 16 to 30 days 10 to 14 days Water
Soft 30 to 60 days Less than
Adapted from Mechanick, J. I. et al., 2013, Aills, L. et al., 2008
Duration Fluids/Foods
Coconut water
Clear broth
Herbal tea
Coconut water
Blended and strained soup
Skimmed milk and dairy
alternatives
Fruit juice diluted in water
Skimmed milk blended
with fruit
Bread or biscuits soaked
in milk
Mashed food (rice,
chicken, meat)
Porridge
Mashed and cooked fruit
Blended grains
14 days
Water
Cooked vegetables
Boiled eggs and cooked
meat
Soft bread
Milk and skimmed dairy
Soft fruit
367
Amount and
Frequency
30 – 50 ml every
20 – 30 min
80 – 100 ml every
60 – 90 min
100 – 150 ml
every 2 h
150 ml every 2 h
25–30 g protein per serving) is regularly integrated within each dietary progression stage, taking into account patients’ individual intake and nutritional needs.
Appropriate chewing and meal portioning training sessions may be provided by
RDs and the multidisciplinary nutrition education team to ensure protein intake is
adequate, and patients meet their recommended daily fluid intake [3, 4].
Following the early diet progression stages, patients are advised to follow a
nutritional pyramid developed by Moizé et al.,[14] to establish lifelong healthy
dietary habits. The pyramid is comprised of five levels. The base focuses on the
importance physical activity, vitamin and mineral supplementation, and adequate
hydration. Patients are largely recommended to incorporate foods within the second and third level, which includes: protein-rich foods (meats, fish, dairy and
eggs) to meet their recommended protein intake (60–80 g per day), in addition to
fruits, vegetables and vegetable oils. Within the upper levels, patients are advised
to limit their consumption of carbohydrate rich foods, such as cereals and legumes, and avoid foods high in saturated and trans fats, cholesterol, sugar, salt and
alcohol [14, 15].

Postop day 1 patients may undergo a gastrogaffin swallow test for
leaks; once tested, patients are advised to begin taking small sips
Guideline
of water
Patients should consume a minimum of 48–60 oz of total fluids
per day; 24–32 oz or more clear liquids; plus 24–32 oz of any
combination of full liquids; examples of full liquids listed below:
• 1% or skim milk
• Smooth tomato soup, no
chunks, mixed with 1%
or skim milk
• Whey, whey isolate, or
soy protein powder (limit 25–30 g protein per serving) mixed with
Protein food choices are encouraged for 3–6 small meals per day;
patients may only be able to tolerate a couple of tablespoons at
each meal/snack
• Lactaid milk, soymilk, or almond milk
• Light yogurt or Greek yogurt
• Less than 25 g of sugar per serving listed on label; no chunks of
fruit
• Plain yogurt
Encourage patients to chew food prior to swallowing ~ 20 chews
after each meal before resuming fluids
per bite
Encourage patients not to drink with meals and to wait ~ 30 min
D. AlTarrah368
(continued)
Patients can supplement small amounts of soft protein intake with
one full liquid as listed in stage 2
Patients are advised to use small utensils and to help control
portions
Clear liquids: noncarbonated; no
calories, no sugar, no caffeine
and 2
Start Fluids/Food
a
Stage 1: Postop days 1
Diet stage
Table 2 Suggested guideline for diet progression stages following Laparoscopic Sleeve Gastrectomy
Clear liquids
• Encourage patients to have salty
fluids at home and solid liquids:
Sugar-free ice pops/gelatin
Plus, full liquids:
sugar per serving
in full liquids
liquids
Postop day 3 (dis-
charge diet)
12
, 3,000 IU total
3
Stage 2:
Begin supplementation:
Chewable multivitamin with
minerals (2 per day)
Chewable or liquid calcium
citrate with vitamin D
Sublingual, liquid, or nasal
350–500 μg vitamin B
Vitamin D
per day
uids 48–64 oz or more per day)
and replace full liquids with soft,
moist, diced, ground, or pureed
protein sources as tolerated
Stage 3 protein sources: Eggs,
ground meats, ground or pureed
poultry, soft, moist fish, added
gravy, bouillon, light mayo to
Stage 3: Week 1 Postop days 10–14 Increase clear liquids (total liq-
moisten, cooked beans, hearty
bean soups, cottage cheese, low-
fat cheese, yogurt

Postoperative Diet Progression …
Avoid rice, bread, and pasta until patient is comfortably consum-
Adequate hydration is essential and a priority for all patients dur-
ing the rapid weight loss phase
• Patient should be encouraged to add fruits/vegetables in a
texture that is tolerated; added fruits and vegetables and adequate
Guideline
hydration will help prevent constipation
ing adequate protein (60 g)per day and fruits/vegetables
• Full liquids may be used for meal or snack replacement
369
animal sources), fruits, vegetables, and whole grains; calorie
needs based on individual needs
Advise patients to eat from small plates and using small utensils
to help control portions
Consider diet a to meet nutritional needs during rapid weight loss
and healing phase
Diet should ensure:
Some protein sources 3−5 times a day with fruits and vegetables
Postop supplementation; as hunger increases and patients are
meeting the Dietary Reference Intake for protein and consuming
fruits and vegetables, and whole grains can be introduced
Patient should meet calorie needs based on height, weight and age
protein foods are well tolerated,
add well-cooked soft vegetables
Start Fluids/Food
a
Stage 3: Week 2 4 weeks postop Advance diet as tolerated; if
Diet stage
Table 2 (continued)
with some fruit or vegetable at
each meal; some patients tolerate
and soft or peeled fruit
salads 1 month postop
5 weeks postop Continue to consume protein
Stage 3: Week 3
May switch to pill form of
supplementation if liquid
or chewable not tolerated;
Healthy balanced solid food diet Healthy, balanced diet consisting of adequate protein (plant or
As hunger
increases and more
food is tolerated
Stage 4
Vitamin and mineral
encourage liquid or chewable
forms of supplements for at
least 3 months
supplementation daily
There is no standardization of diet stages. Patients’ progression is highly dependent on their nutritional needs and food tolerances postoperatively
Adapted from Mechanick, J. I. et al., 2013, Aills, L. et al., 2008
a
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