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Elderly High Risk Patients …
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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 [13].
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 [24]. 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 [46]. 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 [46]. 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 35 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