In the majority of patients after bariatric surgery, this phase is characterized by a significant change in eating habits, improvement in medical comorbidities, and continued weight loss. The most important change in eating habits that result from bariatric surgery is the change in portion size. Initially, the stomach can only tolerate 30 cc at one time, but over time there is a gradual increase in portion size. There are very few reports of the actual change in stomach size. At three months, patients are ingesting an average of 1500 Kcal per day in three to six meals per day. It is important in this stage to emphasize normal eating patterns and prevent development of a grazing lifestyle. With appropriate nutrition advice, patients decrease the need for frequent meals and increase the amount eaten at each meal, reaching three meals a day by six months. Patients learn to be satisfied with very small portion sizes and maintain a dietary intake appropriate for their new size by the 12th month follow-up visit.
For a minority of patients, this phase is characterized by difficulty in adjustment to weight loss, food intolerances, self-destructive behaviors, and, occasionally, requests for a reversal of the procedure. These patients tend to be time-consuming for the treating physician. Discerning the difference between psychological symptoms and physical symptoms can be difficult in this phase. Gallstone formation is associated with rapid weight loss,20 and the reported prevalence of gallstones at six months postoperatively is 22 percent.21 Small-bowel obstruction from internal hernias after laparoscopic surgery13 can present with crampy abdominal pain, nausea, and vomiting (Table 8.4). A high index of suspicion and close consultation with the bariatric surgeon is needed.
Common food intolerances associated with bariatric surgery include bread, rice, pasta, and meat. Vomiting often occurs after eating these foods, resulting in food aversions. For patients who enjoyed these foods prior to the surgery, the loss of food variety results in anger and frustration. These patients will often complain that they experience anxiety and fear when eating. They often express buyer's remorse, may request extensive investigations for problems with the gastric pouch, and request referral to another surgeon for a reversal of the procedure. Reassurance about the ability of the pouch to tolerate a wide variety of foods with time is necessary. Often, fresh fruits and vegetables are tolerated without a problem, resulting in a significant
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