How much will it hurt? What about the nausea?

These are totally appropriate question for people to have when they’re thinking about surgery. The good news is that bariatric surgeons have made big strides in reducing pain and nausea over the last few years. This is obviously a good thing on its own. The cool thing is that reduced pain leads to a shorter hospital stay and then quicker recovery.

The big improvements have come from preemptive treatment of pain and nausea before the surgery even begins. In other words, we no longer follow the old school strategy of treating pain after surgery, instead, we use several tools to suppress the pain and to avoid stimulating nausea.

Old school approach was to react to the pain, and we administered a lot of medicines from the opioid/narcotic group. These can be very effective in suppressing pain, and they still have a place in the surgical toolkit, but the more we depend on them the more downsides we face.

There are several immediate adverse effects from opioids:

• Drowsiness
• Respiratory suppression – low oxygen, higher risk of pneumonia (lung infection)
• Less activity, less walking
• Nausea, which actually gets worse with higher doses or IV meds
• Impaired GI function – persisting nausea and later constipation

Sustained adverse effects

• Slower pain resolution
• Conversion to long term pain syndromes
• In a number of patients, life-destroying effects of narcotic addiction

Beyond the first day or two from surgery, opioid meds don’t really treat the pain. Instead, they put the pain “on hold.” The situation ends up being like taking out a pain “loan,” just like you would take a loan from the bank. You will have to work through the pain eventually, and “with interest.”

There were token uses of numbing medicine, but typically only at the skin level instead of using numbing meds where the most significant nerves are located.

As far as nausea, we gastro-intestinal surgeons used to take it for granted that the work we did on the stomach or the intestine (Sleeve, Gastric Bypass) led naturally to nausea. We’ve learned that’s not correct, and that most of the nausea was caused by opioids and anesthesia meds. Anesthesia meds have become much “cleaner” in the last few years, resulting in much less nausea. And as we steadily reduce the amount of opioid meds that our patients need, we see less nausea from that source as well!

The modern approach is to do everything we can to stay ahead of the pain and nausea, then to treat the smaller residual pain using multiple different pharmacologic groups synergistically, to minimize the need for opioids.

Pre-emptive pain and nausea management begin well before surgery.

• Hydration by mouth and by IV – reduces nausea
• Non-opioid pain meds – these block the onset and the intensity of pain without the nausea and other opioid side effects
  – Gabapentin
  – Acetaminophen
• Nausea blocking meds
  – Aprepitant
  – Scopolamine patch
  – Dexamethasone injection

In the operating room, we continue to block pain and nausea
“cleaner” anesthesia meds including propofol cause less nausea
LOTS of numbing medicine is injected before surgical trauma – lasts for 3 days so that by the time it wears off you are well on the way to healing and there only small pain leftover

After surgery, we give non-opioid pain meds on a regular schedule to prevent the onset of serious pain. This leaves only a small intermittent need for the opioid meds, and patients are typically past this need a few hours after surgery. We also coach our patients on active recovery beginning with walking an hour or so after surgery, instead of old-school bed rest. The more you move around after surgery, the less stiffness and thus the less pain you will experience. Pain prescriptions for home continue the synergistic schedule with little or no opioid meds.

Putting all this together, we often see patients sail through bariatric operations with no nausea and with minimal pain. Most patients find that the pain for their Sleeve or Gastric Bypass was actually less than for gallbladder removal and definitely less than something like a c-section!

Many patients go home at 4-6 hours after surgery and return to all normal activities 3-5 days after surgery. (There is still likely to be significant fatigue up to two weeks after surgery, so we recommend that you don’t commit to work or other important activities within two weeks.)