Biochemical and Behavioral Preparation with a Dietitian
The Liver Shrinking Diet, implemented 2–4 weeks before surgery, facilitates the surgical field and reduces anesthesia risk. This program is based on high protein, controlled carbohydrates, low fat, and fluid support principles.
The goal is not rapid weight loss but to deplete liver glycogen stores, reduce liver volume, and decrease visceral fat. In patients with diabetes, diet–medication–insulin adjustments are planned together to prevent hypoglycemia. During this period, caffeine, carbonated/sugary drinks, alcohol, simple sugars, and ultra-processed foods are avoided; water intake is increased, and chewing, bite count, and eating speed are regulated.
Behavioral preparation includes mindful eating, identifying trigger foods, controlling night snacking, and keeping an emotional eating diary, as the long-term success of surgery depends on adopting these new routines.
Psychological Assessment and Expectation Management
Bariatric surgery is as much a behavioral and psychosocial transformation as it is a biological one. During the initial consultation, signs of eating disorders, impulse control, depression–anxiety scales, trauma history, addiction patterns, body image, and social support are assessed. Establishing readiness for treatment, adherence capacity, and realistic goals together is very important.
Instead of the belief that “surgery solves everything,” it is explained that surgery creates windows for adopting healthy habits. Psychotherapy may be initiated during this period if necessary, focusing on stress and emotion regulation, reward mechanisms, and adapting to the new body schema.
Medication–Supplement Adjustment and Medical Optimization
In diabetes management, SGLT2 inhibitors, insulin, and other agents are adjusted according to hypoglycemia risk; antihypertensives and statins are reviewed. For patients on anticoagulants or antiplatelet therapy, anesthesia and surgical teams plan cessation or bridging.
The need for proton pump inhibitors is evaluated in the presence of reflux. Vitamin and mineral deficiencies are corrected preoperatively; vitamin D, B12, and iron levels are normalized.
Smoking is strictly prohibited (preferably at least 4–6 weeks prior), as nicotine impairs tissue healing and anastomotic safety. Alcohol is stopped, since postoperative metabolism changes and the risk of transfer addiction increases.
Procedure Selection: Sleeve Gastrectomy, Bypass, or Other?
The choice of procedure is determined by reflux presence, diabetes control goals, sweet/liquid calorie intake, BMI, age, liver condition, previous surgeries, and patient preferences. Sleeve gastrectomy targets appetite hormones and stomach volume, while gastric bypass alters both volume and absorption as well as hormonal flow, offering advantages in diabetes and reflux management.
Advanced malabsorptive procedures such as SADI-S or duodenal switch are considered for very high BMI and metabolic targets; however, adherence to supplementation and follow-up is far more critical. In revision cases, indications are carefully discussed. The goal is not rapid weight loss but long-term, sustainable health benefits.
Early Postoperative Plan: Preparing in Advance
Success is planned before surgery, not after. The patient learns preoperatively about the post-discharge first month: fluid–puree–soft diet stages, target protein intake (usually ≥60–80 g/day), water consumption (typically ≥1.5–2 L/day), vitamin–mineral protocol, and the schedule of initial follow-up appointments. Management of leak, dumping, reactive hypoglycemia, nausea–vomiting, wound care, and thromboprophylaxis is supported with written and visual materials. The role of family and close support is clarified: preparing the home, reducing trigger foods, updating shopping lists, and stocking protein and fluid supplements.
Preoperative bariatric preparation aims for much more than a “successful surgery”: it reduces risk, optimizes tissue and metabolism, reprograms behaviors, and ensures long-term sustainable weight management.
During this process, correct laboratory adjustments support wound healing and maintain hair, skin, and energy levels; the liver shrinking diet makes the surgical field safer; respiratory and cardiac preparation reduces complications; and psychological–behavioral preparation lays the foundation for the new lifestyle.
When the power of surgery is combined with disciplined preparation, it results in safer anesthesia, faster recovery, fewer complications, and more durable weight loss. The patient not only loses weight but also becomes free from metabolic disease burden, significantly enhancing quality of life.
