Dr. Jossart

Spasms after VSG surgery tend to occur in the first few months and then subside as the pouch increases in size. Vomiting in the first three months is not always from a spasm. It could be a narrowing(stenosis) of the sleeve or some other anatomical abnormality that may need to be diagnosed with an Upper GI Xray or Endoscopy. If softer proteins are not tolerated, then a visit with the surgeon is necessary to determine if a test needs to be done or a medication given to help with spasms.

This would be surgeon dependent and would also depend on your weight and other factors. It would be best to discuss before your surgery with your surgeon

If there are reasons to remove the gallbladder such as stones, then it is certainly reasonable to remove it.

The gastric cancer issue you refer to would be with a gastric bypass. The sleeve removes most of the greater curvature of the stomach and is not an ulcerogenic procedure. H.pylori can be tested and cleared with medications. The sleeve stomach can always be scoped for ulcers, tumors, etc so screening for cancers is always possible with a VSG

The leak rate of 1-2% for the VSG is correct. There have been some reports that it is higher and some that it is much lower but 1-2% is probably the best number

Generally, terminology like this(Phase, clinical trials) refers to devices and medications. Procedures or techniques do not usually require a specific trial to be approved as there is no governing body that would approve or disprove them. The FDA approves devices but not procedures. Currently, Medicare does not approve the VSG but is reviewing it. Other insurance companies are probably following along with this.

The choic between a purely restrictive procedure(VSG) and a bypass procedure such as the Duodenal Switch or gastric bypass is difficult. The lower BMI group(roughly 35-50) can usually lose an adequate amount of weight with the VSG and therefore avoid an intestinal bypass. The reason to choose the DS over the VSG within this BMI group(35-50) is because your BMI is on the higher end(50); you have metabolic syndrome comorbidities that are more severe(Diabetes, highe cholesterol, high blood pressure) or you believe you have slower metabolism and really need malabsorption. A younger, healthier person with a BMI of 41 can usually do quite well with just a VSG

The VSG does not have significant malabsorption and protein deficiency is essentially unheard of. Any protein drink will be fine. Make sure the carbohydrate count is low(usually less than 10gm) as you don't want to consume alot of sugar. Most health food stores sell good quality protein drinks as well as grocery stores, etc. The general rule is more than 15gm of protein and less than 10 of carbs.

There is no "exact" vitamin recommendation for any of the weight loss operations, but here is a general recommendation that most surgeons would agree on. Everyone should realize that vitamin deficiencies are quite rare and often take several years to develop(except Thiamine which can occur after just a few days of vomiting). The VSG has no malabsorption so you are at a slightly lower risk of having a vitamin deficiency. You are most restricted and losing weight rapidly in the first year, therefore it is relatively more important to take extra vitamins in the first year. A multivitamin and a calcium twice a day is a fairly standard recommendation. It is also reasonable to take a B-complex once a day. At the end of the first year, you should have your labs checked. If the vitamin levels are normal, you could cut back to just one per day. If something is abnormal, you will need to take more. The most important point to make is not the brand of vitamin that you are taking or how much you taking; it is that you must check your annual labs to see if your levels are normal or not!

Great question, difficult answer. The reason to do a VSG for a higher BMI is because it might be safer, not because it would have better weight loss. The idea is to stage the higher BMI patient into two operations instead of one with the hopes of making it safer for the patient. The operation that would yield the best weight loss but is more risky, is the duodenal switch. The RNY may be adequate for the higher BMI patient but some data does suggest that once the BMI starts to go over 55, it may not be adequate for weight loss. Again, this is very difficult to answer adequately.

Leakage or staple line disruption usually occurs in the first 14 days and is rare(with proper technique). It may go undiagnosed for months. It is very rare to occur after the first few months and would most certainly be a staple line problem that occurred early after surgery but was impossible to diagnose. This is also very rare

If the band is tolerated(no vomiting problems) and an Upper GI xray looks good, then it is very possible to do both band removal and conversion to sleeve. If the Upper GI shows problems, then it may be best to limit the operation to band removal only. Band removal to sleeve is not exactly straightforward and proper sizing of the pouch becomes more difficult. Be aware that you may not be as restricted as a sleeve patient who never had a band.

Your problem seems serious and is probably not going to be well addressed on a forum like this. Persistent vomiting with any weight loss operation is not normal. An Upper GI xray will usually diagnose the problem. An endoscopy can usually treat it. You should see your surgeon as he will have the advantage of understanding the anatomy after looking at the Upper GI. He would then be able to decide if you would need an endoscopy, medications, etc.

Obesity is an inflammatory state. That inflammation may actually worsen the symptoms of MS. Weight loss via dieting or surgery should help(in general). The VSG is a good option to consider for a patient with MS as there is no foreign body and no intestinal bypass that could interact with the side effects of MS. There are not many patients with MS that have had weight loss surgery but one of mine told me recently that her Neurologist said she had the best MRI in ten years. She is two years postoperative from a VSG!

The effect of weight loss surgery and weight loss on depression and anti-depressant medications is very complex and not well understood. The only additional input I can offer is that sometimes the dosing of a medication needs to be changed while losing weight due to a change in absorption and a change in the distribution of the drug within the decreasing fat mass.

There are two reasons to have an epiphrenic diverticulum after a VSG. It may have already existed and was not diagnosed by any preoperative studies such as an Upper GI or an Endoscopy. The other possibility is that you may have had a hiatal herniat that was not diagnosed and not repaired and now appears to look like an epiphrenic diverticulum on Xray or Endoscopy.

Sarcoidosis is not common and there are no significant reports on weight loss surgery and sarcoidosis. However, the lung condition usually worsens with increasing weight and weight loss will help. Weight loss surgery is more risky in someone who is or who has been on steroids(due to poor healing), so it is probably a good idea to choose a procedure that is less complex and risk such as the VSG or even a band. Medications will be absorbed and most likely all of your diagnosis will improve or resolve depending on how much weight you lose.

It is unlikely that protein drinks cause kidney stones. High protein diets are implicated because of a higher intake of fatty red meats. The low calorie weight loss surgery diet with an emphasis on lean protein is unlikely to be the reason. More likely reasons are dehydration in the early months after surgery and high calcium carbonate intake. Most weight loss surgeons emphasize staying hydrated and using calcium citrate instead of carbonate. Procedures with malabsorption do have a higher incidence of kidney stones because of factors related to the malabsorption

The rapid weight loss and starvation process after all weight loss operations will trigger changes in many labs. Liver enzymes may go up, cholesterol can go up or down, white blood count may go up or down. The trend of labs over the first 2-3 years is the best indicator of whether you are cured or not. Most likely, the cholesterol will improve by the one year mark, given adequate weight loss and a healthy diet.

39 pounds over 5-6 months is a slow weight loss. Eating 1000 calories per day and lots of carbs while still trying to lose weight will most likely result in a final weight 20 pounds higher than your desired goal weight. It is becoming very clear from recent data that the VSG is excellent for the lower BMI group but the pouch must be made small enough. That size should be less than 2 ounces and between a 32 and 40 French bougie. A combination of large pouch and noncompliance makes it very difficult to achieve goal weight. The best pouch size would be one that would still limit you to less than 2 scrambled eggs over 15 minutes at 3 months post op. However, there is no standard way to evaluate pouch volume.