RickM

I had my sleeve done by Dr. John Rabkin at St. Mary's (he also works out of California Pacific.) I was in LA at the time, but the Rabkins had more experience with the sleeve than anyone down there (they had been doing them as part of the DS for around twenty years then.) Other names to look into are Dr. Gregg Jossart and Dr. Paul Cirangle. Jossart did his DS residency with the Rabkins and Cirangle seems to have specialized with the sleeve. I like that all three are DS qualified, even if one is not particularly interested in that procedure, since owing to its technical challenges, only the better qualified surgeons perform it routinely. And, as it is based upon the sleeve, it means that the DS guys tend to have more sleeve experience than others. Also, while they are all fully capable of doing bypasses, they generally don't do them as a default, reserving them only for those patients have a particular need for it. If one has any liver related comorbidities (not uncommon in the obese population,) Rabkin would be the choice as he is also a liver guy, doing biliopancreatic transplants in his "spare" time. The other thing that I liked with the Rabkins is that their whole process is pretty straightforward - no extensive pre-op diets (other than the usual day before thing,) and a fairly rapid post op progression, as tolerated. Good luck in getting through all of this!

Our program was for 18 months of follow up as part of the surgical fee, and then annually thereafter on our (or insurance's) ticket. In normal situations, follow up with the PCP is fine as they can order labs, etc. However, we find it useful to keep in touch with the surgeon for his annual follow up as a means of keeping him "on retainer" in the event something odd happens. We all have things happen as we get older, and one of the common questions that would come up in our support group (mostly veterans of 10-20 years) is that they are having some health issue, and is that related to their WLS? Usually it is not and just part of the aging process, but if there is something questionable, our PCP can call up the surgeon and ask about it, MD to MD. It is less common for something odd in our health balance to happen with a sleeve as it would be with one of the malabsorbing procedures like the DS or RNY, but that's where some odd long term nutritional balance issue is most likely, and that's where the surgeon's experience can help out.

Our surgeon does a lot of work with traveling patients, and his normal protocol for them is to stay in town for ten days until their first follow up appointment. But, he isn't in the business of doing things on the cheap, but doing procedures that others don't offer.

I can't help from any specific experience, but on the East coast, I would suggest talking to Dr. Mitchell Roslin in NYC. He is one of the big promoter/developers of the SADI (modified DS) but is also long experienced with the traditional Hess DS along with the RNY and VSG. Having all of the major procedures in his toolbox, he can give you better advice as to which procedure best fits your specific needs; certainly better than your corner "WLS R Us" practice that just does the RNY and VSG. While he may not be a big fan of the RNY (common amongst DS capable surgeons who find that procedure better in most circumstances,) I have seen him actively refusing to do a DS to a lapband revision patient because the RNY was the more appropriate procedure in his case. Unfortunately, many surgeons will recommend whatever procedure they do as the best one, as it is the best for them even if it may not be the best for the patient. Finding someone skilled with all of the major procedures if very helpful when one has special needs.

The thing to watch out for when doing a minimally malabsorptive RNY is the prospect of bile reflux instead of the acid reflux that you had with the sleeve. When I was looking into this for a non WLS reason (it's has long been used for maladies such as gastroparesis and gastric cancer,) was that one of the most common problems reported on the patient sites such as Facebook was bile reflux. Talking to the surgeon about it, he said that as long as he keeps that roux limb at (IIRC) 80cm or more, it's not a problem; it seems that many surgeons going for minimal weight loss for such patients go overboard on shortening things. The extreme of this would be the "mini bypass" that attaches the pouch directly into the intestine without the roux limb, and that is well known for bile reflux (and why it was never adopted here in the US as a mainstream approved WLS. However, there are also definitions and standards of care wrapped into the CPT codes that the docs use for billing, that define these things depending upon usage. I know this came up in one of the support groups with my wife's surgeon, and he noted that when he did the RNY, which he rarely did preferring the DS, he liked to make it as malabsorptive as the codes permitted. So there are standards that the surgeons are obliged to follow if it is to be a WLS procedure, and it doesn't seem to be a problem with most RNYs that we see as WLS, but could have been for what I was contemplating (but never proceeded with.) There's always an up side as well as a down side with anything we do.

Yes, the cause is often, if not usually, a mystery. I ran into an Afib problem a couple of years ago about this time of year, though it didn't get picked up until a month or so later when I went in for a pre-op exam for cataract surgery, and we were discussing the moderate shortness of breath I was experiencing while swimming, considered different things it could be until she took a listen and "Oh, that's it... you're not doing surgery tomorrow. Let's do an EKG as see what's going on." She had me in to the cardiologist that afternoon (it usually takes weeks or months to get an appointment). He had me go to the ER that evening to get the medication dosing down right (we can do this the fast way in the ER or the slow way back and forth to my office over the next several weeks to get this down...) Once the basic heart rate was under control, it was a visit with the cardiac electrician (electrophysiologist) to look at resetting things more permanently. The good news is that while he was in there burning out the short circuits he noted that my arteries are nice and clear, and while things are not back to a normal sinus rhythm, it's not Afibbing consistently so I don't need to be on the expensive anticoagulants. Here's to them getting a better understanding of what's going on inside you so that you can get back to your planned life!

You probably don't need to be taking all of that yet, unless your labs indicate a deficiency, but they want to make sure that you have everything ready for post op. However, some programs may want you to start taking all of that ahead of time to get in the habit. Either way, have them with you for your next appointment and if they had wanted you to be already taking them, then you can start then.

Possibly a hiatal hernia has developed, as GERD is a common symptom of that irrespective prior WLS history. An EGD (endoscopy) would establish that as well as anything else that is going on in there; possibly an imaging procedure like a barium swallow to look at shaping of the sleeve and associated connections can help to establish how things are flowing and why backups are happening. Your primary may order those things or refer you to a gastroenterologist to track down that problem, then they can start considering solutions - fix the hernia, resleeve to correct shaping problems or revise to an RNY.

First, a bit of confusion - have you hit your goal weight from surgery, as in 190 or so, or just some pre-op weight target and surgery is still in front of you? If you're still pre-op, then that is a fairly typical starting regimen, and yes, you should take extra calcium and iron above whatever the multi has in it - you won't be getting much nutrition from food for a while so you need the extra. If you are months post op and at your ultimate goal weight, then by now your labs will be guiding you and your doc as to what is needed - with a sleeve, a lot on that list will probably not be needed long term and will go away.

Check with your surgeon but typically/frequently the follow up appointments for the first year or so are included as part of the surgical fee. If so, they you are covered for the first year or two.

They will in time, but these drugs are only now becoming approved for weight loss use; they formerly were strictly diabetic drugs used off label for weight loss, and a darling of the Hollywood set, and followers of them, so that didn't give them a great image on an official basis. They are basically a lifetime use drug, so the cost is a big issue with those covering them, but that will decline as more competition comes on the market and they go off patent, and as they gain respectability in the "legitimate" medical world and not just the fly by night weight loss "spas".

Here is another take on this that just came through my email, aimed more at MDs but still very much at our level https://www.medscape.com/viewarticle/996189?ecd=mkm_ret_231030_mscpmrk_endo_top_content_etid5999473&uac=37787FY&impID=5999473#vp_1

Amongst all the paperwork that you sign with the surgeon is probably a form where you approve him to make a decision on the fly as to which procedure is best once he gets inside you - sometimes they find some obstacle to doing a bypass and will do a sleeve instead (or vice versa, though that is more rare.) Of course, one can not sign that authorization if one really wants a bypass and absolutely not a sleeve (or vice versa,) but then you wind up being sedated and going into surgery and having nothing done. So, a change in procedure once bariatrics are approved is not a big deal.

You likely will be OK, however, plastics have a higher chance of mild to moderate complications (incisions that don't fully heal promptly or reopen, saromas (fluid pockets) can form that need sometimes serial draining, etc. Best would be to talk to the surgeon about your concerns and get his take on the chances of any problems you might experience.

I have not (being over here on the "left coast" but he would be high on my list of docs to talk to if I were on the East Coast - his reputation extends this far. His name comes up positively on occasion in our support group of largely DS folks, as he has frequently given talks at the ASMBS conferences on related topics, and I've seen other positive responses online over the years. I like the way he thinks, from what I have seen that he has written. He is also one of the few capable of tackling the complex RNY to DS revision when that is necessary, so he knows his way around a sleeve.

Basically, no. We do hear this from time to time but I have no idea where it came from (as far as legitimate scientific sources.} I can buy into the idea that protein absorption would decrease some with increasing amounts in a meal, that wouldn't be unusual biologically (as in the first 30g is fully absorbed, the next 30 only 90%, etc.) But looking at it from an evolutionary perspective, our ancestors would gorge themselves on an antelope when they killed one, and then have relatively little protein for several days until they had another successful hunt. They got along just fine. That said, I generally do break it up during the day, but that's more of a balance thing, in order to also get in the appropriate amount of fruits, veg, grains, legumes, etc., though it can take a while before one gets to the point of doing that other than in token amounts (though good for helping to establish good long term habits!)

That's great! But there are surgeons out there whose main solution to any problem is to do an RNY; this is why we need to be careful and get second opinions, particularly on revisions where there are often multiple solutions to consider. Sometimes there isn't much of a choice and the path is clear, other times things aren't so clear and there may not be one "right" call, or only a choice of lesser evils. Surgeons often have a preference based on their experiences, so you can get different choices for the same problem, or they may agree despite preferences. That's why we seek out second opinions as we aren't qualified to make the call, or to fully evaluate a surgeon's proposed solution.

There is a good reason to avoid the RNY revision if you can - the reactive hypoglycemia and marginal ulcer (and all of the medical care limitations that stem from it) issues, but it's not the end of the world, either if that's what you need. It's a common procedure that's been done in one form or another for 140 years, so its quirks and features are well known (but I would rather avoid its quirks if I can). I would certainly get a second, and even third, opinion on it, as while the sleeve is a fairly straightforward procedure most to do these days, repairing one that isn't working correctly is not necessarily so. Most bariatric surgeons started out with the bypass, so that is their comfort zone and they often prefer to go back to the familiar when things get a bit complicated, while there are some who have gone deeper into the sleeve and specialized in it and related procedures, such as the DS, and they are more comfortable doing things that others wouldn't do. We sometimes hear on these forums that "you can't do a Nissen (fundoplication) on a sleeve as there isn't any fundus left (well, not much) yet there are some who routinely perform them. Between that and meshing, there are options, and an RNY doesn't necessarily fix the potential recurring problem, as it, too, yield a small stomach pouch that is subject to herniating. If possible, for a second opinion, I would seek out a surgeon who does the DS (duodenal switch) as that is a good proxy for one who is well experienced with dealing with sleeves, and is more comfortable with more complex procedures as well. If they recommend an RNY revision, too, then that's a pretty solid confirmation of what's appropriate for your specific case.

The main idea for all of these tests and clearances is so that there are no surprises on the operating table. Yes, some things that they may find might lead to a delay while they treat that problem and get it under control - isn't it better that you (and they) know about such problems and get it treated? Most things won't delay surgery, but it does give them advanced notice of any problems so that they can adjust to it for the surgery.

You certainly need to get a second, and probably third, opinion to find out what's going on; they should be able to explain to you, in layman's terms, what your situation is and what the options are for treating it. That is usually a straightforward and insurable step here in the States, but I don't know what hoops you may have to jump through in the UK. It does sound like something's not right in what they did (which is why you want a second, impartial and uninvolved opinion,) as strictures are not common with sleeves that are done correctly; they are common and easily treated with an endoscopic dilation in and RNY, and that may work with a sleeve stricture, or may not depending on what caused it (usually a misshaping of the sleeve.) I did quite a bit of research on these topics a few years ago when they found a cancerous polyp in my stomach; fortunately it was very early and all treatable endoscopically, but all of these various options were discussed and researched. There are some Facebook groups specifically for patients with partial or total gastrectomies, which is what they are proposing for you. The most common approach here, and what it sounds like they are proposing for you, is a Billroth 2 gastrectomy, which has been around for about 140 years, and is the basis of the RNY gastric bypass, The main difference between a partial or total gastrectomy is whether they can use some of the remaining stomach to form an RNY like pouch (partial) or remove all of the stomach and attach the esophagus directly to a loop of intestine, or an additional roux limb as in the RNY, and form "stomach" pouch in the intestine where the esophagus is attached. So, going without the stomach is possible and entirely livable (there are several books on Amazon about "eating without a stomach" which go over what is basically a normal bariatric diet progression.) To the surgeons I was dealing with (at a major regional cancer center,) the total gastrectomy was a much bigger deal surgically and recovery wise than the partial, as attaching the esophagus directly into the intestine was a much touchier procedure with a more extended recovery and healing time (on a feeding tube for several months,) than going through even a small pouch of stomach tissue - something else to consider with whatever choice you have in surgeons (try to find one who has done a lot of these.) One of the things that stood out as fairly common amongst the Facebook group was problems with bile reflux, and you can see how that could easily happen by looking at the altered anatomy. The surgeon I was dealing with said that he did not experience those problems if he kept the various limbs within certain minimum lengths (which presumably some other surgeons didn't do in order to minimize malabsorption and weight loss,) so another point to consider in finding a surgeon who has some direct experience with these problems.

The issue at hand here is that NSAIDs are a big NO-NO for bypass patients, owing to quirks of the bypass anatomy, specifically that the anastomosis where the stomach pouch is tied to the intestines (the stoma) is at a downstream part of the intestine that is not acid tolerant, as the duodenum is (the part of the intestine immediately downstream of the normal stomach.) Consequently, that stoma is easily irritated by the acid from the pouch, and doesn't need any additional stress from stomach irritating medications such as NSAIDs. The most common place for ulcers in a bypass patient is at the stoma. The sleeve based procedures like the VSG or DS don't have that problem as the normal anatomy is preserved in that respect. It still pays to be cautious as the stomach has been cut and reduced, but all the suture lines are amongst normal acid resistant stomach tissues, so there isn't nearly the sensitivity that there is in the bypass. Many practices simply carry over their bypass experience and advice to their sleeve patients owing to an (over)abundance of caution, simplicity, and their lack of direct experience with the sleeve and NSAIDs. When I had my sleeve around twelve years ago, our surgeon's advice was to use them as needed post op as soon as the narcotic pain relievers were no longer appropriate (so, within a week or two,) though when I talked to him more recently he was more of a mind of within a few months post op.

I would want to look closely at this, verifying the bile reflux and determining if there is any acid reflux component to this before getting into long term treatment options as the treatment can differ widely depending upon that diagnosis. If it is bile, then I wouldn't expect Pepcid or other anti acid meds to do much as the are treating acid and not bile, a base. I'm not sure what meds they do use but likely different ones. Bile is used to neutralize the acid coming out of the stomach along with the digested food into the intestines. Is your surgeon in the loop on these findings (I assume so, but check if you haven't heard from them yet,) as that may change his prescriptions. If it is strictly a bile problem, then a bypass will probably correct it, but not guaranteed as it moves the stomach/pouch outlet downstream into the natural path of bile secretions; the key, according to one surgeon I discussed this with, is the length of the roux limb, as that is the one that connects the pouch with the mainstream intestine and how far any bile would have to travel to reflux into the stomach. This doc noted that at 80cm or greater (IIRC) he didn't run into any bile reflux problems. The basic RNY procedure has been around for some 140 years for gastric cancer and gastroparesis (it is usually termed just a partial gastrectomy, or likely some other fancy latin names as well,) and it that use, bile reflux is a not uncommon complication. My non-MD take on it is that in those cases, they tend to keep the limbs short to minimize malabsorption and weight loss (last thing a cancer patient usually needs is more weight loss!) So, the longer limb makes sense here. Discuss this and make sure that your surgeon is up on this aspect of it. The other option if it is basically a bile problem is the DS, duodenal switch, which is pretty much a guaranteed cure for any bile problems owing to the very long path between the bile ducts and the stomach, but relatively few bariatric surgeons offer it owing to its greater complexity. Note this only applies to the "traditional" or Hess DS and not the newer SIPS/SADI/"loop" or simplified DS, which like its mini-bypass cousin has bile reflux as one of its common complications. The DS will not help any acid reflux problem as it uses the existing sleeve (though may resleeve it if it was malformed causing GERD rather than just overproduction of acid,) while adding the intestinal rerouting for malabsorption. The DS is a better choice over the RNY revision if slow or inadequate weightloss is an issue, too, as it is a stronger metabolic tool. Good luck on this - bile is surely a much less common problem with the sleeve than acid reflux, so the industry isn't quite as settled on solutions for it.

Yes, very common, and here is one of the factors - In the middle of the video he goes over the typical progression of meal volume that we can expect, and it is consistent with my experience. I you simply let things happen and eat the same way we did the first year, but more, then there will certainly be the tendency to gain. While I'm not a big fan of everything this guy preaches (or any online guru, for that matter,) one of the things that I do like is his "eat your vegetables first" concept, which he applies after the first few months of protein first. My general evolution was to increase the veg content of my meals over time, rather than the protein, as the protein that we are advised to consume early on is usually our basic requirement, as we can't get that from pills like we can most micronutrients. So, I still have about 3 oz of meat in a meal today like I did the first year, but a lot more veg in there. And, it's still something of a struggle because the junk still wants to creep back in there stimulating old habits (we usually spent a lot more time getting fat, and getting used to it, than we have trying to be healthy now!) With a sleeve, or a bypass, at this point it is basic dieting/healthy balanced eating that we are all familiar with; it is somewhat easier than before as our volume rarely returns to where is was pre-op, but our old bad habits sure can come back.

insurance can vary widely from state to state, even from the same company or the same policy name. Are you working with employer provided insurance or from the open market/Obamacare (it sounds like it)? Finding an insurance broker can help sort through who pays what benefits for what cost - they get their commission paid by the insurance company, so it doesn't cost you any more than just choosing one off the web.

This doc presents a typical volume progression which fits my general experience (though my wife continues to be somewhat more restricted than I am even after 18 years.) Some will progress faster or slower than others, but you do seem to be on the slow side. You might have a minor stricture at the stoma which is overly restricting things - not an uncommon thing with the bypass. Have you talked with your doc about this - it is usually easily treated with an endoscopic dilation if that is the problem. But yes, over time you should be able to have a healthy diet full of fruits and veg - the doc in the video above is a big fan of this - but it may take you a little more time than others. Throughout my loss phase I always maintained at least an homage to a healthy balanced diet with some whole grains, veg and fruits in there, even if it was at times a minimal amount. BTW. what group did you have your surgery through? I have a nephew who works for Atrium, so am always curious how people got along with them. Good luck in your venture...