RickM

A few random thoughts, in no particular order - You will likely lose some muscle mass as you lose weight irrespective which procedure you get; the main emphasis in general for WLS is to minimize muscle loss as we lose. Some maintain that it is impossible to build muscle mass while in a caloric deficit (needed to lose that fat) and while I never like to say "never" on such things, I would say that it would be exceptionally rare for it to happen, Typically, we lose what we need to lose to a healthy weight and body composition, and then work on building additional muscle mass if we so desire. The bypass and VSG have very similar weight loss and regain characteristics - there isn't much to choose between them from that aspect. You may lose a bit quicker with the bypass owing to its malabsorption, but will ultimately end up in the same place. The caloric malabsorption of the bypass is a temporary thing - it dissipates after a year or two - so weight maintenance is similar for both; nutritional malabsorption is a long term affair, however. As long as one stays on top of supplements and lab tests, both are good for long term health. The bypass, however, is somewhat fussier in its supplement requirements - minerals are malabsorbed, so one usually needs to supplement iron and calcium more than with a sleeve (and that may not be enough, as the need for iron infusions is usually greater with the bypass than with the sleeve. Iron and calcium is somewhat fussy as they need to be spaced out during the day. it's mostly a matter of establishing the habit, but this will bother some more than others. The sleeve has a predisposition toward GERD or acid reflux, so if one already suffers from this, the bypass is often preferred unless there is a specific identifiable cause that can be corrected during surgery (such as a hiatal hernia.) In contrast, the bypass is predisposed to dumping, reactive hypoglycemia, and marginal ulcers (which precludes the use of NSAIDs such as ibuprofin or aspirin, which are better tolerated by the sleeve.) The sleeve is conceptually a more straightforward, or simpler, procedure. However, it still takes some time and practice for a surgeon to master, so it is well to ensure that a prospective surgeon has performed several hundred of them. In the US, that isn't a big problem these days as most have been doing them for several years, but in other countries where they have been slower to adopt it, this may be a consideration. Owing to their national health policies, Canada is running about five years behind the US on their learning curve, and other countries seem to be similar. There is a recent poster (from AU, IIRC) here who went through a quick revision from an initial sleeve to a bypass within the first week or two, that is likely an example of this. So, if your surgeon is recommending one over the other, it is well to pay attention to them - their recommendation may (or may not) the absolute best thing for you, but it is likely to be the best that they can do for you, or are most comfortable performing on you.

Not leaving the remnant stomach is an option (that is what is done when the surgery is for something like gastric cancer - you don't want it lying around in there, lol) but there are trade offs as usual. The main one that I can think of is that the stomach is no longer there producing acid to neutralize the bile being secreted just downstream of it, so there may be greater chances of bile reflux. AFAIK, there are ways to minimize that when the surgery is done, but these are things to discuss with the surgeon as to how best handle your individual problems. If I had revised my VSG ro an RNY a few years ago, that is how it would have been done - no remnant stomach.

Another alternative to cutting back to half dose (if that doesn't work) is to cut the dose or frequency, and substitute an H2 inhibitor such as Zantac (ranitidine) or Pepcid, which are a different class of drug without the same long term side effect concerns as the PPI's, but also somewhat less effective or enduring. But they work well in cutting back the PPI therapy. If one is taking omeprazole twice a day, substitute one of those doses with Zantac, or take a half dose of omeprazole in the morning and a dose of Zantac in the evening. Then try going to all zantac after a couple of weeks, etc.

The omeprozole should continue to work, as it is controlling the acid release, which will be concentrated in that remnant stomach, but that also means (AFAIK - not an MD here) that it will still be subject to irritation from it. This is something that I would talk seriously about with the surgeon, as once the RNY is done, you can no longer just pop in there with an endoscope to look around to see how things are doing (that blind stomach is one of the drawbacks to the RNY, and something to consider when weighing the plusses and minuses of the different procedures.)

Revising the RNY to anything is difficult, which is why we don't see many revisions done; typically the most that is done is applying a band over bypass, or tightening the stoma to try to restore some restriction, but neither has a particularly good track record. I have seen a few revisions to the "traditional" BPD/DS performed which is very complex, and there are only a half dozen or so surgeons around capable doing that one. As the SIPS/SADI/SA-DS is being promoted as a simpler, more "accessible" procedure on a par with the RNY on a complexity basis, I wouldn't expect to see many surgeons with the skills yet to do a revision between the two. One doc to check into, who is in your neck of the woods, is Dr. Mitchell Roslin in NYC, who has done some of the RNY to DS revisons, and is a big promoter of the SIPS/SADI - if anyone could do it, he would be it, or he could tell you why it isn't such a good idea, if that is the case. Another possible in your neighborhood (just over the border in NJ is Dr. David Greenbaum who also does a lot of these complex revisions.

I haven't found anything that I can't tolerate (which is good and bad....) There are some things that I don't care much for anymore (got out of the habit, tastes change, etc.) Pot roast doesn't settle or satisfy as well as good steak, but it still works (have one cooking now...) Bread is fine - make a couple small sandwiches for road trip days, but otherwise don't have much. Fruits and veg are all fine (except for the ones that I never liked); lettuce works fine for salads (some have problems with that for some reason) though I usually use spinach owing to its somewhat better nutritional values. It is not uncommon to acquire lactose intolerance, though I haven't.

Does the whey isolate make you feel bad? I am thinking that maybe it is lactose intolerance, which is not unusual post op, and the whey isolate is virtually free of latose, while other cheaper whey proteins (blends, concentrates, etc.) that are probably what's in the slim fast, do still have lactose in them. Also compare to your powdered skim milk - that would also be a test of lactose intolerance. Just a thought....

Too strict is more of a philosophical thing - both yours and your surgeon's - and also a matter of need. I was a "moderate lightweight" of low 40s BMI at surgery time, so really didn't need to get much of a jumpstart on things as the surgery had plenty of power to drive my weightloss toward normal; someone starting in the 60's BMI range needs all the help they can get as the surgery can only do so much. Some surgical programs are pretty high on driving intense diets pre-op (up to six months of liquids only - yikes!) while others really don't want their patients doing any intense fasting as they want them as strong as possible going into surgery. My philosophy, given my moderate needs, was/is to work on developing or reinforcing the good habits that will help control weight in the long term, well after the weightloss has stopped - look five years ahead rather than five weeks or months. I never worried about low carb counts (or fat, or anything else like that) but rather getting the most bang for my caloric buck in real, whole foods. Added sugars and most simple carbohydrates were out, but not the fruits, veg and even some whole grains. On protein, 100g is not unreasonable for a guy - most plans specify something like 60-80 g for women and 80-100 g for men. Protein need most closely associates with our lean body (or muscle) mass, so guys naturally need more than women. My target, based upon my 150+ lb lean mass is about 105g; a typical 5'2" woman would need about half that. If one is seriously working to increase muscle mass (which you are not - now) that number can easily increase by 40-50g and not be excessive - assuming that one does the actual work to accomplish that. Simply increasing protein intake under the belief that that alone will increase or preserve muscle mass (without the work) or will just be more satisfying can lead to excessive consumption (relative to body need) and potential kidney problems.

Yes, it is likely ketosis, which fundamentally means that you aren't eating your fruits and veggies (not unusual early on.) Some intentionally drive themselves into it (to the extent of adding excess fat into their diets) under the belief that it helps them lose weight, but that's just fad diet marketing. As your diet improves, it should go away; in the long term, you shouldn't be skipping your fruits and veg anyway, so by this time you should be trying to add some back into your diet, within your caloric limits.

I think that your RD is being pragmatic, and is satisfied that you are heading in the right direction. Also, if she is saying 5% per meal, that doesn't mean that all the components of the meal meet that number, but the meal as a whole (a bit of butter is 100% fat, but a small quantity will only be a part of the 5% overall for the meal. The avo in there is also high in fat, but the english muffin and salsa are low. All of these numbers should be taken as guidelines or targets rather than absolutes - there is nothing magical about them. Some may be able to fit a Snickers bar into their daily allotment of calories, fat, carbs, etc., but that's the wrong idea - working on nutritious whole, real foods that are close to the stated numbers but represent the kind of habits that we should be developing is a better direction. On the protein front that Fluffy brings up, I think that this is a matter of context - if this meal is typical throughout the day, then yes, it is low in protein; but if is just a lower protein meal that goes along with higher protein meals during the day, then it is fine. When I was following these things more closely (because my calorie allotment was a lot lower then) I would check my progress during the day in planning dinner and beyond - am I high or low on protein trend? If I was high, then dinner could be a lower protein, more veg intensive meal, or if I was running low, then it would be a steak or something high in protein. Each meal doesn't have to be the same, or have the same macro numbers for things to make sense. Even today, I invariably have some protein in each meal or snack, but if they were all high protein, I would be way overloaded on protein and short on a lot of other nutrients.

I would expect that they would not leave any remnant stomach behind for that very reason. That is how they would have done mine had I chosen to go the RNY route (it's actually a partial gastrectomy, which is one of the standard surgical treatments in these types of cases - where they don't need to go as far as a total gastrectomy. ThreeOhThree - something to discuss with the surgeon is the prospect of bile reflux, which seems to be a not uncommon problem with gastrectomy patients with this type of configuration; the surgeon I worked with on this told me that he doesn't see any problem with that if he keeps the limb length above the anastomosis greater than X (IIRC it was 60 or 80 cm). There are a number of Facebook groups dedicated to gastrectomy patients, and that seemed to be a common issue - presumably, some surgeons in an effort to minimize the amount of weight lost kept that limb shorter to minimize the malabsorption; that shouldn't be a problem with you as you are here for weight loss, but something to look into and discuss with him.

I am another 1 in a 1000 case - found a cancerous polyp in the stomach 3+ years ago with a routine EGD. Fortunately it was confined to the polyp so no spread to underlying tissues or lymphatic system (T1a tumor) so all has been handled endoscopically and no funny drugs or radiation needed. RNY conversion was suggested, as well as a total gastrectomy as the overkill option, but no real consensus when consulting other onco surgeons or oncologists. Wait and see with monitoring seemed the best approach at this time for my circumstances. (That's one of the problems with being a rare case like this - US medicine doesn't really know what to do with you; in Japan or Korea where they screen for it, they are more experienced with early stage treatment.) If we had gone the RNY route, they would have not left any remnant stomach behind, as that can't be monitored endoscopically - and that should be done to ensure nothing else develops later. Is that the approach they are taking with you (I assume so)? Lots of worries then as tests were being done and things being defined, much less now that there has been a few years of history and tracking behind it. Hopefully you get through these first few months of them fiddling around with your insides and things settle down to a sane routine and you can forget about it after a couple years. Good luck with it all!

mThis was just discussed this morning: From what I have seen, they work for some and not for others. In general, they don't seem to work well for the DS folks, and this should make one cautious about their use with other malabsorbing procedures like the RNY. Early on, it is hard to tell how well supplements are working as there can still be residual vitamins in your system that show on the labs - the only way to tell for sure is to follow the labs over the months and years. The problem with many of the all in one products that cover multiple supplements is that over time we tend to need more of some vitamins and less of others, relative to the initial recommendations. The place where they would be most useful, assuming that they work for you, is with the items like calcium that often need several doses spread out during the day - the patches may cut down on some of the extra pills (if they work). The other problem of using them early on is that it adds another variable to your early regimen - if you start showing low numbers in some areas, is it due to the dosage, or the patch not working as well as pills?

With a sleeve, you generally don't need to worry much about B12 - some may be inherently low on their own pre-op, so they need to continue doing whatever it is they do (or start doing something to make up for always being low...) Pills usually work fine with the sleeve; the bypass is a different animal and usually needs B12 either as an injection or a sublingual tablet, as their stomach doesn't process it well. The real test is what your labs say over the years as that will guide you as to what you need. I had already been taking a B complex pill before surgery and continued it after and that always pegged my B12 well above the normal range; I don't take it anymore and my B12 remains in the high end of the normal range just from diet. YMMV (your mileage may vary)

It is likely a result of hormonal dumping, where the estrogens (yes, we guys have some of that in there, too, just as the ladies have some testosterone in their systems,) and other hormones that have been stored in the fat gets dumped into our system as the fat burns off. So, just as the ladies are subject to such variations during their time of the month, we all can be subject to it randomly, at any time. One of the guys in our support group told of being in the supermarket checkout and let loose on the person in front for some delay (the usual - waiting for everything to be scanned in and then pulling out the checkbook and pile of coupons, or some other minor indiscretion) then told himself, "wait a minute, I've never been bitchy before....

It is a tough situation, but I would be inclined to contact the bariatric clinic, as they presumably are linked in (one way or another) with the psychs who do the pre-op evaluations, and they probably know better the protocols in making an intervention, contacting the family and "just checking up" (we haven't seen him for a follow up for a while need to keep current for our data....), etc. Ultimately, it is up to him, and/or family, but a nudge from someone within their medical circle may help. Perhaps asking your bariatric clinic in general terms (do they have a support group where general questions can be asked?) that you have heard of this situation, and what can be done to help if this is true? (that way you are not "tattling" but they may ask, "is this one of our patients?"....)

The patches seem to work OK for some, and not at all for others. Most of the DS people that I know who have tried them find them not to work for them. They certainly are attractive for getting rid of some of the hassle in the vitamin regimen, but at this point, as early out as you are, things are very dynamic as your diet is different than it will be a year from now, and you (and your docs) are still figuring out what you need to keep things stable, so the question of whether or not the patch is working is an extra variable to work into the equation. IOW, if, say, your iron or vit D is running low, is it because your dosage needs to be adjusted, or because the patch isn't working? As much as you would like to get away from a lot of the pills, it is probably better to experiment with it in a year or two when things are more stable.

Take a close look at the policy bulletin regarding WLS on the insurance company's website and see what it says - it should spell out exactly what their requirement is. If need be, enlist the help or your surgeon's insurance coordinator as they speak that language. That is their legal document and is what they can be held to - not what someone else's insurance company does. If they want you to have been over a certain BMI number for five years, then they have to spell that out in that document. Such requirements can be waived if you (or more specifically, your doctors) can make the case with them that your health history makes the surgery a medical necessity, irrespective your weight history. This would usually happen after they deny you and you file an appeal. Your state insurance regulator can also order them to provide coverage if they find the requirement to be unreasonable in general or in your specific case. Don't get too far ahead of yourself here, and take it one step at a time. Good luck.

Short answer, for an occasional drink after you have lost all the weight that you want to lose, yes. The qualification here is that it can be a slippery slope to overdoing it, though compared to an occasional slice of cheesecake, alcoholism is a lot tougher to recover from than carb overload. that's the biggest long term concern is addiction transfer, where what was an occasional indulgence turns to full blown addiction, so care is needed to maintain limits. As with other kinds of "treats" the solution for some is total abstinence as they don't have much control, while others can control an occasional indulgence. You know yourself best.

A couple of thoughts here - most find that their sex life improves after surgery..... maybe a slippery slope to be enjoying food that much? On a serious note, do follow the doc's guidelines, as early on our "full" sensations may not be what they used to be, what with everything (including the nerves) being disrupted down there. For some, the first "full" signals are when things come back up - not a good way to find "satisfaction". Eating slow with breaks in between bites as you did is a good practice until you figure out what capacity you have for what kinds of foods (they differ, and will change over time, so it's a long experiment.)

Are they a chewable or gummy type of vitamin? If so, perhaps it is the sweetener that is used in them, typically a sugar alcohol or sucralose, that are known to sometimes have that effect.

The first week or two it seems like we were doing nothing but sitting there with a shot glass (about an ounce) of water sip, sip, sipping it all day, trying to get one in every five minutes (if things went down that smoothly, at least), or every ten minutes if five didn't work. One every five minutes is twelve ounces per hour, or about five hours per day at that. Work that in between your meals and walkies, and your day is full. Good luck!

Likewise, I can't offer specifics for your condition, but this should be worked out between the surgeon and your cardioligist. Most of the surgeons who get into the DS these days are top notch, as it is a more complex procedure than most of the other WLS and it takes time and resources to develop, and maintain, those skills. An option that may be suggested if your condition warrants it is to do the DS as a two step procedure, doing the VSG part of it first and then the intestinal switch part later after you have lost some of your weight and are stronger. This is sometimes done in cases where they don't want to put the patient through a lengthy anesthesia. The VSG can usually be done in about an hour or less, while the whole DS may typically take three hours or so, but occasionally 6-7 in complex cases, It doesn't seem to be done much as it was 10-15 years ago as the state of the art has improved over the years with reduced surgical times and better anesthesia care, but is still used in some cases.

Here in the States, the proximal is the default, and there are specific standards of care that are defined within the insurance billing codes; the distal is outside of that standard and is not usually approved as an initial surgery, but can be justified as a revision if deemed appropriate. Here, for the higher BMI cases that need something stronger than a VSG or proximal RNY, the duodenal switch is the normally approved procedure. My wife's surgeon noted at one time that on the occasions that he still did a bypass (their preferred is the duodenal switch) that he liked to make them as malabsorptive as the codes permitted, which is still far short of what a distal would provide.

The before is not such a big deal, as the fluid empties out quickly; indeed, I there are some bypass specific surgeons who recommend a pre-drink around 15 minutes before. The main exception to this where a half hour-ish wait may be needed is in those patients who experience substantial inflammation in the stomach early on, and the water may not empty all that quickly. Otherwise, physiologically, it doesn't make much sense.