RickM

I suspect that they may be wanting you to go over to a drink that is 100% whey isolate, as that is better absorbed (and more expensive) than ones made from whey blends or concentrates (such as Premier). So, yes, ideally there are others that are better, but the best one is the one that you will drink (such as Premier, if that is your choice) than an "ideal" one that sits on your shelf unused because you can't tolerate it. By all means, try the ones that they recommend (your tastes may change after surgery anyway,) and there may be one that is "better" that you like. If not, as you can see from others, Premier is a popular choice and no one is suffering unduly by using it. As a side note, I've never tried it, as when my wife went through this years before me, we couldn't find any of the RTD products that we liked, but there is a wider selection of powders available, and we can manipulate their taste by way of what we mix it in, and what we may add to it, so when I had my WLS, I never bothered with any of the RTD products.

Pre-op diet programs vary all over the map from many months (!) of liquids to nothing special at all; some will vary depending upon procedure or patient's BMI. Your doc only requiring for the VSG may indicate that he is quite comfortable doing the RNY, but less so doing the VSG. More typical is something on the order of what Chiptress is doing - a low calorie meal or two (lean meat and veg, or low cal frozen dinner) and a protein shake or two; the all liquid seems to be less common, but we hear a lot more about them because they are so objectionable.

If you are talking about an occasional lapse, then it's not a big deal; if you are talking about establishing habits in these directions, then it is a big deal, as good habits are the key to long term success in this game. Vitamins and protein are a game of averages - one missed or low day doesn't make a real impact as the loss is made up before and after. Missed doses of some pharmaceuticals can be a much bigger deal. But, life happens - sometimes I don't notice that I didn't take my evening pills until the next day when I look in the box and see that I missed it (usually because we went out to eat that night and habits got disrupted.) Get back on the horse and forget the minor slip up. NSAIDs are more of an RNY thing than a VSG thing (indeed, one of the selling points of the duodenal switch - a sleeve plus malabsorption - is that it is NSAID tolerant.) Again, habitual or consistent use might be a problem and you should consult your surgeon on that. Eating out regularly is difficult on anyone trying to control their weight, WLS or not, as cost and taste are the priorities over calories and metabolic impact. Restaurant fare is often double the calories of comparable home prepared meals. As with vitamins and protein, it is a game of averages, so an occasional meal out gets lost in the noise of everyday life, but it is the average, it is a bigger problem. One has to be much more diligent in what one orders if is an everyday thing.

First, there is a specific Mexico/Self Pay forum here that might get more or better answers. I can't speak specifically for any of the MX practices, though my wife was self pay here in the states, Most follow up care is done by your PCP including routine labs, and those are generally covered by insurance. From what I have seen, most US bariatric practices aren't keen on doing follow up for other doctors (partly not wanting to support the competition, partly not wanting to get involved in someone else's surgery and potential problems) though longer term if revisions are needed, they are more than willing..... I would expect that the better practices would offer some kind of remote follow up (phone/fax/email/skype, etc.) for some time, but don't know for sure on that. The practice that we used here in the states was set up for travelling patients, so that is routine for them to do the periodic post-op follow ups as well as the annuals. One can also often join the support group for local surgeons to get that kind of support - many welcome patients from other practices - and that may also be a way in to see them if there are any problems that need attention (ask questions at the group meeting - I'm having this or that problem - and that may interest them enough to invite you to make an appointment, whereas they may refuse if you just call the office cold.

Yes - the sooner, the better. The industry standard is for approval with a BMI of 40 or above (35 with comorbidities such as hypertension, sleep apnea, diabetes, etc.), so you have lots of margin to play with before worrying about that. My suggestion is to look far ahead in driving your diet - how should you be eating in 5-10 years to maintain your weight and health, rather than worrying too much about an extra pound or two this month; you will likely lose a fair bit of weight just by making these long term changes, as most of the "diet" plans for weight loss yield short term loss that comes back when you stop. You want to learn how to eat to keep it off in the long term. If possible, work with an RD (dietician, nutritionist) to help you transition - a good RD will work within your tastes and preferences to improve your diet, and help drive your tastes in a healthier direction. The WLS clinic will probably have RDs on staff, or you can find one at your local hospital, Clinics may have very structured pre-op programs, or flexible ones; do what you can to think long term. Good luck...

By an "upper GI" do you mean a procedure where you swallow some contrast and they look at how things flow through you with an x-ray machine, or an endoscopy where they sedate you and run a camera down your throat and take a look around inside? If it was an endoscopy, then they should see any ulcers (at least those within the new digestive tract, which is where they most commonly would be with a bypass, but not in the bypassed remnant stomach) but with the contrast imaging, they may or may not be able to diagnose an ulcer.

I'm not so sure about that - we didn't have any pre-op diet, and didn't really miss "getting used to" post op liquids - you don't really feel like anything else for a while. Now, I can understand that with some programs that impose post op liquids for an extended time - many weeks for some - that one may have to get used to their "new normal", but for us is was mostly just a transitory thing that we used as we needed as we progressed into soft and mushy things.

As I recall, I used them in the hospital, in those little juice boxes. As you can see, this is one of those things that some docs make a big deal about and others don't have any problem. It seems to be another case where if it bothers you (like sucking in too much air - don't try to get that last drop!), don't do it, and if it doesn't, then it isn't hurting anything.

There seem to be several variants of gastrojejuvenectomy, with yours functionally being a total gastrictomy. This was on option that we were considering as a cancer treatment but ultimately rejected (or put off indefinitely.) There are a number of Facebook groups dedicated to gastrectomy patients, both total and partial, and that would probably get you better answers than here, as that is a rare evolution for the RNY. Bile reflux was one of my concerns as well, after seeing that sited frequently within the gastrectomy population. The surgeon that I was working with said that as long as he keeps that limb length to the anastomosis at (IIRC) 60 cm (though it may have been 80cm) that he doesn't see any bile reflux problems with his patients (of course, he is the doctor and not the patient....) so that would be one avenue of inquiry on that issue. Good luck in getting all of this figured out and finding your answers

...and then my doc was having me add veg to my diet after ten days, as my protein intake was more than adequate. Different strokes for different, uh, programs.

This is why ASBS - the American Society of Bariatric Surgeons changed their name some years ago to ASMBS - the American Society of Metabolic and Bariatric Surgeons, to reflect this reality. As a side note, the classic or traditional Duodenal Switch started out in Europe as a procedure specifically designed to treat diabetes, to which the VSG was added to make it a more specific weight loss procedure.

Remember, that this is just a guideline that somebody published, and that your doc's program is king - do what they say in preference to anything else that you see or hear. The liquid (water in particular) intake in the first week clear liquid phase specified in this piece is frighteningly low - most programs will want you to get in that classic 64+ oz of fluids per day as soon as possible - dehydration will get you back into the hospital sooner than just about anything else.

Typical day working on the retirement home (we'll move in one of these days) then a rerun of the road food day tomorrow. Pre-breakfast - hard boiled egg before taking the dogs out for their run/snoop in the woods Breakfast - half waffle (from Kodiak Cakes whole grain protein enhanced pancake mix) topped with greek yogurt and berries Lunch - 1/2 southwest chicken salad from local cafe Snack - other 1/2 of above salad Dinner w sister and BiL - sauteed chicken breast, spinach, tomato & carrot salad, fresh corn on the cob (not room for much of that, but still good when its fresh) Snack - Quest bar

In your shoes, what I would really want to know is just how malabsorptive he made it, as that influences both how you supplement in the future, and how you need to eat to lose the weight, as both will likely be somewhat different than with the mainstream procedures like the RNY or DS. The old purely malabsorptive procedures like the JIB worked fairly well, but had a lot of nutritional complications which is why they were abandoned. The RNY went the other way being primarily restrictive and works well with only moderate nutritional consequences from its mild malabsorption, but weight maintenance is only so-so. The BPD/DS hits something of a sweet spot in being moderately malabsorptive with a similar level of nutritional quirks and a more moderate restriction. The old Scopinaro was more malabsorptive and had more problems than the typical DS (that usually had about a 50cm common channel, compared to 100+ for the BPD/DS). One of the general rules-of-thumb that we discussed in the DS world is that with the DS, the sleeve (restriction) gets the weight off, while the switch (the malabsorption) keeps it off. The implication of all of this (from an amateur/non doctor perspective) is that if there is enough malabsorption to effectively take the weight off by itself (a la the old JIB or Scopinaro) then there can be excessive nutritional problems, or if the malabsorption is moderate enough to not cause significant nutritional problems, the weight loss may be marginal. I would assume (hope) that this is the case with what your surgeon did, and that you will have to work harder at the loss part of the equation, but will have typical DS/distal RNY nutritional quirks to work around. This is something that you really need to understand in working with your surgeon in the coming follow up visits. Good luck!

I've had to do those low fiber diets before - the main benefit that I could see was that on their recommended list was cinnamon rolls and doughnuts! Yeah, right -- even as far out as I am... Been on the road this week, so that's the delay. Will start with Monday's as that was road food day. pre-breakfast: hard boiled egg (I usually have one first thing before taking the dogs out for their run. breakfast: whole wheat crepes stuffed with greek yogurt and berries on the road lunch/snack: small peanut butter on whole grain seed bread sandwich lunch 2 (sorta like a Hobbit - lunch 1, lunch 2..) small sliced beef and swiss on above bread with spinach leaves and avo slices dinner: southwest style salad - chopped spinach, chicken, cheese, corn, black beans, pepper, scallion, tomato, avo, snap peas, carrot, green beans, sunflower seeds (basically whatever is in the veg drawer)

It is variable depending upon insurance company. Mine was for six months, implicitly every month but not specified as such, Between my schedule and my doc's we only had about four meetings during that six months and that was fine. Other companies, as others have noted, are a lot fussier and must be no more than a month apart (they're looking for an excuse to deny you!) Check with the exact wording of their policy bulletin, which should be available on their website, or have the surgeon's insurance coordinator interpret it for you. Good luck!

They often submit all kinds of outrageous numbers to see what sticks and then accept what is paid (particularly if they are under a network contract - then they have no choice but to accept what is paid). But I haven't seen anything that high - 80-100k submitted is not unusual but the normal contracted price is usually somewhere in the 10-20k range, maybe a bit more for a bypass. As to the insurance company asking if you have other coverage, that is just the company looking for someone else to share the cost with (though usually we see that mostly with orthopedic or injury surgeries where there is the possibility of an injury lawsuit or workers comp claim that they can hang it on, but not usually something like bariatrics that they normally have already pre-approved

Did he just not do any stomach reduction at all, or did he make a pouch type structure like a traditional RNY gastric bypass? If he made a pouch, even a larger one, and connected it well downstream to provide DS-like malabsorption, that would be what is known as a distal RNY, which is rarely done, but is a cousin to the traditional RNY which is primarily a restrictive procedure with a minimal amount of malabsorption added. Another possibility is that he did a DS type of intestinal routing but with a large stomach pouch similar to an RNY, and this would be a Scopinaro procedure, which was a precursor to the standard or traditional BPD DS and was rarely done in the US. Another possibility from your description is something like the old jejunolileal bypass which was a purely malabsorptive procedure done in the 60's and 70's that kept the stomach intact along with the duodenum and some portion of the small intestine but bypassed the majority of it, reconnecting things down near the colon. It was abandoned owing to a lot of complications though he may have done some less malabsorbing variation. It was mostly replaced with the now traditional RNY gastric bypass. I'm sorry that you didn't get what you were expecting, but you should be able to make this work. It is important, however, that you get a clear understanding of what exactly he did (get a copy of the surgical report for your records) so that you, and any doctor who may need to work on you in the future for whatever reason, has a good understanding of how your insides now work.

While RH is classically a bypass thing, owing to rapid stomach emptying from the lack of pyloric valve, it is not unknown with the sleeve, too, as rapid emptying can happen due to the reduced stomach size and with slider foods (such as ice cream) that don't trigger the valve to close, particularly if they are eaten by themselves and not with something else more dense. If I need something overnight, I usually have a piece of cheese or a protein bar to satisfy things. Having a glucose meter handy is nice, as you can test things next time you have one of those bars - check your BS after maybe a half hour, hour and two hours to see how your body reacts to it. That will tell you for sure whether that is the problem. Orthostatic hypotension is also possible, though I would expect that you would have seen evidence of it (light headedness when standing from a bed or chair) before this, as it will start to happen when we start losing weight rapidly and the cardio system is trying to adjust

Yeah, there are some of those on forums on different platforms, and they come and go in popularity. Perhaps if we stick to a single thread that everyone updates daily, rather than a new thread each day, its volume would stick it into the "Trending Topics" section on the right and not monopolize the "Recent Topics" section, Just a thought.

In Canada, for these more complex jobs, one doc to look into is Michel Gagner, who I think is in Montreal. I don't know how that works for you on location or on insurance coverage, but he was in on some of the early DS work and does a lot of complex revisions and procedures, so is worth checking out.

I haven't had any problem with any fruit, but this early out for you, lots of things might not be tolerated well, but that is such an individual thing, that it's hard to make any generalizations. The biggest thing I would be concerned about with the diarrhea is not so much getting cleaned out, but dehydration, so I would make sure that I was hydrating a bit extra if I could.

This is a tricky one, as the bypass is difficult to revise. The most common things that are done are basically minor tweaks to your existing bypass - either putting a lapband over the pouch, or tightening up the stoma to try to restore some restriction. Neither seems to have a very good record of success. The most successful thing that I have seen is to revise it to a duodenal switch, but that is a very complex procedure, and there are only a handful of surgeons (maybe half a dozen) around the country who can do it. The other thing that is sometimes done, as the DS is too complex for most, is to convert to a distal RNY, which basically moves the pouch much further down the intestinal tract increasing the malabsorption, but that seems to be more trouble prone than the other alternatives.

If you are still having pain, then this was just the first step in tracking it down - abdominal pain is not necessarily from an ulcer. There can also be an ulcer in the remnant stomach which won't show in a normal endoscopy (though the "typical" place for one in a bypass is at the anastomosis between the pouch and intestine,) Pain is not normal and is telling you something. Be a squeaky wheel (and a pain to the docs) until they figure it out. Good luck....

Most any surgery that you can contemplate, in addition to the basic risks associated with surgery, hospitals and anesthesia, will have some risk of side effects that may be less than desirable, however we take those risks in order to correct a problem that we have created by injury, disease or genetics, with the intent that the result will be much better than what we started with. The various bariatric procedures have different predispositions to consider - conditions that happen more commonly than in the general population. The VSG is predisposed to GERD as the stomach volume is reduced much more than its' acid producing potential, and while usually the body adjusts and corrects the problem, sometimes it doesn't completely. Similarly, the RNY is predisposed to marginal ulcers (typically around the anastomosis) because the part of intestine to which the stomach pouch is attached is not resistant to the stomach acid like the duodenum is (the part of intestine immediately below the stomach outlet, which is bypassed along with the remnant stomach.) Likewise, it is also predisposed to dumping and reactive hypoglycemia owing to more rapid stomach emptying due to the lack of pyloric valve. Usually, these problems don't hit most patients, or don't persist if they do, but sometimes they are long term problems. These are things to consider ahead of time, particularly if one has any relevant pre-existing condition. Another consideration is that the VSG is fairly easy to revise if it does run into a problem that can't be resolved otherwise, while the RNY is difficult to revise or reverse. Another point to consider is that while the sleeve leaves behind a relatively "normal" anatomy, the bypass leaves a blind stomach and upper intestine which is more difficult to examine endoscopically, so some problems may not be diagnosed until they are more advanced and symptomatic. For instance, if one is subject to stomach polyps, that is a pre-cancerous condition that should be monitored, but is difficult to do after a bypass. An pre-op endoscopy is a good idea to understand what is happening inside you, even if your program doesn't require one. On the diabetes front, they both do well, typically seeing 75-85% remission rates (remission is what it is, rather than a "cure" - it can come back, particularly with some weight regain) though the bypass is generally considered to be marginally better. The best results come from the Duodenal Switch which typically shows remission rates in the 98-99% range, but that is a more complex procedure that few surgeons offer. However, if the diabetes fails to go into remission, or comes back, after a VSG, a revision to the DS is straightforward (as the DS uses the VSG as its basis) while revising an RNY to a DS is very complicated, which only a handful of surgeons are able to perform. So, while the VSG may not be quite as good as the RNY in that respect, it has a much more viable "plan B".