RickM

Liquids tend to flow right through, so those restrictions don't really apply (is your sleeve really 4 oz - that's a big sleeve for a VSG?) Some will have significant inflammation in their stomach for a while, so things don't flow too well, but others have little and liquids are pretty easy. I had no problem sipping away a bowl of broth (6-8 oz?) and a juice box in a sitting (half hour, maybe?) in the hospital; when my wife went through this, she could barely down her nominal stomach size of protein drink in one sitting. Our basic goal was to sip an ounce every 5 minutes - some could do better than that, others not so much. For the protein shakes, I usually considered 8 oz to be a "meal" and used as many, at 25-30g protein each, as I needed to get my protein numbers for the day (typically only one or two, but we had other protein options to play with then, too, as we weren't limited to just liquids) The rest of the time between meals was spent sipping water until those numbers were hit.

800-1000 probably isn't too much for you, but I would be cautious about going much above it. The 6-800 level that GradyCat mentions seems to be something of a sweet spot for many - low enough to provide enough caloric deficit to get the desired weight loss for most, but high enough not to trigger any major metabolic problems from being too low - and is fairly common in many programs that specify calorie levels. Many patients, particularly average to below average height women, will find that they maintain in the 1000-1200 calorie range, so it pays not to go too high unless one has better info on their personal metabolism. Being a guy, and young, that implies a higher metabolism so you can tolerate higher calories in you loss phase; starting at close to 500lb may work against that some. Another consideration is that your overall metabolic rate will decline some as you lose weight (your resting metabolism, in theory, shouldn't change much assuming minimal loss of muscle tissue), as it takes fewer calories to move 400lb around all day than 500, and fewer still to move 300, and 200, etc. So avoid the temptation to increase calories as you lose, or you may come up short of your goal. That said, I settled fairly quickly at 1100, (no set calorie goal in our program, either) and that worked well for me, though I only had about 100lb to lose, but did so in about seven months or so (and that was intentionally slowing things down some in the last couple of months) Do you have an idea what your calorie level was when your weight was stable (not gaining, not losing) before surgery? That can provide some guidance in estimating what you need to do. I was stable in the 2600-2800 range before surgery, and now maintain at around 2000-2200. A slow down at this stage is to be expected, as most go through a bit (or more than a bit) of a stall at around three weeks. There is usually a fairly quick initial loss of mostly water weight as we burn off our short term energy reserves of glycogen (basically stored carbohydrate) and then a pause as the body shifts gears to burning our fat reserves, which burn more slowly than the glycogen. I, likewise, lost about 30 lb the first month, then 15 each of the next two months. Completely normal.

Have you talked to your surgeon about this, as they would be the most familiar with the absorption quirks of the procedure (though a pharmacist should also be familiar with it as the RNY is pretty "mainstream". Generally, time release meds (and a lot of the psych meds are time release) can have problems depending upon their delayed release mechanism. My wife has a DS, which has a different malabsorption scheme than your bypass, but she still has to research how a new ER med works and whether that is compatible with her anatomy.

From what I have seen, yogurt and such is often/usually considered a "full" liquid, but as usual, docs vary in what they put into what phase and how they define things, so that is your go-to source of info. We didn't even have a "full liquid" (or even liquid) phase, so what do I know?

It is anybody's guess as to which is more accurate; repeatability and how the two correlate is more important. I know that my PCP's scale consistently reads about 5 lb more, with typical clothes and shoes on, than my home scale when I'm naked - I can tell the nurse within a half pound what the reading will be based upon what I weighed that morning. There is no requirement for a doctor's scale to be calibrated, and they don't normally do so unless there are many complaints about it being off (assuming that they care.) I had one doc whose scale shifted about 25 lb when they moved his office from one end of the building to the other (obviously, someone dropped something!) yet he was oblivious to the change (it used to be consistent with other scales in my universe, then it changed when he moved.) Of course, that change happened at a time when I had lost 25-30 lb between meetings with him, so he didn't believe my claim as to how much I had lost..... If you are really concerned about total accuracy, find a scale that is used for commerce, as that will have to be calibrated periodically. My dad used to go down to the shipping room at his work to weigh himself, as their scales were used for figuring their freight charges.

Ours was clear liquids only the day before surgery, and then a bowel prep/clean out in the afternoon. The doc who runs our support group now quite specifically doesn't want his patients doing any kind of multi-week fasting diet as he wants them as strong as possible going into surgery, and fasting doesn't do it. It's a big YMMV thing.

I don't know, and really don't care (he may not have even used one, for that matter) - it's the end results that matter more than what specific tool the doc uses. When I first go into this, there was a group on another forum that insisted (according to their doc) that if you didn't have a tightly oversewn 32F sleeve, that you would never lose enough weight, you would live a life of misery, and no one would ever love you. Yet you couldn't really tell by the results who had a 32, or a 36 or a 40 as there are so many variables involved, and bougie size is just one (and a pretty minor one at that.) How tightly does he follow it? How many cuts is he making in following the minor curvature to make that banana shape? My wife has an absolutely huge sleeve - probably a 56-60Fr (typical for a DS sleeve) - yet after all these years, her meal size is about the same as mine, sometimes a little more, sometimes less. It can be an interesting philosophical discussion to understand the tools, procedures and techniques the doc uses, but ultimately, it comes down to what we put into it as much as what the doc puts into it.

At least they aren't being too fraudulent, as they state on the label that it doesn't count toward your RDA of protein, so at least they are a half step above Genepro on the honesty scale. Considering the other fadish stuff they sell on that site, I would walk away quickly. Supplement Facts Serving Size: 2 Scoops/5 Tbsp (24g) Serving Per Container: about 21 Amount Per Serving Calories 90 % Daily Value* Protein 22g 0%1 Sodium 75mg 3% Hydrolyzed Collagen 24g ** * Percent Daily Values (DV) are based on a 2,000 calorie diet. ** Daily Value not established. 1 Collagen Protein does not count toward the FDA recommended Percent Daily Value for protein because it lacks one essential amino acid: tryptophan.

When things are questionable, second opinions are a useful thing. But, I can understand the surgeon's concerns from a couple of different perspectives. One is that the bypass is predisposed to ulcers (typically marginal ulcers which would be of a different cause of what you have,) so as with the VSG which is predisposed to GERD and they often shy away from doing them with patients that already have GERD, I can see the reason to be apprehensive about doing a bypass on you. The second is that the bypass leaves the bulk of your stomach in a blind limb that can't easily be inspected by endoscopy, and as ulcers can be a pre-cancerous condition if left unchecked, it is something that you want to monitor; waiting until obvious symptoms such as pain or bleeding occur is seriously bad news. The marginal ulcers that are common with the RNY are typically at the anastomosis between the pouch and intestine, so is in a place that can be monitored; anything happening within the remnant stomach that has been bypassed is out of reach. As others have noted, not all bypass patients dump (maybe 30% or so?) so according to Murphy's Law (if something can go wrong, it will....) those who are looking for dumping as a form of aversion therapy will be amongst those who don't dump. As FluffyChix, the bypass is something of a one shot deal - it is difficult to revise to something else if it doesn't work for you, either on weightloss or regain or due to medical problems (such as your ulcer problem) and even a reversal is no walk in the park (we have seen a couple go through here the past few months due to intransigent ulcers) while the sleeve is more readily revised if necessary. So there is some additional "margin of safety" or "plan B" available with the sleeve when things are questionable. Overall, the results of the bypass and sleeve are very similar - whatever difference there may be in the intrinsic "strength" of each procedure is overshadowed by the initiative and habits of the patient - there are many successes with the sleeve (8+ years out here) just as there are those who fail to do well with the bypass, including going back to junk foods because they never dumped. There is plenty of work on your part whichever procedure you get. good luck....

Danger Will Robinson!! It sounds like this is way too important to you than it should be. Transfer addiction is a significant problem in the WLS world - this is where whatever addictive tendency we may have had toward food is transferred to something else (alcohol, drugs, gambling, shopping, etc.) in its absence. So, what was a casual occasional drink thing can easily become full blown alcoholism. You seriously need to find a way to not "need" it. Sermon over. Doctors and programs vary widely on their directions for when it is OK to consume some alcohol, from a few weeks or months for the benefit of healing, to a year or two to prevent further liver damage (our livers tend to be in poor shape to begin with from our obesity - hence the common "liver shrinking" pre-op diets that are often imposed - and is further stressed by its role in metabolizing all the fat that we are losing, and it doesn't need the additional stress of metabolizing alcohol. Some go further to advise never again, for the transfer addiction reason. Check with your surgeon's program directions and go from there.

Yes, this is something to pass by your surgical team. The BPD/DS and VSG are a lot more tolerant of NSAIDs than the RNY (which started the whole NSAID thing in the bariatric world) but they are still something to be careful with, and surgeons' experiences and opinions vary widely. Our program allowed them as soon as when narcotic pain relievers were no longer appropriate; others wait longer into the healing phase and others may not permit them at all. In any case, if you are permitted to use them they are something to use under medical supervision (even if they are OTC) and have your surgeon in the loop.

Ours was basically the same as for a colonoscopy - clear liquids the day before surgery with a bowel prep/clean out in the afternoon/evening. The last is a bit of overkill for a VSG, but is understandable as their mainline procedure then was the DS where they are operating on the lower end of things.

You do have to look around more to find a doc who does the DS as it is something of a niche market. https://www.dsfacts.com/duodenal-switch-surgeons.phphttps://www.dsfacts.com/duodenal-switch-surgeons.php has a very incomplete listing, but is a start. I don't see it as markedly more risky than the bypass; it is a more complex procedure and takes more resources for a surgeon to develop, and most particularly maintain, the necessary skills to perform it. This means that it tends to be the better surgeons who go into it, which tends to even out the risks, though that does mean that one needs to vet their prospective surgeon more carefully as there have been some over the years that got in over their heads. Thankfully, they tend to get weeded out, but it still helps to seek out a surgeon who has done several hundred of whatever procedure you are interested in. It does get a bit of a bad rep in that there are some practices out there that advertise doing it (it is actually fairly common to see it listed on a surgeon's CV, or on a practice's list of offerings) but if one inquires about it, they sell you what they actually do perform, saying things like 'we used to do it but the patients had too many problems...' which by my experience means that either the guy in the practice who did do them left the practice, or they never got up the learning curve to do them correctly. It isn't something that a surgeon just "picks up" and starts doing, but is something that most go back to school to learn, usually doing a residency of a few months with an established practice to learn all the in's and out's of it. That's a lot of time off for a busy surgeon, so it often just means that it isn't worth it business-wise to go to the trouble to learn it. But many don't want to lose the business, so some will bad mouth it in the process of selling their own offerings. Oddly, when looking at practice's offerings, it is not unusual to see them list the Vertical Banded Gastroplasty (the old "stomach stapling") which has been obsolete for at least twenty years, but it seems that some will list anything they may have done once in the past as a current "offering". My wife is about fourteen years out on her DS and is still doing well with it, and we still regularly attend a support group that is composed of mainly 10-20 year vets, and it is overall a healthy population. There are things that can crop up over time that is a result of the malabsorption, which is something that it has in common with the bypass. One may not recover from a blood loss event as readily as a normal person, or a VSG patient; iron infusions may be needed to get things balanced out again rather than just upping oral iron. One will be more sensitive to nutrient deficiencies (with either) which means that it is much more important to stay current on labs; maintaining nutrient balance doesn't seem to be a big issue if one is aware of what one needs; skip the labs for a few years and odd things can happen as the potential deficiencies are different than with the normal population. But overall, with a fairly compliant population, it is hard to tell what issues people are having are related to their DS, and what is simple aging (one of the occasional topics of discussion when someone asks about a particular problem). Most of these people are in their 60's or early 70's now (a few later 50's too...) so things are naturally falling apart a bit - but not nearly to the degree that they would be if they were still 3-400+ lb!

I don't have any specific studies (though I'm sure there are some out there, FWIW) but from experience over the years on various forums, and looking at the basic results of the virgin bypass and sleeve procedures, I wouldn't look to such a revision as being a big help. The sleeve and bypass are quite close in overall results, that it doesn't seem to make much sense to switch from one to the other in order to get significant additional loss. You can expect some just from going through the whole pre-op/post-op diets and that initial restriction that you get, but longer term, the metabolic effect of the two are similar. The DS would make more sense as you are already half way there, and any competent DS surgeon can do a "completion" (and if it seems appropriate, do a re-sleeve as well.) The other consideration is that the bypass is something of a dead end procedure, in that it is very difficult to revise it to something else (like the DS) if it doesn't work out - there are maybe half a dozen surgeons around who can revise it to a DS owing to the complexity of that revision. That said, I have seen a number of people go through that revision when their bypass didn't provide satisfactory results that did do well (including a couple double revisions who went from a band to a bypass and ultimately to the DS to get the desired result.) That would be my choice if I had no other conditions dictating a bypass.

On the insurance front, companies may well cover WLS, but the employers who buy the policy may choose to exclude that benefit to lower their (short term) cost. If you are dealing with job provided insurance, there may be other providers available during the open enrollment period that do provide the WLS benefit, or it may be worth your while to go with an outside policy that does cover it (though I suspect that it wouldn't be worth the cost, but worth checking out,) or changing providers if you are already on private insurance if the costs work out. On Mexico, there are lots of people who have a very positive experience and there are plenty of good surgeons there; however, you don't have the recourse there if something doesn't work right - surgically or contractually - which is a big part of the reason that they are cheaper. Due diligence is the word of the day. In the States, you can shop around and see who has the friendliest self pay programs; IIRC, there is a program around Las Vegas that seems to have fairly friendly rates of around $10k or so for a VSG, which isn't that much higher than the better MX programs.

I didn't lose anything, as we didn't have a pre-op diet (other than the day before thing) and I just kept on with the basic weight maintenance life that I had been on before. A word of caution, though - we will typically experience a big loss of primarily water weight when we first start a major caloric deficit program and then things slow down to a more sustainable rate as we get into drawing from our stored fat. So, if you see others reporting big number losses the first couple of weeks after surgery and you seem to be lagging that, just remember that you already had your big initial drop before surgery, and you are just running a little ahead of the others. Good luck,

The best that I can think of would be Dr. Ara Keshisian out here in California, as he is one of the handful of docs that can do the complex RNY to DS revision, and he seems to be able to do other complicated procedures that others can't or won't do. Closer to you, Drs. David Greenbaum in NJ and Mitchell Roslin in NYC are also well regarded for complex procedures and worth consulting. Good Luck....

Do you even need to do such a diet on your program, or are you basing your fears on what others post that they go through? Many programs don't do liquid diets, or any at all (some docs don't even want their patients doing them.) If you do, as others have related, you get used to it after a few days; if you don't, follow what your program directs and don't worry about what others do - there are many ways for this to work.

This is another of those "it's anybody's guess" things. There is a different Blue Cross organization for each state, and they will all vary on their coverage details depending upon local market conditions and state laws. Then there is a difference between individual plans, ObamaCare plans and employer provided plans - all of which can vary depending upon what options the employer chooses to buy. Some plans don't cover WLS at all (even if they did in the past) while others limit the benefit to only one WLS per lifetime. Muddying the waters further, if the revision you seek is due to complications of a previously covered surgery, then it is not a WLS procedure but is treating that complication (it sounds like it to me, but it isn't my decision.) There should be policy bulletin for your BC policy online that spells out what applies to your policy - what they cover or exclude as relates to WLS. You can call their number, but don't take their answer as the last word, as the customer service reps have been known to be wrong. When you find a surgeon to handle your case, their insurance coordinator should be able to tell you exactly what your policy covers, as it is their job to know the lingo and understand all of that fine print. I understand that some surgeons are averse to working on other surgeon's patients (fixing others' mistakes...) but that is not an exclusive thing. One of the docs that I associate with (he runs out support group now) does a fair number of RNY to DS conversions, which as he doesn't ordinarily do RNYs, means that he is fixing other's mistakes (as well as fixing wonky sleeves that others have left behind) so they are out there - you just have to look. Thinking about that a bit more, if a surgeon doesn't want to revise other's patients, then he is either making a lot of mistakes himself that need revising, or he isn't very experienced in doing revisions, so you are better off searching for someone else. Good luck,,,,

Typically, if they cover anything, it will be reconstruction for medical necessity (that is what you have to establish, so document all related problems). They will cover, if at all, the minimum to restore function, so the most that we typically see would be for a panniculectomy (cutting of that overhanging skirt of loose skin) but not an abdominoplasty (tummy tuck) which will usually have some muscle tightening along with more extensive sculpting, or a lower body lift, arm lift, etc. If they cover anything minimal, any additional work is on your ticket. Likewise, hernias - incisional or umbilical - are often a ticket to partical coverage as the hernia can pay for a base charge for the OR , anesthesia, and day or so of hospital recovery, with the additional time and labor for additional work paid by the patient.

You should be looking for a bariatric surgeon; most bariatric surgeons are also general surgeons, but not vice versa. general surgeon may be able to point you in the right direction of which procedure might be best for you, but a bariatric surgeon should be looking at the whole picture - surgery, diet, psych issues, eating disorders, etc. Not that they will handle everything, but they will be more aware of all the issues that typically afflict seriously obese patients and provide some guidance in those areas. The lap bands are falling out of favor very quickly owing to their high long term complication rates and poor overall performance, though there will be some special circumstances where they may still be appropriate. The RNY and sleeve gastrectomy are the two most common procedures now, though there is also the duodenal switch which works better than either in more extreme cases that you should be aware of, though it is less commonly performed owing to its greater complexity. Here in the states, you want to look for a surgeon who is a member of ASMBS - the American Society of Metabolic and Baritric Surgeons - as a guide as to who is serious in the field.

I use a resident program called Nutribase, which is a slightly lightened version of what they sell to doctors and RDs (lightened mostly in that it can only handle a few "clients" rather than hundreds) as any of the online apps when we started this around fifteen years ago sucked, particularly when trying to handle menus for more than one person. These apps are only as good as the databases they use, typically USDA and the manufacturers, (Nutribase also draws from Canadian gov databases, as well), so one product is unlikely to be any more "accurate" for what you are looking for than another. If you are worried about how net carbs are being calculated, you are way overthinking the problem, as that has virtually no impact on your WLS success. The fiber is important to keep track of to help keep things moving and the overall calories largely govern your loss rate. For the rest of it, learn to eat good quality food and the rest pretty much takes care of itself. With things like carbs ( and fats, when that was the big diet thing) quality is a lot more important than quantity. 60-70 g of high quality complex carbs from fruits, vegetables, whole grains, etc., is a lot better for you than 20-30 g of junk carbs from artificial sweeteners and frankenfoods. Note - I never worried about carb and fat counts and still had to slow down my loss rate as I got to the six month mark.

Have you talked to your surgeon about this (as opposed to the printed handouts they give you)? The sleeve is more tolerant of NSAIDs than the RNY (where they are really bad news) but often practices lump the two procedures together in their diet/supplement/medication protocols, though they are both quite different. If you talk to the surgeon directly about your specific problem, you may well get a different answer than what is given as general advice in their booklets. In the DS world (that's a sleeve plus intestinal rerouting) the ability to use NSAIDs has long been one of its selling points over the bypass, and the surgeons in that side of the bariatric world are well used to working with them (we were permitted their use as soon post op as narcotic pain relievers were no longer appropriate.) That said, this is something that your surgeon should be in the loop on, rather than just going it alone. They are serious meds that can cause problems even for normal, non-WLS folks, so there should be some MD oversight on their use, but usually occasional short term use, as for an attack, is tolerable, as opposed to consistent use for something like chronic arthritis. You do want to be careful with Tylenol as the toxicity levels are not that much higher than the therapeutic levels shown on the labels - that can be a problem when people up the dosage because it doesn't work that well.

Yes - calcium and Iron compete for the same absorbancy feature in the intestine, so need to be taken apart, further, calcium is limited to around 600mg per dose, so that needs to be spaced out as well. Typically, the bypass procedures call for about 1500 mg Ca, or three doses, and the VSG usually starts at 1000 mg or two dose, and then adjustments are made later on as diets improve and volume increases. I target 2000mg per day of Ca, but only take one dose as diet provides the rest.

The best one is the one that you will use - it's no good buying the "ideal" product that you can't tolerate and will only sit on your shelf unused. That said, whey isolate is the preferred as it is the most absorbable, with the whey "blends" and "concentrates" being a notch or two lower, but will still work. Experiment now, try sample packs from different vendors, aim for isolates if you can but go with what you prefer, don't stock up too much as your tastes may change post-op (and they may not...) so if you have a few different ones on hand that are OK with you, you should be fine for a while.