RickM

Muscle does not weigh more than fat - a pound is still a pound. Muscle is more dense, so you may show fewer inches for the same weight if you are more muscular, but weight can still be the same. Few can actually gain muscle mass while losing total weight, but we can seek to lose as little as possible while losing the fat. Typically we will lose some muscle mass, particularly in the legs and core, as we don't need as much muscle to support and move our reduced weight around, and few can dedicate the time and effort required to build up a comparable amount elsewhere (and then keep up the extra work to maintain it so that it doesn't turn to fat over time.) For the OP, yes get a body composition scan to see where you are - Dexa is considered the best, but water or air displacement or even the scales give useful information if used properly. As a woman, mid 20's body fat percent is typical healthy range, but individually, you might be better as 22-23%, or 27%, so don't obsess over it.. I aimed for mid teens, which is mid to lean normal for men, and called it a day. Even Dexa isn't accurate enough to obsess over a point or two one way or the other. To get back on track, as you have acknowledged falling back into old habits, try just going back to basic lean meat and green vegetables for a while. What is typically needed is a few days of "detox" from the (typically sugary) junk that has crept back in to alleviate your cravings for them. These liquid "reset" diets don't do anything better and just reinforce whatever tendency you may have toward yo-yo dieting. They are premised on the observation that when we first had our WLS we were typically on a liquid diet for a while and we lost like gangbusters, so therefore if we go back to a liquid diet, we will lose like gangbusters again. Unfortunately, it was not the liquid diet that caused us to lose rapidly, as even those of us who never did a liquid diet lost like crazy those first couple of weeks. It was all about the heavy caloric deficit that we were in courtesy of our surgery, and the resulting water weight loss as our body adjusted to the new reality. In short, cut out the junk that has crept back in and replace it with high nutrition, low calorie real food that will satisfy you nutritionally and cut your cravings for sugar, and is something that you can stick to in the long term, rather than a quick fix yo yo diet. Good luck,,,

It sounds like (non expert, non doctor here) that it may be reactive hypoglycemia, which is fairly common in the bypass world, as it is a result of rapid stomach emptying due to the lack of pyloric valve in that procedure, causes an insulin spike followed by low blood sugar triggering hunger. With the sleeve, we can also experience somewhat rapid emptying due to our small stomach size. DIfferent foods affect this, too - the so-called "slider" foods that slide on through because they don't trigger the pyloric valve to close, typically highly processed carbohydrates. If this is what is going on, try sticking to meats and high fiber vegetables that tend to stay in the stomach longer and see if that helps. If it is not RH, then an endrocinologist may be in order to see what is going on with this imbalance. Whether or not your sleeve was botched, you should check with a bariatric surgeon to evaluate this - if you go to your original surgeon, a second opinion from another may be in order to verify whether or not it was "botched" (would the original doc really admit that he goofed?) good luck in working this out,

Is your bariatric surgeon in the loop on this? It would not be unusual for liver numbers to be wonky between your obese condition pre-op, any pre-op diets for "shrinking the liver" and subsequent weight loss which stresses the liver owing to its job in metabolizing the fat that is being lost; in short, there's lots going on that can cause unusual liver numbers, so I would want someone familiar with bariatric patients weighing in (so to speak) on this so that they don't go overboard on treating something that may well be "normal" for your circumstances. Good luck, and glad they got the pain issues under control,

Yes - liquids usually flow right through you with little restriction, though some people will have notable inflammation in their stomach after surgery and will be much more restricted (hence the usual instruction to sip, sip, sip our liquids until you see how things flow in you. I was doing similarly in the hospital with no concern on the doc's part. As you move into more solid foods your eating volume will be much more restricted, and that is when the usual volume restrictions (whatever your doctor provides, if any,) apply.

I went through much the same thing of researching all of this a few years ago for a prospective cancer treatment (though didn't have to go through with it, as it turns out.) Your surgery should be coded as a gastrectomy, partial or total, for the sake of your GP, rather than an RNY gastric bypass for weight loss. Same basic procedure, (called a Billroth II, which has been around for about 140 years for just this kind of problem) but different codes and rules for the insurance. So, you shouldn't have to jump through the same insurance hoops of psych eval and possible 3-6 month diets, etc., though neither is a bad idea given the lifestyle changes you will probably encounter post op. There are a number of Facebook groups for partial and total gastrectomy patients, which would be good to look into. One of the things that I found there is that bile reflux is a relatively common problem post op, which doesn't seem to be that common within the RNY population. Discussing this with my prospective surgeon, he told me that he has never had a problem with that if he kept the limb length over 60cm, which would be fairly typical in the RNY. He also wasn't restricted on choice of limb length as he would be under RNY rules; he could go shorter or longer as needed for the circumstance. Implicitly, this means that many surgeons who perform this procedure for non-weightloss purposes try to keep that limb length, and the associated malabsorption, short to minimize weight loss, but that brings the pouch and anastomosis closer to the bile ducts. Since you are in the BMI range that would normally qualify for WLS, this should not be an issue as you can benefit from the weightloss, but it is something to discuss with the surgeon. It is good for you to work through a bariatric surgeon (most major hospital GI surgery departments are also their bariatric department,as well, given the overlap in skills and experience, though the surgeons may drift to their own specialties within) as you should get all of the necessary education on dietary, medication and supplement restrictions that you need; my wife knew a guy in her office that was having all kinds of health issues and it turned out that he had this same type of procedure for non-weightloss reasons (don't know if it was GP or something else) but he was never told about the ramifications of the procedure, so duh - yeah, he was having issues. Between your bariatric office (most are pretty good these days) and these forums, you should pick up what you need to know to live healthy in your post op years. Good luck.....

I would get a second (and even third,) opinion on any kind of revision surgery. Partly due to the added complication in doing revisions, and in the wider range of underlying problems that may create the need for a revision. Different doctors have different experiences (even if they are equally "experienced") which can give them a different perspective in solving a problem. On these forums, we certainly see some come through who have hiatal hernias repaired post sleeve; there is also wide variation with amount of sleeve experience that surgeons can have, given that it has been gaining popularity rapidly, so many surgeons are not as experienced with sleeves as they are bypasses. This leaves many in the situation of not really knowing how to correct a problem that occurs with a sleeve, and instead stay within their comfort zone and revise to a bypass instead of fixing it. So, in short, you may be in a situation where some surgeons can correct the hernia fairly easily while others would have difficulty, or it may be something that no one can correct without doing the revision. We forum lackeys can't make that judgement, but that is what second opinions are for. Good luck,

A few random thoughts in no particular order - Does your doctor have you on a PPI acid reducer medication such as omeprazole? Excess acid can mimic hunger. In the early post op time, our sensations of hunger, satiety, fullness, etc are altered due to what has been done to us, so these feelings are not a good gauge as to what we need, This also means that any appetite suppressor would unlikely work on whatever you are feeling. Many experience "head hunger" which is more psychological than physiological hunger. There are literally hundreds of protein supplements out there, so it is likely a matter of keep looking to find one that suits you, or try a different approach to it. I never go along with the ready to drink products, but found that I could adapt most any powder to something that I could use. Unflavored powders can be added to soups or broths (and there are chicken broth flavored ones out there, too), flavors can be added, temperature and consistency changed, mix with water, milk, fake milk, etc. There are clear liquid varieties such as Isopure which I cant take on their own, but mix in with Jello quite well; my wife makes a smoothie with vanilla powder in some juice and a banana and frozen strawberries (may be a bit early for them, though - ask your doc). Unflavored powder added to oatmeal, cream of wheat or even mashed potatoes are classics; make protein pudding with powder of your choice.

It isn't really an insurance thing, as few of us get any insurance coverage for PS, but rather the time it takes for the body to stabilize. Once the weightloss stops, fat and musculature shift around some and the skin can shrink back some as things adjust to the new you, which is why most PS advise waiting up to a year (at least 6 months) after reaching ones goal weight. Around the time that I reached goal, I started working with a personal trainer along with my wife, and rolling around on a mat doing stretches and exercises, I could feel the skin on my back folding up; a year later it wasn't noticeable - either I had adapted my moves to avoid it, or things had tightened up some (likely a bit of both.) Likewise, around the same time I had new seats for my racecar fitted to me (they're supposed to be snug) but a year later, my butt was loose in it, though my weight hadn't changed, so things had certainly moved around. This is another of those tradeoff things, but may well be one of those things that is second nature to a WLS specialized PS that may not occur to a more general PS. Again, talk to him about it and see what he says - it may or may not be a big deal in your particular circumstance. It may also still be worth the effort to get a consult with the less convenient specialist PS to get his view on your situation, even if you don't intend to go with him.

Predicting how much weight loss or size change will happens at a specific time is about the hardest thing to do in this game (will you lose 30 lb in those three months, or 60?) Flexibility is the key. Wedding night attire is much easier! Congratulations and good luck!

Walk down Wilshire Blvd and you can't help but run into a few of them! As with everything, it is a trade off. PS certainly has a higher risk of mild to moderate complications - some of which can be handled with email and selfies while others need a hands-on office exam, so being close is a big help. The compromise is on what you need to have done and how much experience the PS has with the extensive reconstruction that is often needed after massive weight loss. There can be a big difference between an abdominoplasty or lower body lift after losing 100-200lb and a "mommy make over". If all you need is an arm lift or maybe a minor tummy tuck, a "regular" PS that you know and trust may be just fine. Talk to him and see what he says. My bariatric surgeon has gotten into doing the post bariatric reconstruction, but for some of the more "artistic" jobs like the breast implants and reconstruction he brings in a breast guy to do that part of the job.

I don't know what a GLP is, but generally with any of these procedures there can be a wide variation between patients as to how rapidly one can progress through liquids into thicker and more solid foods, as well as tolerating different individual foods. A key factor is the amount of inflammation one gets in the stomach and other surgical areas. Liquids may pass through very slowly (thus the usual advice to sip, sip, sip our liquids constantly) if things are swollen inside, or they may pass with little restriction if not. Likewise with the ability to progress on to thicker liquids and purees. I had no problem with thicker and soft things like yogurt or eggs even the first week (yes, that was on our program), but my wife was much slower to progress through those things. It's a big YMMV thing and we all have to go at our own pace

The primary question here is,,,why? What do you hope to accomplish with it? If keto is something that you are already doing and like, and makes sense for you to keep doing it for the foreseeable future, then yes, you can do keto after surgery and it will work as well as anything. If you are hoping to adopt it because of a belief that it will improve your WLS performance, then forget it. Summerset, above, has the right idea that the WLS by itself is plenty strong enough on its own. Looking back 20-30 years, patients were often told to just "eat like you always did, just less..." and it worked! For a while. Of course, eating like what got them fat in the first place didn't prevent them from gaining weight again in the longer term. But this does illustrate one of the big powers of your WLS - that it is relatively insensitive to what style of diet is used that first six months to a year when we are losing rapidly. Low carb diets that are popular today work just as well as yesterday's low fat diets. This means that we can concentrate on learning how to eat for long term health and weight control rather than promised quickie weight loss followed by inevitable regain that we get from the various fad diets. In the non-WLS world, diets fail 95+ percent of the time when you look out beyond a year, as people either hit diet fatigue and fall back on old habits, or they may actually get down to a normalish weight, and then regain as they fall back into old habits. The same thing happens with WLS, only it usually takes longer given the lingering restriction that we have - but the weight can come back over time if we don't learn how to keep it off, and most diets don't teach that.

As I read it, the MK4 comes from meats, cheeses, egg yolks, etc; green leafy veg is great for K1 which is the anti-clotting K, and I usually get a lot of that, but very little of the fermented veg, (not good for my cancer potential) so I concentrate on the MK7.

Yes, it is most likely just the glycogen thing - being on a low carb diet and having a low glycogen level will make one more "carb sensitive" than those on a more normal diet. I maintained a relatively high carbohydrate diet (for bariatrics), typically in the 70-100 g range (no particular goal on that, other than trying to optimize nutrition of the non-protein segment of my diet) and never noted any particular weight changes associated with such dietary fluctuations. Indeed, after four months or so I specifically increased my complex carbohydrate intake selectively (addressing some workout energy issues) so that 120g was not unusual on those days, and likewise, no particular weight impact from that (other than continued on trend loss!) Presumably, my glycogen levels were already maintaining at a semi-normal level. I doubt that half a dozen wheat thins would have enough sodium to make a big difference, though as we usually have fairly low levels with our low overall food intake. In our American/Western diet, the high sodium levels that are a characteristic typically come more from the packaged/processed foods in our diet (things like monoSODIUMglutamate, etc.) than table salt we may add to a meal or from classically "salty" foods. Most every time that I travel, I will gain 2,3,4 lb that week, even though calorically my diet hasn't changed much, but I am eating out more that week, and restaurant foods are usually pretty high in sodium, even the "healthy" dishes. That weight drops off after a few days.

Most likely, it is. The tricky thing with protein need is that it is based upon lean body mass rather than overall weigth; various calculators simplify this as most don't know what their LBM is, but do know their scale weight, so assumptions are made, and they typically work reasonably well for people of normal-ish size and body composition, but not very well for the seriously overweight. The "ideal" weight or your goal weight works better for these calculations. Most bariatric programs simply specify that women should get 60-80 g, and men 80-100 g, or something in that ballpark, which tend to be a bit on the high side from general population health recommendations, but a bit of overkill isn't a bad thing considering that we are healing for a while, and want to make sure that we preserve the LBM that we have to the extent possible. I use a little more complex formula that I found that specifically uses LBM (if you know it) and seeks to provide the protein required to renew the body tissue every six months, and it overall comes up in the same ballpark as other recommendations, though provides some insight into some of the mechanism involved. For my 150+ lb of LBM, it works out to a protein need of 100-105 g for a basic maintenance level; a short-ish woman (5ft, give or take) with a normal weight of around 110 lb, her typical LBM would be around 80 lb, so a protein need of a bit more than half of mine - call it 55ish g. Were I to want to add some muscle mass, say about 10lb over the next six months - a reasonable goal without funny drugs and a reasonable amount of appropriate work - my need would increase an additional 40-45g; a reasonable dietary goal if one were so inclined, and far short of the extreme "recommendations" from the body building sources intent on selling protein supplements.

I take a 90 mic capsule of MK7, which is the bioavailable component of K2. K2 is one of those vits that is fairly newly appreciated, so dosage levels are speculative - recommendations are all over the map - so I figure that some is better than none. I already eat a fair amount of the foods that supply MK4, but very little of those that supply MK7, so I bias it that way.. Maybe a general K2 might be better - who knows?

With a bypass this early out, I would be inclined to go with the three doses (1500ish mg) as you are malabsorbing some of it and not getting all that much from diet at this point. It is usually better to supplement on the heavy side at first and then cut things back as diet improves and labs indicate - it's easier to cut back than to try to catch up if things were too low. I try to keep my Ca intake on the high side of the 1500-2000 range from all sources, which meant that early on I took 2 doses per day (1000-1300 mg, depending on product) but now only do one dose as diet fills in the rest. Magnesium, D3 and K2 also play a role in the calcium loop, so those should be considered as well.

From what I have seen on these forums, unlike pre-op diets which you can shop around on, this is a near universal requirement (like quitting smoking) as they don't want you coding out during your recovery stay (they don't want the liability). You can ask around, but I suspect that you are stuck with it. There are a multitude of different masks and appliances for them, so it is probably best to keep trying different ones until you hit the right one (or the least objectionable one.) Good luck in getting to the table,

Our general goal was to sip an ounce (30ml) every five minutes if you can. Inflammation in the stomach after surgery can vary widely, so some can drink fairly normally (no guzzling or chugging!) while others may have to sip very slowly, I could sip down a bowl of broth (6-8 oz?) and a 4 oz juice box in a half hour sitting in the hospital, and that was of no concern to the doc; when my wife went through this a few years before things went through much more slowly. Both can be considered to be "normal".

Eventually (as in a few weeks or months) it will flow through almost immediately, unless there is already some food left from a prior meal getting in the way (this is why they often advise to not drink for 30 minutes or so after eating. Your pouch is basically a funnel moving the water from your esophagus into your intestine, with only the stoma as the resitriction - that will be the determining factor. Initially after surgery, you may have some inflammation in your stomach area which may restrict things further, so instead of being like a funnel, your pouch may be more like a pinched soda straw, so we usually have to sip, sip, sip our water for a while (a few days or weeks usually) until we can drink fairly normally.

Actually, with the DS (at least the "traditional" bileopancreatic diversion (BPD) DS. bile reflux is near impossibility, as the duodenum is split between the bile ducts and stomach, forcing the bile and pancreatic enzymes to flow downstream some ten feet or so (depending on individual variations) until it hits the common channel where it meets the food flow and actual digestion can occur; for it to reflux into the stomach, it would then have to flow back upstream some 4-5 feet or more (again, depending upon individual variations) before it could get to the pyloric valve and reflux into the stomach. The newer "simplified" SIPS/SADI/Loop DS is more of a classic Billroth II configuration (cousin to the RNY) where bile reflux may be possible, depending upon how the surgeon sets up the limb lengths. With the RNY, like any Billroth II based procedures, bile flows downstream from the bile ducts and can reflux into the stomach pouch. The main counters to this is neutralizing the bile with stomach acid from the remnant stomach, and limb length between the bile ducts and pouch. Bile reflux is not uncommon amongst cancer patients who have had a gastrectomy, where the basic layout is an RNY without the remnant stomach, The surgeon that I worked with when I was considering this told me that he has never had any bile reflux problems if he keeps that limb length at 60cm or above; presumably, some of these cancer patients received a shorter limb in an effort to minimize malabsorption and weight loss. As with many things in life (and medicine in particular here,) there is a balance between the therapeutic and objectionable side effects - and people will vary as to where that balance may be in their particular case. Perhaps the OP experienced classic RNY marginal ulcers from the acid incompatibility with the intestine and anastomosis, and in the process of these serial revisions, wound up with an overly short jejunum? Hopefully she can get this sorted out, but the DS does provide something of a last ditch option of other avenues don't resolve the problem; unfortunately, such revisions are very complex, and there are only a half dozen or so surgeons in the country with the skills and experience to perform it. Perhaps a distal RNY, where they move the pouch waaaayyy down the intestines toward the colon may be a middle ground that might do the job.

Sometime in the first week after I got back home. Your weakness and lethargy is unlikely due to vitamins, but just a hangover from the surgery as you go through the initial healing, and quite possibly a result of your current diet being very low in carbohydrates (intentional or not) which is what helps keep our short term energy levels up.

Our plan was for liquids, mushes, purees and soft proteins like fish. eggs, beans, etc. from the hospital on out for the first month, and then everything else after that. The primary rule was to try new foods one at a time to test for tolerance and if a small amount went down OK, then great; if not, go back to known foods and try it again in a week or two. You likely won't be doing much solid food yet as protein still is a priority and you probably can't get enough protein with solid food yet, so there will still be a lot of protein shakes, yogurt, etc for a while as you experiment with more advanced foods. Some people will be able to progress more quickly than others - that would be normal so don't worry if you can't take some things yet.

This is something with a two part answer. The first is that, on average, we will be slowing down continually as we lose, simply because it takes fewer calories to move ourselves around all day at 300 lb as it did at 400 lb, and even fewer at 200 lb, etc. We will likely see stair steps, and some weeks or months will be lower or higher than others, but the overall trend is declining. The second part is that we will usually experience a big drop the first couple of weeks or so (and then typically get the dreaded "three week stall") and the proceed lower at a somewhat reduced rate. This is because our initial loss it mostly water weight associated with burning off our short term energy reserves of glycogen (basically stored carbohydrate) which gives us the "easy ten" lb that we typically lose when we start seriously dieting. After the glycogen is used up, we start to draw from our fat reserves, though there is often a pause or stall as the body changes gears.

I'm glad that you like their program - my nephew just finished his RD internship program at OSU (now he can be frocked as an RD!) Our program didn't have an RD at the time, but I used on associated with our PCP. I only saw her 2 or 3 times but she was very useful. I had already learned a lot about nutrition on my own (as opposed to "dieting") when my wife was going through her WLS journey and I was doing fairly well effectively living a WLS maintenance lifestyle prior to surgery, so she helped in translating the surgeon's nutrition program to my tastes and needs, and then later helped in transitioning to maintenance once all the weight was off and I needed to ramp things up to get stable again.