RickM

The best relative pain guide would be how many inches of incisions do they need to do, as it is the skin that has the most nerves; the interior work like for muscle tightening would be less noticeable. So, a basic panniculectomy to cut off the excess skirt would not be greatly different than a full tummy tuck/abdominoplasty. You do want to find a surgeon who specializes in reconstruction after massive weight loss, as there can be a lot of difference between a basic mommy makeover and a person who has lost 1-200 or more pounds. They usually specialize (at least for our typical need) by patient type rather than body part, though some of the bariatric surgeons who get into plastics as a sideline for their patients will often leave the more "artistic" aspects (like breast implants or facial work) to a specialist PS, though that can sometimes be combined into one procedure if they work in a team effort. People do go to Mexico or other countries for PS as, with the bariatrics, the cost can be much less. The downside is that PS procedures have a much higher chance of mild to moderate complications - incisions that don't heal promptly, or open again, fluid build up not caught by the drains, seromas, etc. Much of this can be handled by taking selfies and email instructions on treatment, but sometimes it takes an office visit, so dealing with someone local is a big plus.

Yes, the same experience on our side (my wife's DS was about a month after yours,) and several in our support group have gone through this and came to much the same conclusion. Things don't get cleaned out quite as readily by the liquid diet, so most do the clear liquid thing for 2-3 days rather than one, and then whatever the bowel prep of the day is the evening/afternoon before. I haven't heard anything odd happening with the bypass folks, and they are common enough that I would expect the gastroenterologists who typically do these things would know if there were. With your DS and the typical 100cm common channel, that is a good meter above the colon, so well above where they are scoping (and it shouldn't be a problem if it was, as long as they knew what they were getting into - bypass guys can routinely have endoscopies that go past the anastamosis/stoma from the top end.

Our doc doesn't restrict them - that's an RNY thing - though it's best not to use them consistently if you can avoid it (and do so under medical supervision.) I used them some after orthopedic surgery a couple years post op, as my wife uses them some occasionally now (13+ years post op) as a result of some spinal problems.

Dark meat poultry is usually better tolerated than light meat at this point - the extra fat and moisture helps it go down easier. Likewise, meat lube - gravies and sauces are helpful now (but not so much later when they might lead to over eating.) While it is generally good to get away from the protein drinks as soon as one can and get into real foods, we still need the protein, so one should use them as long as needed until all of your protein needs can be met with real food - that can be a big variable. Don't be concerned about how other programs define their stages or what they allow when - we never had a liquid or puree stage as it was all mushed together along with soft foods that we could progress through as our tolerances dictated for that first month or so. If mushy things like oatmeal or cream of wheat are what settles well for you now, go for it, and just sample other things in small quantities to see how they work.

What does your program instructions say? I was on them as they are the most effective means of getting the requisite protein in early on, even for those of us not on a strictly liquid diet.

Another good one to talk to would be Dr. Ara Keshishian in Glendale. If you need a revision, he would most likely go for a DS rather than a bypass as that is more his specialty. But since the DS uses the sleeve as its basis, that means that he has been doing them a lot longer than most bariatric surgeons, so if there is something wrong with your sleeve, he would be the one to be able to fix it rather than revise it to something else. By your description, it sounds like your sleeve may not have really been done correctly, so a correction rather than a revision may well be the answer. Typically, a revision from the sleeve to the bypass doesn't do a lot to correct a poor weight loss problem as the sleeve and bypass are so similar in their metabolic strength; if one really needs a stronger solution, the DS is the way to go, but it sounds like a simple resleeve may the the answer for you. Good luck,

I was on a pretty normal diet by then - steak, chicken, veg, etc. Greek yogurt and a few berries for snacks, maybe an occasional protein shake if I was short for the day, (very) small salads with a couple ounces of meat and cheese for lunches - overall fairly normal things. But it all depends upon how your surgeon's program progresses (as above, some are slower than others) and how you tolerate things, which can also be a big variable.

My wife and I were on a similar progression, starting with soft and mushy things along with the liquids from the hospital on out. The basic rule was to try new foods one at a time to test for tolerance - if they go down well (and don't come back up!) that's great; if there is a problem or it doesn't feel quite right, back off to something familiar and proven and try it again in a couple of weeks. Protein drinks are usually a staple for a while as it is hard to get enough protein in with real food for a while, and things tend to be on the liquid side to start and get progressively thicker and firmer as you experiment with your tolerances - strain out the chunks of chunky soups, then next time mash up the chunks, then try them without mashing them. You just need to get a feel for how your stomach is working.

What does your doc say? Physiologically, you probably can as many programs don't have any clear liquid phase post-op, but if you have any problems and were advancing your stages without permission, then you get the blame for those problems, for being "non-compliant".

Many aspects of his approach I like, particularly his "veg first" approach to long term maintenance - he is one of the few docs that I have seen who discussed how our meal size evolves over time, and has a prescription to mitigate that (see his vid on "sleeve/pouch stretching") His green smoothies aren't popular with the low carb/keto crowd, but the do seem to have a better nutritional basis than most of those common fad diets. His protein requirements (45-60 g, IIRC) overall seem a bit scant for all but the smallest women, but overall, his focus on getting into real foods as soon as tolerated seems to be good thing, and fairly consistent with the program that I was on.

Do you have an EOB (explanation of benefits) from the insurance on this - that is their take on the situation, and on what you are obligated to pay (in their view)? It sounds like the insurance is paying for the first anesthesiologist, but (correctly) not for the second. Call their billing service as the first step, and ask what is going on. Then you can also take it up with your surgeon, as he is the one who usually specifies what anesthesiologist he works with, and any problems here reflects upon him (or her). My wife had some spinal surgery a couple of years ago, half a day's worth in the OR, and we got a bill from an OR nurse asking for over $16k, of which the insurance paid around $300. Unresponsive billing service, so we asked the surgeon about her and he made a quick text to the nurse and we had a call from the billing service removing the obligation by the time we got home. Unhappy surgeon is not nice on the hired help!

It is worth noting that the group doing that paper (Inabnet, Gagner, Pomp, et al,) were early adopters of the DS, so they were already well familiar with the VSG as part of that, so this study was contemplating applying what was then a fairly normal two stage DS approach of doing a VSG followed by the switch to the RNY. Most bariatric surgeons of the day were unfamiliar with the VSG, and the more normal approach of two-staging the RNY at that time was to use a lap band as the first stage, as that was familiar ground to most bariatric surgeons of the time. The VSG did not start to become a normal practice in the bariatric world until 6-8 years ago when the insurance industry started covering it more consistently; prior to that is was largely the "property" of the DS world, and that is where most of the early work in moving it toward a stand alone procedure came from.

Yes - what's typically done for a colonoscopy, or an endoscopy for the other end, is all that is needed to clean things out. Our surgeon has a similar day before pre-op protocol as they specialize in the DS which slices up and rearranges the small intestine, so things need to be cleaned out for that - its a bit of overkill for a VSG that only operates on the stomach, but they always like to keep their options open. They have any other pre-op dieting requirements as the potential fatty liver problem doesn't seem to be an issue with them, but it can be intimidating for some surgeons (there was someone on here recently whose surgeon actually followed through the the common threat to "pull out and close 'em up" if the liver wasn't shrunk enough for them.) So yes, you want to do what your surgeon asks to make him happy (that particular poster had complied with all requirements, but it apparently still not enough for that doc.)

Let's take a look at these: #1: most patients will lose 10-15 lb on any substantially low calorie diet, whether solid or liquid. #2: liquid or solid is irrelevant to protein content, though lean meat and green veg will have better nutrition than most any protein drink. #3: liquid or solid diet is irrelevant to change in liver condition - it's the carbohydrates, or lack thereof, that counts. #4: how does one gain a /mental awareness of calories, portion sizes and ingredients when restricted to liquids? #5: so this is just a test or challenge for the patient? #6: it only takes a few hours for the stomach to be empty for surgery, not weeks. This is why most gastric scopes or surgeries simply require no eating after midnight prior to surgery. #7: unless one has to buy a proprietary diet product from the surgeon! Overall, I prefer bariatric surgeons who know their way around obese patients and who prefer their patients to be as strong and healthy as possible going into surgery - which multi week fasts don't do. If a surgeon is intimidated by fatty livers and needs help in working around them, then by all means do everything necessary to make him feel comfortable when he is rootin' around on your insides, but he should also do everything to help the patient feel comfortable with the process - at least let them have some steak along the way!

I have never found a satisfactory answer to this question (usually the liver shrinking thing is sited, but as you note, that only requires a low carb diet, not a liquid one.) I suspect that it is one of those "that's the way we've always done it" things. Sometimes we may hear something like "getting the patient used to their post-op diet" but that doesn't really wash, either, unless the program is specifying post op liquids long after they are necessary.

Maybe you do, maybe you don't - it's one those "it depends" things. Your new carrier may not even have a 6 month diet requirement, or it may be 3 months or something else. Check the website of your new company and look for their "policy bulletin" on WLS which will detail their specific requirements. The surgeon that you choose may or may not be in their network (check on the company's website, or ask the surgeon's insurance coordinator). Out of network usually just means that you pay more in co-pay to get the surgeon that you want, but some policies may restrict you to only those in their network. Unless the company has some pre-approval requirement that you pass through before starting the process, there should be no harm in starting before the policy is in force, as the requirement is usually just a documentation exercise, but worst case is that you may have to continue the effort an extra couple of months.

It is quite normal; it is all up to the surgeons (and occasionally the patient) and what he needs to feel comfortable doing the surgery. Some surgeons are intimidated by the nearby (often) fatty liver and impose these diets, while others have different skills and experiences such that they know their way around that potential problem. Indeed, some surgeons specifically don't want their patients doing these multi-week fasts as they want them as strong and healthy as possible when on the table, and fasting doesn't do it.

The best general source of potassium that I have found is the low sodium version of V8 juice, which has around 1100mg per 11oz can. Most of the sports drinks have little in them, and the legal FDA limit for OTC supplements is about 100mg, vs our RDA of about 4400mg, so it is tough to get much in on a liquid diet without Rx supplements - the V8 is the best around (it's hard to OD on real food sources, so that's your best bet.)

Programs vary all over the map in many areas, though the common elements are: Protein - consistent with need, but generally 60-80 g for women (though shorter than average women can do fine in the 50's) and 80-100 g for men. Protein need is most closely associated with lean body mass, hence the difference between men's and women's needs. Eat protein first, then veggies, fruits and starches Eat slowly, chew well Don't drink calories (protein drinks excepted, though you won't need to do them at this point) Avoid drinking with meals and for 30 minutes after meals. Drink a minimum of 64 oz, though the need is often higher depending upon activity and weather. Those are the things that are common to most plans. Minimizing sugar intake is often sited and sometimes a number is put on it; likewise, carb numbers are occasionally specified, though those can be deceiving and best not dwelt on. Calories are sometimes specified in programs and sometimes not. Those that work best seem to cluster in the 6-800 calorie range, but that is hard to maintain in a regain recovery program. It is best to work with your individual metabolic need, which again can be quite variable; Try for 1000-1200 and see how that goes; 12-1500 is often a maintenance level for many women. Keto and vegan/vegetarian are largely irrelevant - they are more lifestyle type diets that don't have any inherent weigtloss properties, though they can be used if one keeps the calories low enough. The key factor is what kind of diet will help you stay away from the high calorie/low nutrition junk that promotes weight gain. Good luck in your endeavor....

The benchmark that we used was to try to down an ounce (a shot glass or one of those small medicine cups) every 5 minutes, That gets you 12 oz per hour; if you can do more or faster than that - great- if not do what you can do, but it's a reasonable rate to shoot for.

They aren't the same thing, but have the same basic root cause of rapid stomach emptying from the missing pyloric valve (as with dumping, people with an intact stomach can also experience these things, though it is rare.) In addition to the symptoms that you have noted, RH is also associated with greater inter-meal hunger that can lead to regain, so that is another reason to keep it under control and learn what triggers it in you.

30 min after a meal, most certainly; 30 min before meals, maybe (depends on specific program instructions.) You don't want to drink after meals to keep the food in the stomach as long as possible; drinking too soon can help empty the stomach sooner leading to more inter-meal hunger and is associated with weight gain or poor loss. Drinking before meals can be a problem for some for a while immediately after surgery as with the potential for inflammation in the stomach, fluids may still be in the stomach at meal time, impeding getting the food in. As the inflammation resolves - a few days to a few weeks, the fluids move through the stomach easily and quickly and drain out in just a couple of minutes, so the pre-meal limitation is no longer needed. Some programs mention this last detail and open up pre-meal drinking at some point, but many don't bother and leave their patients hanging. (Similar problem as to how long does one need to sip, sip, sip their water before one can drink normally - many programs don't bother saying.)

Yes, it is. But are you expecting a better answer from us than from those with the expertise to know you and your condition best? Were you not in the hospital, the most appropriate answer for a question such as this, one which is giver quite frequently for situations such as this, is to either call your doctor and check, or to go to the ER and get it checked out. Blood coming out of any place after surgery is a concern, It may be a "we gotta get on top of this - now!" type of thing, or it may be a "let's keep an eye on this and see if it clears up on its own" situation, but that is something that needs professional medical judgement.

The industry standards are for coverage at BMI 40 without comorbidities such as hypertension, T2 diabetes, sleep apnea, etc. and 35 with comorbidities. The lap band industry got FDA approval for their devices down to a BMI of 30, and some insurance companies followed. My inclination would be to find another surgeon, as this guy doesn't seem to want your business - any surgeon worth a salt would send a patient such as yourself to get a sleep study to check for previously undiagnosed sleep apnea, which would qualify you for WLS. He would also verify your height to make sure that the calculation is correct.

It simply means that you no longer have any significant inflammation in your stomach, so fluids are flowing pretty freely, as they should. You won't really feel much fullness until you get into more solid foods that stay in your stomach longer.