RickM

Yes, it is quite normal - some don't do a liquid diet pre-op diet at all, preferring just low carb and/or fat, calorie restrictions, or no dieting at all - we didn't have any restrictions until the usual day before general surgery thing. A big YMMV thing. While I wouldn't go overboard on starting a liquid diet early, transitioning to more protein drinks and the like to get used to them and find your preferences is certainly useful. I don't find the getting used to post op idea all that compelling, as you likely won't feel like having much else other than liquids, but some programs go overboard on the back end with extensive liquid dieting post op, so for them, it might be useful. Our program had liquids in it, but transitioned us as we could tolerate thicker and more solid foods, with their findings that their patients tended to do better as they moved into more real food. But programs vary widely, so go with their instructions.

I believe that is the idea - I've never looked at it from the mathematical perspective (though I tend to be a numbers guy,) but that makes sense. Lower GI foods have a lower impact on your insulin responses than high GI foods. Then there is the related idea of Glycemic Load, where the important factor is the combined GI of an entire meal, so that high GI foods are averaged with the low GI foods to estimate the response to more real world eating. That way, pineapple on your ham has a much less impact on your system than it does by itself. There is a related concept that I have heard offered more recently that the beyond the basic food statistics, that processing of the foods, including cooking, impacts its absorbability and can/should be considered. This makes some sense in the apparent problems with packaged or processed foods, beyond just the added sugars that are often included. The problem with this seems to be objectively measuring these differences on a wide enough scale to be useful, beyond the basic "avoid packaged/processed foods" advice, or raw is better than cooked as the body needs to do more to break it down. This whole topic does illustrate the futility of simply counting carbs as a guide to health or weight loss.

I think that it mostly gets down to the relative amounts of simple vs. complex carbohydrates in the food - a big difference between 50g in soda pop vs. a plate of broccoli or raspberries where the sugars are mostly bound up with the fiber, which takes longer to break down and absorb. The free sugars in the soda starts being absorbed in the mouth and all the way down, so that starts tickling your insulin responses immediately while the more complex fruits and veg need to be chewed and digested before much of that happens.

Ah, the infamous straw question! Practices seem to vary on their opinion on this from "never use them, ever!" to "what's the big deal - go ahead and use them if you don't feel any problem?" My doc, as with many things, is of the "go ahead and do it if it doesn't feel bad" camp and we used them in the hospital. I think that the concern is that you might suck in some air with the fluid, which you might if you are trying to get the last drops out, and that that might be uncomfortable or worse. The general consensus that I have seen is to use them and if you feel any discomfort from it, then don't, but if you don't feel anything unusual from using them, you aren't doing any harm. As usual, go with what your program recommends, as you will get the blame for anything going wrong if you don't, even if it is irrelevant to what you did.

The mini, as its name implies, is a simplified variant of the RNY. Rather than bringing up the added Roux limb below the stomach pouch, they tie the pouch directly into the intestines downstream of the duodenum; how far down depends upon how much malabsorption they want to induce. The classic proximal RNY is fairly minimal in the amount of malabsorption it offers, and indeed the caloric malabsorption tends to dissipate after a year or two. There is a distal RNY which is more highly malabsorptive - similar to the DS - but it is not often done in the US. The mini has been kicking around on the periphery of bariatrics for some twenty years or so but has never gained traction in the US and is not usually covered by US insurance. Classically, it is more prone to bile reflux and possibly acid reflux as well, as with the bile, there is the prospect of things getting recycled and refluxed back up into the stomach. There are claims that some techniques have been developed to mitigate this problem but I haven't seen any independent verification of that. But, there may be something to that as the mini has become somewhat mainstream in other countries, so we do see it discussed here some, But in the US it is rare and it is mostly offered in Mexico as a cheaper alternative to the RNY.

Yeah, being in a small community, one often has to go to "the city" to see specialists quicker or are more specialized. Some complain that their surgeon is scheduling months out, to which my response is, "do you want a surgeon who is just sitting around waiting for you to come in the door, or one who is in demand?" But for a check the box type of specialist sign off like this, I see little problem with jumping the line by going out of town to get a sooner appointment. The only down side is if you wind up needing recurring treatment from that specialist, then you need to either continue with one who is inconveniently located, or transfer care to the local guy with the waitlist. Either way, as cat suggests, waiting does have its benefits in being better prepared - I found that the extra time gave me the opportunity to work on changing my habits for the better in the long term - most of the dietary habits and disciplines that I evolved to while leading up to surgery stuck with me as things progressed post op - when I "cheated", I did so on things that were fundamentally healthy rather than just junk, and didn't have a significant transition from "weight loss" mode to "maintenance" mode.

I doubt that Blossom does the DS, though we do generally hear decent things about them on the other procedures for those on a budget. She could also go to one of the DS guys in CA - Rabkin or Keshisian - but they will be in the same range as what she was quoted in WA, if not maybe a bit higher.

I think that it partly depends upon how soon after surgery you are travelling, and then your individual experience with healing and recovery. Our surgeon had us stay in town for ten days, in order to have the first post op follow up visit in person, and then head home. That, and also just the basic conservatism of being local for the first few days as that is the time of greatest likelihood of complications needing rehospitalization (and with a DS, he doesn't want anyone else fooling around with your insides if something does need to be done, as uncommon as that may be.) On bathroom issues, most any of us are subject to problems early on as our systems get used to the changes that were made (you may have run into some of them with your sleeve - constipation being the most common, but it can go the other way too...... As you aren't eating much then, there is proportionately less coming out the other end, but again, the diet is different and your system may object, no matter which surgery you have. The DS is known for bathroom issues, but it overall isn't greatly different than what many RNY folks go through - it's just that many surgeons will emphasize it with the DS when they are trying to sell you on something else that they know how to do. The malabsorption will change things, and early on things may be more inconvenient or urgent until your diet gets squared away and you figure out what does and doesn't work for you. Up until Covid hit, we had a regular group support meeting that was primarily vets 10-20 years out that was a restaurant dinner event, and you wouldn't know that it was a group of primarily DSers in there (other than on average being more normal weight.)

There is a thing called "bariatric keto" which is basically Atkins in that it is higher protein than current keto fads call for, but Atkins is "old school" while keto is "in" and what people want to do if they are keeping up with current fads - so they label it appropriately. But, I wouldn't compare a bariatric diet (which is basically maintenance level protein and then whatever else to fill in the minimal caloric requirement one has,) to keto, or Atkins, though one can use them if so inclined, but neither is all that sustainable long term, and that is what you should be striving for. Think in terms of what your diet should be in five or ten years - if that's keto or Atkins for you, great, but there's no compelling reason that it should be either. It can be vegetarian or vegan if that floats your boat, and that will work just as well.

The mini bypass has been kicking around for a long time - it was around the periphery of bariatrics some twenty years ago when my wife and I first started looking into WLS, and it's still there today, not having achieved mainstream status (and many, if not most, US insurance companies still don't cover it.) in the meantime, the BPD/DS, VSG and now the SIPS/SADI have gone mainstream, gaining acceptance by the ASMBS and insurance industry. It would pay to understand why that is. When I last looked into these things, 2-3 years ago, ASMBS was fairly positive about the SIPS/SADI, but they didn't yet have the data to recommend it; they apparently do now. I would suggest looking through their site to see if they have any current opinion on the MGB and why it doesn't get on their recommended list. Amongst the MX surgeons, the MGB seems to mostly be sold as a cheaper alternative to the RNY rather than a technically better one. Classically, bile reflux is one of the problems with these simplified, single anastomosis procedures. There are claims that some techniques have been developed to mitigate that problem, but I don't know how much of that is real progress and how much is marketing. The MGB does seem to be more mainstream in other countries, so there may be something to the claims of improvement, and it simply lost its best opportunity to be sold to the US industry and authorities. Given that, I would be apprehensive about getting it done while living here in the states, if for no other reason than long term support - how many US doctors, bariatric or otherwise, understand it, and how to treat you in the years ahead should there be a problem. It's something like owning a French car here in the States - parts and service are a problem. My wife has a DS, which has something of that issue, despite being mainstream and approved, as it is still something of a niche procedure, with few surgeons understanding it. It, however, has the redeeming value of having demonstrably better performance - both initial loss and most particularly regain resistance; the MGB doesn't, as it's not markedly different than the RNY or VSG in performance. Have you had your GERD evaluated as to its cause? A hiatal hernia or shape issue can usually be corrected while still maintaining the sleeve, though some surgeons may not be well practiced at that and would simply revise to a bypass to correct it (the old "VSG + GERD=you need an RNY" thing rather than fixing the basic problem - it might need an revision, or it might not.) In correcting regain, these revisions seem to be only moderately successful - count on maybe twenty pounds or so - about what one would expect from the intense dieting required around surgery time, and one can expect similar results from a hiatal hernia repair. Basically, you have already learned how to eat around a small stomach, so shrinking it further with a revision doesn't yield nearly as good a result as your virgin procedure. Some do show remarkable improvement, but they seem mostly to be those who take the regain seriously and swear to "not let that happen again" and really buckle down and get with the program. One can almost consider the revision to be a placebo. If I were looking to seriously tackle a regain problem, I would lean more toward the BPD/DS as that more directly addresses the metabolic problem, though not the GERD as it retains the sleeve - that would remain an issue as to whether the sleeve itself is the cause of it and that can be corrected.

As far as whether its too early or not, that's up to your program, as they vary widely on such things. At this point, protein is king, and then whatever else that goes along with it. Corn tortillas aren't a high density nutrition food, either for protein or anything else, but they aren't particularly bad, either. I used them during the loss phase mostly as a faux pizza crust - crisp up a thin corn tortilla and add mean, cheese and token veg, seasoned appropriately, and some pizza or pasta sauce - and that fit my needs of protein vs. calories for a meal. I always strived to maintain at least an homage to a normal healthy balanced human diet within the confines of our protein requirements and minimal intake, and that would be a part of that.

While many programs don't specify calories, early on or at all, my gut instinct is that your feelings are right and that is a bit high. I ran 1100 from about that time through maintenance and it did well, but I have a guy's metabolism that seemed to be working fairly normally (doc's RN was telling be to SLOW DOWN at about six months, which was a good call as goal weight was just around the corner. But many go much slower, and my gut feel is that as an average to shorter woman starting in the 50+ BMI range you will be slower losing and should keep the calories a bit lower, if for no other reason than it is much harder to cut back in a few months if you find yourself lagging on loss rate than it is to increase your intake. Presumably, you are still working through the diet progression and are still on liquids and mushy things, and it will be harder to consume as much as you get to firmer and more solid foods - take advantage of that and try to reduce your intake some as you progress - 800 or so seems to be a good range for many. Some programs, particularly some of the bypass oriented ones, do call for fairly high calories - 12-1500 calories sometimes - and many people get along ok and lose well on that. But those programs also tend to be the ones where many of their patients fall short of their goals, and the program considers 60% excess weight loss to be a good goal; other programs, and patients, strive for better. Points to consider.

Unfortunately, you still need the change in lifestyle/diet habits to make this work long term. I like to think of the sleeve/RNY as being a "do over" rather than a total fix, because it will indeed help get the weight off, and usually faster, than going alone, but there is still the tendency to gain again over time, as one can still "eat around" the surgery. The DS (duodenal switch) is better in the regain resistance area, but that is even greater overkill for a low BMI patient. I decided on the sleeve after my wife had here (much needed) DS and I had lost 50 or so lb of my excess weight, and kept it off for 5-6 years, but couldn't sustainably lose the next 100 that I needed to lose. So I had much of the habit part taken care of ahead of time, and it worked well, though it still takes work to keep it off - most of us long timers have been through periods of gain that we have had to lose again. Regain tends to be slower than without the WLS, but the bias is still there. So, you may well be in this same boat again in 5-10 years. In short, the sleeve will help you with the part that you already can do fairly well - lose when needed - but is only soso on helping you with the part that you struggle with - keeping it off. That's a consideration when trying to match the "personality" of the surgery with your own personality.

It does sound like an endocrinologist is the place to go. A few years ago in the Rabkin/Keshishian group in Ventura there was some discussion about such things and there was an endo down there who was DS knowledgeable that several patients had seen. There was a discussion about osteoporosis, calcium, etc. a couple of weeks ago on Rabkin's monthly Zoom meeting, so that would also be a place to check out to get some general knowledge on these topics, and certainly a consult with the doc can zero in on specifics. From your other thread, it does seem like Prolia is the treatment of choice today - my wife (DS class of 2005) is on that and it seems to help.

I'm not sure what California has to do with it, as I know several surgeons who do resleeves, either by themselves or as part of a DS conversion. I suspect that it is more of surgeon's preference as resleeves can be more challenging than a virgin sleeve, as is often the case when doing a repair vs. an original build. Have you had your sleeve evaluated as to what is its' problem - is there a hiatal hernia causing your GERD, or a bit of a shape problem? Some surgeons aren't all that well practiced on fixing hiatal hernias on a sleeved stomach and will go direct to a bypass instead, as that is what they are most familiar with; a bit of overkill for that problem, but easier for them (if not on the patient....) I wouldn't consider a revision until understanding what the problem with the original surgery is (was there something wrong with how it was done, was it incompatible with my personality, or did I just learn how to eat around it and need something stronger along with better habits?) It's good that you are taking in a new attitude on the regain problem, as neither a resleeve by itself nor a bypass do great things for that overall - most of the additional loss seems to come from a return to extreme dieting around surgery time, but the actual revised anatomy doesn't do a lot that you already haven't had done; A revision to a DS tends to do better (actually more of a completion, as the DS uses the sleeve as its basis,) but that probably isn't an option with the group you are dealing with if they can't do a resleeve (if it were appropriate.) But with a sleeve, regain and "some" gerd, I would at least be looking into the DS as an option before proceeding, as the bypass is a difficult thing to undo or revise once it is done.

Adding to what SpartanMaker mentioned above, the other major concern with alcohol use post op is that it is a liver toxin (physiology here, no moral judgement) and that our livers already tend to be in poor shape owing to our obesity (hence the "liver shrinking" pre op diets that some programs put their patients through) and then the liver is further taxed by its role in metabolizing all of that fat that we are rapidly losing. The last thing that it needs is the added stress of metabolizing alcohol. Surgeons vary on how much this point bothers them, largely depending upon their experience with such things (and maybe their own alcohol tolerance?) Our surgeon also moonlights as a biliopancreatic (liver, pancreas) transplant surgeon, and the last thing he will tolerate is one of his bariatric patients coming back onto his transplant table.

As you note, the scales and calculators are mostly a "best guess", as they are highly algorithmic. The more direct measures like the vox tests and the like are better, but still have some population algorithms in there that can go astray of one is far outside normal population standards, as WLS patients often are. Similar for body composition checks - the scales are OK if you know how to correct them, but the more direct measures such as bodpod, water displacement and even dexascan are trying to solve for more variables than they can measure, so they are comparing to norms. Getting into BMRs and the like, of course there is the judgement as to burn rates and exertion levels above resting, but then with our WLS of different flavors, that impacts the intake caloric level that we consuming and absorbing, and how the body adjusts to the insult of surgery over time, what the surgery that you had does to the absorption of different foods (fats absorbed differently from carbohydrates which are different from proteins, simple carbs different from complex carbs.) In short, you may get a number from some lab testing as to what calories are appropriate for you, but the ultimate test is whether your weight is stable at that point, or gaining or losing so that you need to make adjustments.

Also, the written instructions are sometimes just boilerplate, created for general cases, and sometimes not even bariatrics, and sometimes they just go obsolete and haven't been updated, so certainly go with what instructions you get personally from your doctor or RD (and sometimes even that will vary.) The post op discharge instructions given to you by the hospital can be some of the most generic (often written more by lawyers than be doctors....) and can conflict with what your doctor will tell you - go with the doctor's instructions. Sometimes the guidebook given to you by the bariatric program may be a bit out of date - I have seen some be told by their doctors to advance to the next stage now, even though that may be a week or so in advance of what the book said, with the doc telling them that "we have learned that the patients are doing better by going a bit faster, and we'll change the book next time we print some..." Again, go with what the doctor tells you.

Programs will vary all over the place depending upon their experiences, convenience and tolerance for potential minor complications. Our program, for example, allowed us most everything liquid, mushy or soft for the first month, and we could switch between them and experiment depending upon our personal tolerances - if something didn't settle quite right, go back to what did and try that food again in a week or two. Some programs may prefer to keep their patients all on one track based on the most problematic patients (lowest common denominator) to avoid hassles and calls to their staff.

Adding to the good points that have been made here, metabolic rates are somewhat individual, beyond genetics but personal history and even your gut flora that helps digestion and absorption. The BMR tests are interesting as a reference, but they mostly tell you what the algorithm thinks your metabolism should be, but not what it actually is. Also, this is a somewhat tough time for a bypass post op, as the caloric malabsorption of the bypass dissipates after a year or two - you tend to lose that extra help in losing weight and become a more "normal" person in that regard. Some may never notice the effect if they lost quickly and early, but it can also bite you in maintenance if one gets used to being stable at say, 1700 calories, but then that stability point drops to maybe 1600 or 1500. So, stay flexible and try to keep the calories down as much as you can until you get to the weight you desire (or to where it just won't go down anymore) and adjust to maintenance Good luck....

This doc gives a pretty good timeline for you things progress. yes, you will be able to eat more over time, but not as much as you can now, but that is still enough to get into trouble if you don't learn how to use your WLS to keep things in check. This doc's recommendations are one way, and a somewhat unusual way, to do it, but it works, (though I'm not so sure about his green smoothies) as do others. It's a matter of what you can find that works for you over the long term.

The article I read recently on that indicated up to 3", or possibly 6" if one is wants to go through if with both the tibia and femur. Ouch. And I thought that the old penis enlargements were kooky.

Never trust a fart.

If it's the same doctor who did your sleeve, then the post op diet and progression will likely be the same; if it's a different doctor, then it will be whatever they normally do, but usually the sleeve and bypass are treated the same (there's usually more difference between doctors' practices than there are between procedures.) While there are variations, you will probably be set back to much the way you were with your sleeve, and will evolve to eat similarly over time. Weight loss will not usually be as quick or as much (and may be disappointing if you are expecting a lot,) as you have already learned how to eat around a small stomach, and the size difference isn't nearly as much as between a virgin WLS and natural stomach.

"Never trust a fart...." Also, do a search for the Al Roker White House SHART story. You are not alone. My wife, who has a DS, so is subject to the same issues for the same reasons, has a small battery powered bidet wand thing that she used for some time, and also a bidet seat is worth considering for those times, as that is gentler than even the nicest TP. Beyond that, as above, you have to figure out what dietary things trigger it (and sometimes it may be a total mystery...)