RickM

How about four sips of Coke, or only half a Twinkie? It's habits that got us into needing WLS, and it is changing those habits, with the help of our WLS, that helps us recover and learn to control our weight long term.

You probably can (always check with your doctors on such questions, rather than someone else's) but do you really want to be letting junk food back into your diet so soon? It may be keto, but it is still basically empty calories, and liquid calories tend to be the best way to eat around your WLS. Not good to be getting into such habits so soon.

Similar procedures are done with the RNY (Band over Bypass - BoB) without a lot of success - that is something else for your to research to see how well the band works in that application. The couple of thoughts that I have had on the idea is that there is likely some over-promotion of the idea from the band manufacturers who have seen a dramatic decline in their market as the problems of the bands have become more widely recognized, and they are looking for new markets. The other concern is that acid reflux are relatively common complications of both procedures, so if you haven't had a problem with it post-VSG, will adding the band bring about that problem where it didn't exist before? Another concern (make that three, now) is what are the longer term implications of this, given that the bands have a fairly high revsion/removal rate due to band failures or damage to the stomach via slippage or erosion - will it work any better, or worse, on a sleeved stomach?

Someone here recommended these a while ago, and they work pretty good - not as good as being nekked, but help keep things under control when ya gotta be presentable to society - https://www.amazon.com/Athletic-Underwear-Adjustable-Support-Spandex/dp/B076ZYKNLZ/ref=sr_1_7?ie=UTF8&qid=1524703913&sr=8-7&keywords=ufm+underwear+for+men

They had to make sure that you knew that it wasn't their fault! Leaving the scene of the crime is a sure sign of guilt.

I never crushed any pills - it depends on your doc. From what I have seen, crushing pills is mostly an RNY thing where some are worried about pills getting stuck in the stoma, and some docs carry that practice over to their sleeve patients.

Does your doctor have you on a PPI acid reducer med - they are commonly prescribed for a while post op, and excess acid can mimic hunger.

I suspect that you are headed toward revision, given your lifelong experience with this, but there are always things that should be tried before going for surgical solution. Given your history, I suspect that you have tried most of the various tricks and treatments for GERD, such as sleeping with head elevated, not eating X hours before bedtime, etc. There are some books out there by MDs who specialize in the problem that may give some more insight. One common thread seems to be that dietary fat may be contributory to the problem, so your keto efforts may be working against you if that is the case (OTH it may have little to do with it and is just a throwback to the days when low fat diets would fix anything, much as low carb diets are today's universal solution.) It may be worth a try to shift your dietary balance for a while and see if it has any effect on you, There are also some foods that supposedly help or hinder the functioning of the lower esophageal sphincter, and likewise some medications that target it, so those are things to explore. Given your history, I assume that shifting meds may have been discussed - transitioning from PPI to H2 inhibitors such as Zantac or Pepcid - they are generally somewhat less effective but generally preferable from the long term use perspective. Given that you are still seeing reflux evidence in the EGD even on the PPI, it is unlikely to make a significant difference as symptomatic relief doesn't necessarily mean that the problem doesn't still exist and is doing damage, but it is something else worth considering. Historical curiousity - back in the dark ages, vagotomies were performed, severing part of the vagus nerve to disable some of the protein pump ports as a chronic reflux treatment; this was obsoleted by the introduction of PPIs, but maybe it's time to reintroduce the "old school". Good luck in working through this.....

I never used any particular product, but working with my RD on this problem she suggested that the classic nutritional approach is to have a small meal/snack an hour or so before that is high in complex carbohydrates, moderate in protein and low to moderate in fat. I played with that and settled on a small sandwich with a slice of whole grain bread/toast, meat and cheese, and that worked well, extending my workouts in the pool beyond and hour, where I had been hitting a wall. Going higher fat and lower protein like a peanut butter sandwich didn't work as well, so there seems to be something to that particular mix, at least for me. On days that I did a strength circuit, it didn't seem to matter, as I could readily work around an hour and a half without distress no matter what I ate beforehand, so this also seems to be somewhat task dependent - what is your body looking for. My nephew, who is an RD in training likes to use a classic CLIF bar for convenience and a similar nutritional profile. It seems to be a big YMMV thing, so play around with it and see what works for your routine.

Our program was liquids, mushes/purees and soft proteins like fish or beans from the hospital on out, progressing as individual tolerances allowed. Try new foods one at a time to test for tolerance and if went down OK that was great but if not, go back to things that worked before and try again in a week or two. My wife was slower to progress than I was as she probably had more inflammation in her stomach, but we were both within the normal progression range.

You might try the revision forum here on BP or on other bariatric sites, as they may reach a more relevant audience. A couple of resources that I found useful when facing a similar prospect are: https://www.facebook.com/SupportGroupForPartialTotalGastrectomyPatients/ https://www.amazon.com/Art-Eating-Without-Stomach-Gastrectomy-ebook/dp/B00NQZRGV2/ref=sr_1_1?s=books&ie=UTF8&qid=1524198227&sr=1-1&keywords=dr+peter+thatcher

Here is one surgeon's perspective on revisions, though not specifically addressing this particular technique. The general consensus that I have seen regarding the common RNY revision techniques of band over bypass or different means of tightening up the stoma is that they aren't particularly effective, but that they are about the most that can be done without totally revising the RNY to a duodenal switch, which is much more effective but a very complex procedure done by few surgeons. Another thing to recognize is that when you are dealing with a trademark named procedure like Stomaphyx, Lapband, Realize band, etc., is that there is manufactured surgical product involved, with a manufacturer that can provide extensive marketing power in promoting their product, so like with the bands, there tends to be a lot more optimistic over-promotion of the procedure than there is for procedures that don't us a specialized product, like an RNY, VSG or DS.

It can be done, as total gastrectomies are done for cancer and some other extreme gastric morbidities, and what is often done is they make a pouch out of part of the intestine where they join in the esophagus. There is apparently a substantial difference in recovery and adaptation time between a total gastrectomy and a partial gastrectomy, even with a marble sized pouch of stomach tissue - tying the esophagus directly into intestinal tissue seems to be a much bigger deal than taking the stomach tissue at the base of the esophagus and tying that into the intestine. As with any revision, particularly when dealing with potentially odd configurations, I would want to get a second opinion or two, as you aren't dealing with just a straightforward virgin bariatric procedure. A bariatric practice that is associated with a major cancer center would be a good place to start in finding good experience in such abnormal procedures. Good luck in working this out,

It looks pretty good - I will have to play with it more and try some things. So many of these sites, particularly those targeting bariatrics and weight loss make the mistake of confusing low carb, keto, or whatever the diet of the day is with low calorie or weight loss friendly, and they don't always go together, Most of these diet concepts make compromises to fit within their charter, so that low carb or gluten free recipes are often higher calorie than normal. This site seems to flag their recipes to these different diets so one can pick and choose what ones may fit whatever diet they are on.

How much sugar is in a tablespoon, and does that fit within your program's guidelines? Divide the amount of sugar in a serving by how many tablespoons are in that serving.

Yes, it should be recorded along with everything else, and if one is concerned about carbohydrate counts for whatever reason it should be considered in those totals. It was nothing that I ever worried about.

It sounds like you found a good guy to work with, one who isn't rushing you into a decision - things tend to work best when your mind is firmly made up on the right path rather than being "sold" on what the doc likes best. It looks like the height/leakage issue is a minor one, that is more of a tie breaker if everything else works out to a split decision between the two.

Absolutely - I couldn't afford the side effects that can accompany the low carb diets. These days in maintenance it is usually in the 150-200 g range (on a 2000-ish calorie diet) while when losing it usually wound up in the 70-120 g range (though I had/have no particular goals for it; it is what it is when everything else balances out nutritionally; same for fats.)

I have not heard this objection before, and there are a couple of tall RNY guys in other forums that I monitor. However, I do tend to take surgeons' advice seriously, even if it may differ from the average or norm - if he has had some experiences that would cause him to make such a suggestion, that should be considered. It may be a general thing within the industry that isn't mentioned much to outsiders, or it may be something specific to him. For instance, we sometimes hear of surgeons threatening to "close you up and walk away" if a patient hasn't complied with their "liver shrinking" pre-op diet (though I have never heard of this threat carried through) while other surgeons have no such problems and make no such impositions on their patients - they seem to have no problem working around a fatty liver that may be an issue for others - differing experiences most likely. The upshot of this is that this may well be something specific to this surgeon and not a big deal to someone else. If one is inclined to favor the bypass, then a second opinion from another surgeon would be a good idea. If you really click with this surgeon and want to follow through with him doing your surgery, I would take his advice seriously and lean toward the sleeve. Overall, both procedures yield similar results, though as you note, the bypass may get you there a bit sooner - but is that such a big deal on something that you will be living with the rest of your life? The bigger point in my mind is getting what fits you best. All of these procedures have their advantages and disadvantages, and they all have something of their own personality - you want to get what fits you best

Starting where you are, with a low 40's BMI, 90-100% EWL is quite attainable, but as always, "it depends". Implicitly, your metabolism isn't too badly screwed up by obesity (yet) or you would be heavier - so that is in your favor. While the oft-quoted 60% is an average, that is an average over all patients with the VSG, with starting points from BMI 35 to 70 and above, and also includes early patients who were sleeved as the first step of a DS where total weight loss was not the goal (only partial loss to attain a healthier condition for the more extensive surgery.) There is a rule of thumb that some surgeons use in comparing procedures, that assigns average BMI losses to each procedure, with a lapband being "worth" about 10 points, a VSG 15-20, an RNY 15-25, and a DS 25-35 (or numbers to that effect - best of my recollection.) But this does put you right into the middle of the VSG "sweet spot", where it works quite well. Some/many can do better than these numbers, but it takes more work, and the numbers give a rough idea of the how much success can be attributed to a procedure, on average, and how much to individual effort and/or circumstances. Another aspect to this is - how "average" do you want to be, or does your surgeon or program strive to be? As you can see above in some of the posts, many programs quote overall averages to their patients, with the implication that average is "good enough". Other programs will push their patients harder, striving for 100% EWL, and even if some fall short and "only" attain 90%, isn't that better than 60%? It is not unusual for programs to base their VSG protocols on their RNY practices and call that "good enough". The problem here is that the RNY gives the patient and added performance boost during their loss phase of some caloric malabsorption, which allows for a somewhat more permissive, higher calorie diet, so sleeve patients on the same diet tend not to do quite so well. Some practices tailor their protocols more closely to the sleeve's characteristics, and get better results. There is also a psych aspect to this is well - some patients will be very pleased get to 65-70%, beating the goal, and will be encouraged by that success to maintain their discipline longer term and avoid substantial regain; others may be bummed out by "failing" to get more than 90%, throw in the towel and go back to old habits and subsequent regain. Still others will hear a doc say 60% and think "I'm not going through all of this for a measly 60%, I can, and will, do better than that and show them!" Where do you fit in to that spectrum?

Do you need to do a liquid pre-op diet in your doctor's program - this isn't a standard part of bariatric programs, only some of them (though with the number of complaints about them that we see in these forums, one would think that they were normal practice.) My wife was a long term T2 diabetic when she went through this years ago, but neither of us had to go through any pre-op surgical diet (just the 6 month insurance thing) so there was no real issue there. Post op, medication adjustments kept things stable for her until she was off of the med completely (many leave the hospital off of meds, particularly those more recently diagnosed, but others take their time about it.) You may need some medication adjustments currently with the dietary changes that you have made. Discuss your concerns with the surgeon and/or dietician about keeping things stable through whatever pre-op dieting they impose - it is supposed to make you healthier leading into your surgery, not the other way around.

There are so many variables in what we can tolerate that it's hard to make a blanket recommendations. Many do have problems with lettuce, though many do not - I never did, though I usually use raw spinach for its somewhat better nutritional profile, and was having small salads after a month or so. I don't think I tried raw corn all that early, but haven't had any problem with that either. The general rule that we have followed is to try new things in small amounts one at a time to test our tolerance for them.

Start at a lower weight and choose better parents. Yes, short and a bit snarky, but that is the essence of it - there isn't much that you can do about it. You can do some muscle building in the areas where musculature can replace fat (arms, thighs and the like, but that only goes so far) but that won't help around the abs where no amount of muscle can replace all the fat that can accumulate there.

I take iron as a separate pill as whatever iron they may use in a multi is the cheapest least absorbed form available and you will likely need to supplement it anyway; likewise any calcium in the multi I consider to be a throwaway. I take Iron with the multi (when I take the multi - they're only a 2-3 per week thing for me now, the iron is daily) and then calcium citrate at lunch (if needed) and dinner.

b12 with the sleeve is a somewhat debatable point, as the intrinsic factor and absorption problem that is common with the bypass isn't nearly as pronounced; our program doesn't specify B12 supplementation at all for their VSG and DS patients - it's only used on as "as needed" basis. I was already taking some B12 as part of a B complex tablet for other issues long before surgery and didn't change anything and my B12 levels were always at the top or above the normal range on the lab tests; even today without any supplementation beyond the multivit, it still runs on the high side from diet alone, so I never got into the sublingual or injectable forms (and my multi is down to 2-3 per week.) This far out, I would let your lab tests guide you as to what is needed - you may not need any at all beyond what is in the multi.