RickM

The duodenal switch typically uses a larger sleeve - they started using the smaller sleeve when they started doing stand alone VSGs. My wife's DS sleeve stomach was roughly twice the size of mine at surgery time (4oz vs. 2.5 oz) but our nominal meal capacity now, many years out, is roughly the same. Others may find that a larger sleeve will allow for excessively large meals down the line - depends on the individual, depends on the surgeon and how they make their sleeve. From what I have seen over the years in a DS centric practice, the DS doesn't seem to have as significant of a problem with reflux as the basic smaller sleeve does, so I think that there is some merit to the idea.

It sounds like a junk food - high calorie, low/no nutrition; it may be keto/paleo "compliant" but still a junk food - think paleo Twinkie, and do you really want to get in the habit of eating these? Protein, particularly meats and other firm proteins, tend to be the most satisfying longer term for hunger, and cravings are usually best controlled either nutritionaly (you're craving foods with nutrients that you are short on) or by limiting foods that trigger cravings, whether they be carbohydrate or fat based. Your classic junk carbs like chips, cookies and other sugary things fit that description, but many are also triggered by fat based foods like nuts or cheeses. It's an individual thing that you need to figure out for yourself - what triggers one person may have no effect on you, and vice versa.

It is tough, even for those of us who weren't obliged to do a strictly liquid diet and could do soft things, we're still doing a lot of liquidy things because that's what's tolerated initially, Though I could do some yogurt and eggs, I still got awful tired of soups and protein jello and couldn't stand the thought of them for a couple of years.

My wife had a similar problem with ground beef for a while, and the surgeon noted that it is not an unusual tolerance issue, and suggested that good quality steak like filet is often better tolerated. He was right - the best Rx we have ever gotten from an MD, and one we still fill often! I think that part of the problem is that even though ground beef "seems" soft and easy to digest because it is ground (pre-chewed?) it is often poor quality meat when bought commercially, and you never quite know what is in it. I suspect that if you grind up a good quality steak and cook that, then it would probably be better tolerated.

Protein drinks are the staple early out; I would avoid that Genepro stuff as it neatly fits into the "too good to be true" miracle supplement scam category (and nobody really knows what it is.) Whey protein, preferably whey isolate, is the well accepted, best absorbed form. I also had greek yogurt, eggs, and some sloppy tuna salad, though those may not be permitted on some diets the first week or two - check with your program directions.

Unless you have access to a scale that is used for trade which is calibrated periodically, like in the shipping department if you have one at work, it's anybody's guess. First thing is to correct for clothes - my PCP's scale consistently reads 5 lb high relative to home, which is consistent with wearing about 5 lb of clothes and shoes, otherwise the two track very closely, and I can tell the nurse what the scale will read before I get on it based upon what I weighed that morning naked. Digital or analog doesn't make much difference if the scale isn't calibrated (which most home or office scales aren't.) I had one doc's triple beam balance scale - the type with the weights that you move back and forth - theoretically the most "accurate" type, which was off by about 25lb from the rest of the scales in my world. This was after he moved his office to the other end of the building, so obviously the movers dropped it or otherwise damaged it in the move. If you need to depend upon one scale for qualifying for surgery, for instance, then go with that one as your "standard" and correct you home one to match (either directly or in your mind.) Otherwise, go with the one you use most often; the main thing in that case is repeatability. Hopefully, all of the different scales that you may use at different times will be consistent with each other; if not, discount the less reliable one.

The revision that you are contemplating, a RNY to DS is a very complex procedure, so tread very carefully and research, research, research. I haven't been as up on the DS world as I used to be (my wife is 12+ years out on hers,) but 4-5 years ago there were only about a half dozen surgeons in North America that one would trust to do this revision, none of whom were in Mexico. A virgin DS is already a step up in complexity to an RNY or VSG, which is why there are relatively few bariatric surgeons that offer it; the revision from an RNY is another step up from there. The Mx doc with the longest DS experience that I;m aware of is Dr. Gilberto Ungston (he was the only doc doing them reliably in MX 4-5 years ago, and had been working on training others to do the DS. Whether he is tackling the RNY/DS revision, I don't know, but he would be a good place to start if you want to keep it in Mx. You need to find people who have had that specific procedure done by surgeons that you can consider. I have run into a few people who have had it done, as I have dealt with a couple of the Calif surgeons who do the procedure, and it has been very worthwhile, at least if done by the right surgeon. You can't depend on advertising or online profiles of surgeons, as many will say they do this or that procedure and then sell you on what they actually can do once they get you in their office (something like a distal RNY is sometimes offered as "DS-like" revision that doesn't work nearly as well). It gets even trickier when you are self-pay as you don't have an insurance company on your side as an enforcer - a doc saying that he is doing one procedure and billing insurance for it and then doing a different procedure is guilty of insurance fraud, and the companies take a dim view of such things. So, you need to be extra careful when you are self pay, whether in Mx or the US. Good luck in your search....

As your lung doc suggests, this is something for your bariatric surgeon to answer. This is an unusual situation for these forums, so there isn't much experience here with this problem, and even those few who may have something similar, the situations can be quite variable between cases. You may have to get opinions from several bariatric surgeons, as something that may be intimidating for one may be "no big deal" to another, depending upon their backgrounds - you may find one who has prior pulmonary experience. As an example, patients are often required to do a "liver shrinking" pre-op diet, sometimes with the surgeon threatening to close them up and send them home if they haven't complied and shrunk things enough, while other surgeons basically laugh at the idea, having developed techniques to work around a fatty liver. So, I suspect that your problem can be managed, though you may have to look around some to find the right surgeon.

Ours is simply a clear liquid diet the day before surgery and a bowel prep in the evening, similar to what's done before a colonoscopy (the last part being a bit of overkill for a sleeve, but consistent with the bulk of their practice being DS's.)

There is nothing wrong with proceeding as you are and see how far you can take it, and most particularly if you can stick with it. It is certainly a long shot to lose to a normal weight range and keep it off - as others have mentioned, there's about a 5% success rate in doing so. But that doesn't mean that you can't get part way to your goal and learn a lot in the process. I started out on this WLS venture some 14 years ago when my wife and I got serious about our weight problem, and after doing some investigating on procedures and surgeons, started going to our surgeon's support group meetings. Long story shortened, it took a couple of years to get my wife on the table (she was #1 on the runway with her weight and comorbidities) but in the meantime, starting to comply with insurance requirements, started out 6 month diet/exrecise program. As I would probably taking more time, and was disinclined to play with fad diets, took a very strict no-fad-diet approach to this. Most of us know what we need to do - lower calories, minimize/eliminate junk food, more fruits/veg, whole grains in place of refined white grains, leaner meats, etc. etc. etc. Ultimate weight loss was not the primary goal as much as learning sustainable dietary/lifestyle habits consistent with long term weight control. If i could be amongst that lucky 5%, so much the better, but at least it should make the surgery and subsequent life easier and more stable. I wound up losing a net of about 50 lb, or about a third of what I needed to lose. As we were still working to get my wife on the table, (eventually self paid) I just let it ride and kept going to see where I could go. Ultimately I couldn't lose any more sustainably, but continued in what eventually was a WLS maintenance life along with my wife after her surgery - I didn't lose any more, but didn't gain any back, either. After about six years our insurance started covering the sleeve, and as I wasn't going to lose any great amount more without surgical intervention, went ahead and restarted the process. While this did delay things a few years, it also helped make some decisions. As I had developed a modicum of weight control, that helped move my decision toward the sleeve; had I regained my loss or more, as often happens, that would have moved me toward the DS (duodenal switch), which offers better regain resistance than the other mainstream WLS procedures. Also, the fundamentally good dietary habits that I had established (not perfect by any book's standards, but sustainable for me,) made the surgery and subsequent post op loss phase much easier as it helped me resist falling for any of the quickie fad diets many do to "improve" their WLS performance, but also have to unlearn to maintain the loss in the long term. 6+ years later and the weight is still stable. So, if you are not in a hurry to get surgery, by timing of insurance coverage, or intolerable comorbidities, it can be worth it to wait and experiment with the diet/lifestyle habits. It seems that you are already well on your way. Really short answer - there's no need to make a yes/no, surgery or diet, type of decision; rather one can easily take an evolutionary plan A/plan B approach and decide, or change decisions, later.

A couple of questions/comments I have on this evaluation. 1. How did this surgeon come to the conclusion that your sleeve is too small? Did he specifically seek to measure that, or was this just an incidental observation while he was in there removing your gallbladder? Not trying to slam your surgeon, but if he is indeed a general surgeon rather than a bariaric surgeon doing that job, does he really know what to look for with a sleeved stomach? Sometimes we see posted on these forums a picture of some marking pens that represent the different bougies that are often used as a guide in making the sleeve, and there is very little difference between a "large" sleeve and a "small" one. 2. If he wasn't specifically looking to measure or evaluate your stomach, then it was likely empty as it usually would be when you go in for surgery. Even a normal non-WLS stomach is a deflated balloon in that state and hard to determine its actual size. If one is looking to evaluate the stomach, then something is put inside of it to see its actual shape and size - a contrast fluid if they're doing a radiographic study, or it's inflated with air if their doing an endoscopic evaluation. I don't see how one can make an incidental judgement on such things, particularly if they aren't that familiar with all of the nuances of your particular surgery. At a year out, a half cup, or 4 oz, is not that unusual - some will be higher and some may be somewhat lower still - particularly if you are largely sticking to firm meaty foods. To slow and arrest your loss you need to add calories within your capacity by adding meals and/or making your existine meals more slippery; basically going against all of the basic WLS rules for losing weight. More liquid calories or sliderish foods (I find many fruit and veg dishes, with some meat added to keep up the protein as needed, to be fairly sliderish, so I can add calories to get where I need to go. Fats are good to add as they are very calorie dense. Clinically, high fat/low carb diets are used to minimize weight loss and regain unwanted lost weight in non-WLS gastrectomy patients. So, look for more calorie dense, but nutritious, foods to add to your menu. The tricky thing here is to avoid establishing too many habits based upon these techniques that could make it harder to control your weight in the future. Be flexible. Good luck in this transition,

https://www.bariatricpal.com/magazine/556-fact-or-myth-the-5-day-pouch-test/ Yes, it's fundamentally a fad diet. The basic premise is that since most were on a liquid diet just after surgery and we lost weight like gangbusters then, all we have to do is go back to a liquid diet again. Reality check - even those of us who were never on a liquid diet still lost like gangbusters initially, as that initial drop has nothing to do with the composition of the diet, only the very low calorie level that is forced upon us by the recent surgery. If you want to do a "reset", go back to a basic meat and green vegetable diet to help you detox from whatever junk has crept back into your diet.

This is one of those "it depends" things. Some are really into the low carb thing and wouldn't touch them. I never concerned myself with carb counts, just overall nutrition. Sugar is some concern, but more the added sugar in processed foods than the intrinsic sugar that naturally occurs in our fruits and vegetables and are bound up on fiber and slower absorbing. If you are diabetic/formerly diabetic or insulin resistant, it's a bigger deal than if you are not. For me, if protein is taken care of for the day (which it usually was), and it was within my caloric budget, it would be fine.

You can, though you have to check how much you can eat overall and if it fits in to the meal and your plan for the day. My fast food of choice, on the rare times I had such, was an order of Chipotle soft tacos with corn tortillas - one to have there and two for future meals. While I was losing and well restricted I mostly just at the filling and that was enough. The main use I made of corn tortillas at that time was to crisp up a thin tortilla and use it as a small pizza crust - that was about the right size. The main thing that I would be a bit concerned about is that you are craving tacos - what about them are you craving? If its the tortilla, that may be a warning sign that you are being triggered to overeating foods that aren't doing you much good. If you can be satisfied by just eating the filling, thats a good sign that you are being driven by something fundamentally nutritious, which isn't a bad thing. If you just gotta have the tortilla, that's not so good as they are mostly (not entirely) empty calories, which can be a big negative for your long term weight control efforts. For me, the tortillas are incidental - I can take them or leave them; I just use them as a convenient carrier for other foods, but am not bothered if they aren't there.

For us, it is still largely guesswork, albeit somewhat scientific guesswork (we call it a SWAG - scientific wild-assed guess - in the business.) The problem with most of these online calculators is that they use body or scale weight as their basis rather than lean weight which is what is really needed to figure BMR. This particular calculator does offer the opportunity to enter a body fat %, assuming one knows it, which few of us do (and they offer an opportunity to sell you a set of calipers to measure it by far the least accurate way of making such a measurement.) The biggest problem is that most in the WLS world have metabolisms that are damaged to one degree or another by their lifetime of obesity and dieting. This is where two people of identical age, height, weight, body composition, etc. are put on a treadmill - the person who has been through the life of morbid obesity and yoyo dieting will usually burn fewer calories on that treadmill than the never-fat person, sometimes substantially so. So, take these calculators with a grain (or kilo) of salt, look at them with some interest but don't take them too seriously, particularly if they are trying to sell you something. The protein maintenance suggestions they make for me are between 180 and 240 g per day, which is roughly double my physiological maintenance requirements and well into the protein supplement selling zone.

I would talk to the surgeon's people to verify that this is what they want you doing for the six months. It is not unusual for a couple of weeks pre-op for those docs who need to do the "liver shrinking" thing, but six months is counterproductive. Perhaps things got confused between your six month insurance requirement and the surgeon's week or two requirement? If not, and they want you to do this for six months, I would look seriously at finding another program.

Who is requiring it to be 700-1000 calories? Most such insurance requirements that I have seen don't specify a calorie limit (nor should they, given the wide variety of patients covered by such requirements) but a more generalized statement about a limited or controlled calorie diet, maybe with something about increased exercise levels. Philosophically, I look to these requirements, though of dubious value other than for discouraging less serious patients from WLS and saving the insurance company some money, as an opportunity to start developing the good lifestyle habits that will serve them well in the very long term, which will also usually yield some moderate weight loss during its term. Take a look at what the actual insurance requirements are (there should be a policy bulletin about WLS requirements on the company's website) and discuss them and your specific needs with whomever is imposing this requirement on you. You can consider changing doctors or programs if you don't get a satisfactory solution. Best of luck,

If one is severely limiting their intake of carbohydrates or fats (whichever fad one chooses to follow) they are severely limiting their nutritional potential. 20g or either doesn't leave much room for the vitamins and minerals normally obtained from those skipped foods. Fat burning usually starts 2-3 weeks after starting a major weight loss effort, and corresponds to when one's glycogen reserves are burned up and the body gets the idea that this caloric deficit thing is for real. Then it starts drawing from its fat reserves. This usually corresponds with the dreaded three (or third) week stall. As long as on continues a major caloric deficit, one will burn off the stored fat - whether one is on a low carb diet, high carb diet or whatever one chooses. There is a mythology promoted by some of the fad diet gurus that you need to "eat fat to burn fat", which is true to a certain extent - if one adopts a fat heavy diet, the body will adjust to metabolizing more fat, as we are an adaptable species, but if you want to burn off all that stored fat that we typically have here, it still takes a caloric deficit; otherwise all you are doing is just burning your intake and none of your stores - you can get all the "benefits" of ketosis - the bad breath and BO - without the weight loss. If one does a more classical "balanced but less" diet, there is less chance of the nutritional deficiencies that are inherent in these fad diets. You can burn off the stored fat just as well, though the overall fat burn will be less as you are consuming less of it, but the overall diet will be healthier and more sustainable. For the OP, CloudNL, another approach to consider is Dr. Matthew Weiner's veg first philosophy that he presents in several of his youtube videos, It is somewhat contrary to the classic "protein first" bariatric approach, but does have some merit, particularly for those of us many years out. I'm not real high on his lower protein recommendations (which seem a bit scant for all except the shortest women) and I;m not so sure about his green smoothies, but as veg is inherently bulky and low calorie, it does make sense as the basis of a weight control diet/lifestyle. I follow something akin to it in that my diet is fairly high in fruits and veg, but doesn't eliminate proteins, fats or starches - as they all have something to contribute to a healthy diet. It's worth considering if you are amenable to a higher plant based diet. The other related concept, conveyed by one of the surgeons in my network, is to eat as close to dirt as possible - eat what grows in the dirt, or what eats what grows in the dirt, with as little processing and packaging in between as possible. This has a lot more merit for a long term sustainable lifestyle than any random macro counting/limiting diet.

Of the WLS procedures, the DS is certainly the best in addressing bile reflux - it's almost impossible (never say never...) for it to occur due to the geometry, With the small intestine being split at the duodenum in the DS, keeping the bile and pancreatic enzymes separate from the food flow until they get down several feet to the common channel (and for reflux to occur, things would have to flow another several feet back upstream,) it's a near a certainty to eliminate bile reflux as one can get. Contrast with the RNY geometry where the stomach access is moved downstream of the bile ducts, and the pyloric valve is eliminated from the food flow, and bile reflux is more likely with that procedure. Bile reflux is a relatively common problem with gastric cancer patients who undergo an RNY like procedure to eliminate the cancerous stomach or portion thereof. Surgical technique can reduce but not eliminate the chances of it occurring with that procedure. The DS is a more technically challenging procedure than the other common WLS procedures, so that does put a premium on the surgeon's experience with it (not just experience in general, however - one should try to find a surgeon who has several hundred of them under his belt.) The DS world is a relatively small one as a result of not many surgeons developing and maintaining the skills to tackle it routinely, but amongst that well experienced cadre of surgeons, complication rates don't seem to be abnormally high relative to the more common WLS procedures. Many do have to travel to have a DS performed, and as a result most of the DS surgeons are set up to handle travelers. When my wife had her DS 12+ years ago, the main lower cost self pay alternatives to the US doctors was Dr. Baltasar in Spain and another doc in Brazil. both of whom are now probably retired. We ultimately stayed in the US but still traveled about six hours for her DS. DSfacts.com has some good information on the DS, and a rather incomplete listing of surgeons who perform it. There is one listed in London, though I don;t know anything about him - the DS world is a fairly small one so one becomes familiar with most of the major players. Another potentially complicating factor is if you are revising from an earlier WLS to the DS. A sleeve gastrectomy or lapband is a fairly straightforward revsion, little different than a basic, virgin DS, but a revision from an RNY is a more complicated revision that limits the list of qualified surgeons further. Good luck in your quest, and ask away with any more questions. There are also a couple other DS forums on other sites that can also offer some help if you haven't found those yet.

It is hard to engage in "price gouging" when people have the choice of half a dozen or more other merchants to shop at (when one is a sole supplier, it is a different story.) Overall, they do tend to offer higher quality products, meat and produce in particular, which does cost more to bring to market. Whether the higher cost is worth it relative to what one gets at Kroger, Albertson/Safeway, TJ;s, Sprouts, Costco, Walmart, local farmers markets, etc. is an individual decision.

Clinically, low carb/high fat diets such as keto or the current interpretation of paleo are used for non-WLS gastrectomy patients who need to avoid weight loss and ultimately regain unwanted lost weight. You can figure out whether that is appropriate for your needs, but those who use these diets in weight loss attempts need to be vigilant with their calories.

From what I have seen over the years, the better docs, most particularly the long standing DS docs, don't need to do these extensive pre-op diets that many complain about. I didn't need to do one nor did my wife when she had her DS twelve years ago. Dr. Roslin would be high on my list of docs to consider if I were on the east coast, and I would generally avoid those docs who impose these multi-week liquid pre-op diets. They just aren't necessary if the doc knows what he is doing.

Self pay will avoid the 3-6 month diets often imposed by insurance companies to slow things down and weed out the less serious patients (and hopefully delay things until they are on another company's policy), but the only way to get around the shorter diets often imposed by surgeons is to go with a different surgeon who doesn't require them. From what I have seen, most of the DS guys, particularly those who have been at it for a while, don't impose any significant pre-op diets. For the OP, as you can see, surgeon's requirements vary all over the place - my wife was a 65ish BMI and didn't have to do any pre-op dieting or weight loss. From my experience, particularly if you are going with a sleeve or a bypass, the more that you can work on your dietary habits ahead of time the better - not for any specific weight loss goals, but to help establish or reinforce the good habits that will serve you in the years ahead in maintaining your loss and controlling your weight.

I would be inclined to get a second opinion on this. As you can see from other posts here (and in many other threads) a hiatal hernia repair is very common combined with any of these WLS procedures, and I haven't seen any comments overall that recovery from a hernia/sleeve surgery is markedly different than from a sleeve alone or from a bypass (there might be a small difference for some, but nothing major.) Even if the pain is a bit worse, is avoiding a short term pain increase (which can be medicated) worth getting a procedure that you aren't comfortable with? It sounds like this doc is more comfortable doing bypasses than sleeves, which is not uncommon given that the sleeve is the newer procedure and many docs don't have that much experience with it yet. This is fine if you want a bypass, but if you want a sleeve, or are on the fence between the two, it would be best to seek the opinion of a surgeon who is more experienced with the sleeve, even if it means delaying things a bit - much better to take a bit more time now to be sure than regret things for the rest of your life.

If it is an insurance requirement, there usually isn't much you can do, and any effort to waive those requirements usually takes close to six months anyway. If it is a requirement of this specific clinic or practice, then it's a free market and you can go elsewhere - this isn't a standard industry practice. The practice that my wife and I used had no specific pre-op diet requirements beyond the day before surgery. With the typical pre-op testing and clearances and a semi-normal requirement to attend a support group meeting or two, or other class or seminar you could get in within a month or two, depending upon sheduling.