RickM

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.

I have never found a good reason sited for the liquid pre-op diet. As you note, for those docs who need the liver shrinking thing, a low carb diet is the way to go, irrespective the form that it takes (liquids, solids, whatever.) It is not unreasonable to take a step in that direction by substituting protein drinks for a meal or two a day to get used to them, and that is a common approach (probably more common than the all-liquid diet for those programs that do pre-op diets.) The main reasoning that I could ever discern for them is the "that's the way we've always done it" excuse - close to what your doc's position is (which probably means that he doesn't know why they do it, either, and since it's not him having to do it, why do anything different?) Yes, other people are miserable on these diets, which is why we hear so much about them on these forums (those who don't have to do them have little to complain about, so they don't post much about it.) You won't feel like this for the rest of your life, though it may be a while, depending upon how long they have you on liquids post op (though your stomach helps out then, you will still probably get sick of them by the time your are into solids. Most who go through these things generally report that things get better after a few days of it, if that's any help OP, don't read the following (I really don't want to rub salt in the wound,) but for those who are lurking and researching, these diets are not a standard or required part of the sleeve (or bypass, or any WLS) procedure, but are something imposed by some practices for reasons unspecified. Other practices do other forms of diets for various time periods, or none at all other than the day before. Some programs specifically don't want their patients fasting for weeks prior to surgery, as they want them as strong as possible going onto the table, while others feel that a low carb diet for some time provides them with an extra margin of safety or convenience. Personally, I would avoid those programs that use these liquid only diets, at least until they can provide some viable rationale for imposing them on their patients. Ask questions early during the information seminars, and at least go into it with your eyes open. But do follow your doctor's advice, as that is what you (or your insurance) is paying him for. Good luck all,

Absolutely on letting the stomach heal some more. One of the things that I have learned from the physical therapists while going thru orthopedics over the years is that the connective tissues - tendons, ligaments, and of special interest to us, fascia that makes up part of the abdominal wall, have a much lower blood supply than the muscle tissues that they support, which means that they heal a lot slower than the muscles. We may feel strong enough to progress and lift more, but the connective tissues disagree, which leads to tears and other such injuries. In our case (and in general for abdominal surgery) incisional hernias are fairly common and can be caused by something as simple as a sharp sneeze or cough (hence the frequent advice to have a small pillow handy for such occasions.) Most docs put a lifting limit on for six weeks or so; mine restricted abdominal work like sit ups and crunches for twelve weeks, which arguably is not conservative enough. I did start back with some weights after three weeks, at about half the level I had been, avoiding abdominal work, using machines rather than free weights to isolate the core; it was more about reestablishing range of motion and getting moving again more than strengthening anything at that point. I started using the elliptical again, likewise more as a means of moving more things than just walking. The Y is good, but as usual the trainers are quite variable. The best that I have found there are those who are working in becoming physical therapists, so they have the interest and curiousity to work to your unique needs, rather than just showing you how the machines work and egging you on. If you can, take advantage of your doc's fitness guy to learn the trade offs on healing vs. strengthening after surgery. You might also talk to the doc about the possibility of a few physical therapy sessions with the same intent. My wife went trough a few such sessions after much muscle/strength loss resulting from plastics and subsequent blood loss and anemia that put her down for quite a while and she needed to recover basic functional strength. The PTs helped with that and were able to refer her to a trainer who was experienced with post surgical issues to do follow on work. Short answer - take is slow and let things heal (although hernia repairs are can partially subsidize plastics later on....)

Follow your doc's instructions and don't read things into them that may not be there based upon what other people do - some docs don't want their patients fasting for weeks leading up to surgery. If you want to get a jump start on things, by all means integrate protein drinks into your routine, trying different ones, including the clear ones, to see which you like or at least tolerate Then keep the rest of your diet to leaner meats and green vegetables, minimizing your carbohydrate intake - that will do as much good as any liquid diet without the side effects. And rejoice that you don't have one of those docs who like multi-week/month liquid diets.

People typically go for a sleeve to bypass revision because there was something wrong with the sleeve (strictures, excess fundus left behind, etc.) that the surgeon didn't know how to correct or was incompatible with their physiology, often causing significant reflux problems that couldn't be corrected with diet or medication. Doing such a revision simply for inadequate weight loss or regain reasons is less successful as the two procedures are very similar in their strength, or power, against weight problems. Regain characteristics are similar for both procedures, though some patient may be more compatible with one or the other (think of it as a personality fit or conflict.) Look carefully at what the reasons for your regain were and address them first, or else you are likely to have the same problem in another few years. The more one gets into doing revisions, the more one paints oneself into a corner, leaving fewer options in the future. Also, the bypass is something of a dead end procedure, as it is very difficult to revise it to something else if it isn't compatible with you - they can do bands over the bypass or various means of tightening the stoma but none have a very high success rate. The best way to correct a poorly performing bypass is to revise it to a DS (duodenal switch) which offers much better regain resistance than either the sleeve or the bypass, but is a very compex revision from a bypass (there's maybe a half dozen surgeons around the country qualified for such a procedure.) Fortunately, the DS is a very straightforward revision from a sleeve as it uses the sleeve as its basis, so that would be something to seriously consider if you need to revise a sleeve for weightloss or regain purposes. This doc has several youtube videos out there that are worth watching and maybe get some ideas of what can be done in your situation. His overall diet/lifestyle approach is fairly vegetable intensive approach which has a lot of merit but may or may not be something that you can do. Good luck in working through this problem.....

As noted, it can be dietary changes causing the problem and there are a number of over the counter meds that can help with them. However, the sleeve can cause reflux problems in some, so if you are having problems with it pre-op, the sleeve may not be the best procedure. If the reflux is caused by a hiatal hernia (very common in morbidly obese people,) that can be corrected when the sleeve is done and the problem never reoccurs. For others, the problem gets worse, or crops up where it never existed before, and medication is needed long term (short term use of PPIs for a few months is a normal post op protocol), or even a revision to a bypass in the more extreme cases. This is certainly something that I would want to get evaluated before surgery, as it may influence choice of procedure.