RickM

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.

It depends heavily on just how the insurance company's policy bulletin is worded - that is the legal gospel. Mine was for the typical 6 month physician supervised diet/exercise program that implied but did not specifically specify monthly visits. Monthly was our intent but due the the usual scheduling issues between my PCP and myself it wound up only being four visits over the six months, but that was no issue with getting approval. It's a great, big YMMV thing, but you need to do whatever their policy specifically states (that's what's legally enforceable as they wrote the rules, and that's what the regulators and courts follow.)

Calories can generally be somewhat higher than women, but there's still a lot of individualism to it. Some guys have more significant metabolic problems than others, such that they may have similar metabolic levels to many women - maintaining in the 1200 calorie range, etc, so they need lower calorie levels to lose. My guess is that at your starting point that your metabolism isn't that screwed up so you can lose like a "normal" guy. My doc didn't have a specific calorie level (they're a DS centric practice, which has fuzzy math in this regard) but I quickly settled in around 1100 calories. Protein target was 105g, based upon my lean body mass. Carbs and fats were "whatever" - not particularly important with our caloric deficits - but I simply endeavored to get the best overall nutrition for the remaining non-protein segment of the diet, which in retrospect worked out to be a rough caloric split between fats and carbohydrates. For the vast majority of us, it's the caloric deficit that drives the weight loss and not any magical macro splits Your missing watermelon may be an indication of some missing nutrients contained within - potassium perhaps, as our typical supplements don't make much of a dent in satisfying our requirements. Many sugar substitutes are known for having a laxative effect in many people, particularly some of the sugar alcohols and a few of the zero calorie sweeteners so you seem to be right on track with those.

Yes, it is likely a result of ketosis, which simply means that your diet is low in carbohydrates and will get better as your diet improves. There is a common mythology put out by diet promoters that you need to put up with this in order to burn your fat stores which is untrue - all you need is a suitable caloric deficit, which is what your WLS enforces. People have been successfully navigating their WLS adventures without such side effects for, literally, decades.

Keto is the latest evolution of the low carb craze - Atkins, Zone, South Beach, etc. which emphasizes even greater carbohydrate restriction and higher fat consumption than previous incarnations. "LCHF" (low carb, high fat) and Paleo diets are kissing cousins. Clinically, such diets are used for minimizing weight loss for non-WLS gastrectomy patients and regaining unwanted lost weight.

As noted, there are no universal rules. For diabetics and the insulin resistant, carbohydrate restrictions have long been appropriate and you should be working with an RD for guidance; for those without those morbidities such restrictions are simply part of today's low carb diet fad and it's up to you whether you want to participate, but with the caloric restrictions imposed by our surgery, our diets are by default low carb and low fat, so there is little reason to worry about it.

Is a liquid diet part of their program as you get closer, or is this an assumption based upon what some post here - liquid pre-op diets are not a standard feature of sleeve programs, only some require them (so don't go volunteering for things you don't need to do!) I would agree that it is useful to get used to protein drinks, trying different ones to see which you prefer.

Start with a bite or two at a time and let the rest of the meal be something familiar. Soft cheeses would be like mozzarella (cheese sticks are a common snack staple) or the Babybel mini cheeses or spreadable swiss cheese wedges. Vomiting will usually be from too much and you exceed your stomach's capacity, which is why we start out with very small amounts. If liquids are going through without much restriction, that's an indication that your stomach is not overly inflammed and is ready for something a little firmer. If liquids are not flowing easily through then its better to go slower in advancing; I am assuming that your doc is taking this into account in advising you to proceed.

I think this depends on what you are consistent in doing - consistently low or missing doses isn't a good thing! More important is being consistent with your lab work to get the feedback as to what is needed as things progress. One is usually given a baseline supplement protocol to start with (typically something like 2 multivitamins, an ADEKs tablet (the fat soluble vitamins A,D,E,& K in a "dry" or water soluble form since the DS malabsorbs fats) and the multiple calcium and iron doses during the day and maybe a few other select items like zinc or magnesium. Then things get tailored as labs dictate over time; frequently people may need less A and E but more D and K than the combined ADEKs provides, so go with separate vitamins for those. There may be other potential deficiencies that can sneak in that are more individual (my wife, 12 years out on a DS, tends to be low on potassium so she supplements that, but that's uncommon). It's the labs that do the most to prevent problems in the long term.

Yes, it is quite do-able, though as usual quite individual as well. We were on soft proteins like yogurt and scrambled eggs in the hospital, and other soft foods like softer cheeses, cream of wheat, refried beans, mashed potatoes (protein loaded, of course!) and soft meats such as tuna once home. That doesn't mean that they have to be staples yet, as much of your protein will still come from shakes as things transition, though their general finding has been that we do better as we move into real food. You can also mix up transitional foods like tuna/chicken salad or chunkier soups with some more meat added - "meat lube" is a good thing at this time, though it may allow you to consume more than desired later on. The general rule of thumb, as indicated above, is to try new things one at a time and in small quantities to test for tolerance. If it doesn't go, back off to something known and try again in a couple of weeks.

Surgical diet programs and philosophies, pre- and post-op, vary all over the board. Ours was just clear liquids and bowel prep the day before (just like for a colonoscopy,) and then purees and soft proteins along with liquids from the hospital on out for the first month. One surgeon I talk with occasionally, who works out of a different practice but has similar protocols, says that the last thing he wants his patients doing is fasting for weeks ahead of surgery - he wants them as strong and healthy as possible when on the table. Quite a different take from the usual liver shrinking thing we frequently hear, but no less valid. YMMV.

Here is a thread on that very subject that's been going on for the past five years! Similarly, the ladies will experience similar functional improvements on penetration depth from loss of that fat pad, though they won't show the "locker room" improvements that the guys get.

Beyond activity levels, such factors include prior dietary history and genetics. There is a genetic predisposition toward diabetes, insulin resistance and genuine "carb sensitivity" that some people have, and they can benefit form low carb diets; for those without that genetic makeup it's just another fad diet. I don't know if I was considered a big exerciser who "should" succeed with a 100g diet, but I couldn't afford the common side effects or nutritional deficiencies of low carb dieting and knew from history and experience that it has little to do with weight loss success. My wife lost 200# without regard to carb counts, and she is exercise averse. Carb counting and such severe restrictions was never an emphasis in our program an no one seems to be suffering from it (sugar, simple carbs and junk food in general, yes, but carbs as a macro, no.) In the absence of WLS, the success rate of losing large amounts of weight and keeping it off is about 5%, whether one does a low fat diet, low carb diet, balanced, Atkins, Keto or whatever one chooses. With WLS, success rates are similar - people have been successfully maintaining massive weight loss for decades before low carb became the fad of the day. In the fourteen some odd years that I have been involved in the bariatric world, I have never seen anyone fail because of "too many carbs". whatever magic number is chosen - 100g, 40g, 20g... Too many calories relative to their metabolism - absolutely; though those excess calories may be from carbohydrates, they can just as easily be from too much fat or protein, or more typically a combination of them all. Excessive fat consumption is often a problem in maintenace as people who adopted the "full fat everything" habit early on when their volume was severely restricted often continue it as their volume increases a few years out and they let their calories slip away from them. They may blame the carbs for "getting away from them" and exceeding the magic 40g. but then ignore the 1000 calories of fats they are consuming, with a 12-1300 cal metabolism.

I guess that it is possible, depending upon why they are imposing the diet and what their expectation and requirements are. The VSG itself doesn't require any particular pre-op diet other than the day before to ensure that things are empty when they do surgery, but individual surgeons and programs can impose them (or not) for their own specific reasons. In your particular case, if the diet and loss requirements are something that your surgeon believes in, then he may delay things if he doesn't think that you are making adequate progress. OTOH, if your surgeon is more of just an employee of the practice or hospital and the diet is someone else's idea or policy, then he may well give you a pass on it if he doesn't really believe in it.

The even protein/carb split sounds like an early stage rule of thumb, which isn't unreasonable and seems like a decent approach to avoiding the problems of the overly low carb set, though it should probably be tailored some for individual needs such as diabetes/insulin resistance. Later on in maintenance stage it should be reviewed to be consistent with higher caloric needs - typically protein doesn't need to increase but fats and carbohydrates should go up according to individual circumstances and nutritional needs. Protein is only about 20% of my dietary needs, so carbohydrates usually wind up in the 40-50% range (though there is no specific target.)

You have some good suggestions of several products that meet the need (Pure protein and Costco's store brand version of Quest work well, too) though I wouldn't consider protein bars to be any more of a "real" food than the shakes. Try working more toward meats, cheese and yogurts are the classic real food protein sources that our body tends to like better overall.

While insurance companies will vary on their policies, in general, if your weight is still, or has regained to, the typical 35/40 BMI standards, then you are good to go (assuming that there are no lifetime limitations for WLS that apply.) If the revision is due to complications of the original surgery, then the BMI restrictions usually don't apply.

What is "too many carbs"? Does your doc or program have a specific limitation, or are you thinking of the fad diets that some promote for weight loss? I only use the isopure when I have a need for clear liquid protein,

Generally, yes, you can usually take your multivits at the same time - it depends upon how much calcium is in them. The typically recommended max dose of Ca for absorption is about 600mg, and most multivits are a fraction of that (mine is 220mg). Also, most multivits use the cheaper calcium carbonate rather than the better absorbed calcium citrate, so I basically consider the Ca in multivits to be a throwaway - I don't count it. And, if you're doing three doses of Ca (around 1800mg) with a sleeve, you probably don't really need whatever Ca is in the multivit - that would be more for the RNY or DS folks who malabsorb those minerals.

Usually a half hour or less - you spend more time prepping and recovering from anesthesia than the actual procedure.

From what I have seen over the years, most docs want you to wait until you are done losing weight and stable before getting pregnant, as the minimal nutrition we get during weightloss conflicts with the nutritional needs of the developing fetus. Many docs recommend using two forms of birth control during the loss period to avoid this conflict (and fertility tends to improve rapidly (and surprisingly sometimes!) as the weight comes off.