RickM

Are you still in touch with your DS surgeon (are they still in practice?) They would be your first source of help as they know all of the odd quirks of the DS (my wife is a DS, class of 2005.) Standard calcium citrate is the most absorbable that I know of; the patches seem to work for some but not for others, mostly not from what I have seen from other DSers. Also to look into is the entire calcium/absorption complex - vit D3, of course, but also K (usually K2) and also magnesium. I would expect with your problems that the thyroid numbers have been checked and things are going the right way, but that is something to be up on as well. Is there an RD (dietician) associated with your surgeon's practice, or elsewhere who is knowledgeable about the DS (not just bariatrics, but the DS specifically.) An endocrinologist can also be very helpful with these problems, again particularly if they are familiar with the DS. I don't think that there are any injectable/infusable forms like there is for iron, but I don't think that getting it into the bloodstream is the hard part, (just the first step,) but rather getting it from the blood into the bones (and not the other way) and that is the tricky part where there can be lots of subtleties.

Likewise, I would ask your doctor or RD on this. It sounds like it could be a holdover or overlap from a cardiac diet that the hospital uses that may not really be appropriate for WLS, unless there are some specific problems associated with your case. From when I was monitoring all of that, it was difficult in those early days to get all that close to the RDA maximums for sodium (though I was more interested in potassium vs. sodium consumption), so it's a legitimate question to ask.

You sure have been through the wringer. While there are some who have had severe complications from their WLS, their cascade of events will likely be different from yours, so won't be directly comparable. The best that I can suggest for second opinions would be a major regional cancer center that has a GI department, as they will usually have a more experience with a broader spectrum of unusual cases than an ordinary bariatric or GI department. Duke has a good bariatric program with a reputation for doing complex revisions, so they may be a place to try as well if they are in your area. Good luck in getting this resolved and getting back to the health that you were aiming for.

This doc gives a rough guide as to how much volume one can consume over time - I have found it to be consistent with my experience, though my wife, who is five years or so further out than I am, generally eats less than that - she is more restricted, so there can be a lot of variation. Generally, it is good to try to not push things volumewise, as that can lead to more over eating over time - you get used to what you get used to! To some extent, your stomach will respond to how you treat it and adapt to be bigger if you consistently eat more. The other possible problem of over stuffing things is that it can promote pressure on the lower esophageal sphincter - the valve at the bottom of your esophagus that helps keep things down in your stomach and prevents reflux. So, there are some benefits to keeping meal sizes down, and if one needs more calories to maintain weight, adjust caloric density (more fats) or add another meal or snack as needed rather than eating more at a sitting.

Orthostatic hypotension - low BP when quickly sitting up or standing - tends to resolve itself as the body adapts to being smaller, though some may continue with lowish normal BP, but not particularly symptomatic. Bradycardia - resting HR under 60 - is often long term but not a big deal if unsymptomatic, I've had that since shortly after surgery, normally about 50, and it is only notable when I go in for some procedure and the nurse notices the low rate; I mention that it's been that way since I lost 100 lb and they say, "fine, OK." When an anesthesiologist for an EGD noted that I was running 39 on their table we looked into a bit more, had a Holter monitor test done to see if anything untoward was going on over a day monitoring, and there wasn't. One might occasionally notice a palpitation or "skipped beat" because the heart has multiple pacing mechanisms and sometimes one of them gets overeager and decides that a beat "should have happened by now" and sends a signal out of sequence, but then things return to normal sinus rhythm. Again, that's not a big deal or worry. I have seen someone on these forums whose bradycardia was not that well controlled and did show symptoms (possibly similar to yours, though can't quite remember the details,) and she needed a pacemaker to keep things running smoothly. That might be your situation, given the time since surgery indicates that this isn't just a transient thing.

There are some Facebook groups specifically for people who have had gastrectomies, both total and partial, and that may provide better context and patient experience than a basic WLS group like this. That said, it sounds to me, in my non MD view, that you may have some kind of stricture, where the stomach has twisted or folded over in itself owing to it now odd geometry; the sudden onset leads me to this type of conclusion. What you have had surgically is not a classic sleeve gastrectomy (most likely, at least) but rather some variation, particularly if they were trying to minimize the amount of stomach they were removing. That puts it outside the normal bariatric experience base. Frequently what is done in these cases is a partial gastrectomy that is more akin to an RNY gastric bypass, where they remove the lower part of the stomach including the pyloric valve, form a pouch with the remaining stomach and tie the exit some distance down the intestine. This, of course, depends upon where the tumor is, how much they need to remove, and surgeon's preference and experience. We rarely see these problems these days with a conventional WLS sleeve as they are fairly cookie cutter and routine once the surgeon has done a few dozen of them, but it does happen occasionally early on owing to inflammation from the surgery, but that usually resolves itself in a couple of weeks or so. The RNY type procedures are somewhat prone to strictures around the joint between the stomach pouch and intestine from scar tissue if that is the type of configuration that you have. The endoscopy (or a barium swallow test) should provide some answers, though I am a bit surprised that they aren't expediting that considering the situation. Hopefully you can get some answers soon.

Of course, check with your surgeons' team, but I would be inclined to add some calcium citrate to the mix, at least for a while. The calcium included in multivitamins is usually not a full dose (check the label) and is usually cheaper calcium carbonate which we don't absorb as well, I would want to aim for at least the standard calcium RDA (1200mg, IIRC) between supplements and food, and since our early diets tend to be fairly scant on everything other than protein, I would err on the cautious side and go with something in the 1000-1200 mg range, which is two doses that need to be taken a few hours apart. Calcium can also be tricky to measure on labs as the body seeks to keep serum levels steady, at the expense of bone mass if necessary, so measuring that status involves some inferences from other measurements rather than just calcium blood levels, so a bit of overkill is usually better than not enough (within reason.) Personally, I target 2000mg per day as I have family and personal history of osteopenia/porosis, but only need one dose of about 600mg to do that on top of diet. Things to consider, but question your doc and RD about it.

It's unusual to go that direction, but sometimes necessary if the RNY needs to be reversed - something needs to be done to help keep the weight off, though what I have seen done more (though much more complex) is going beyond a sleeve to the DS. Both the sleeve and RNY are similar metabolically, so one doesn't usually work much better than the other if weight regain was the problem. What the OP seems to be referring to in her dissatisfaction is the matter that dumping is rare with the sleeve based procedures but more common with the pouch type procedures such as the RNY, and some surgeons use that as a marketing point for the RNY - a form of aversion therapy. Unfortunately, dumping is not universal with the RNY (maybe 30% or so) so it's nothing to depend on as a weight maintenance tool - those who need it most will likely not dump; it sounds like the OP was one of the "lucky" ones who did. Perhaps the OP should look into a DS, as that is fairly straightforward to do once the sleeve is done, and most any good DS surgeon should be able to put her sleeve right - it doesn't sound like it was done right in the first place. While a straightforward procedure, the sleeve does take practice to get consistently right, particularly if the surgeon is having to reconstruct the stomach first as with such a revision.

When you have an unusual situation such as you have, I have found it useful to get second and even third opinions. A general or general GI surgeon may not have that much experience with bariatric patients, and a strict bariatric surgeon may not have run into this type of problem before (though is more likely to be familiar with such complications. Is this a problem with something that's odd about you, or was there something odd about the way the bypass revision was done - good to get a fresh set of bariatric eyes on that to check. Is it a hiatal hernia - some bariatric surgeons have a hard time dealing with them, (and some don't...) and likewise some general surgeons may have a hard time dealing with that in a bariatric patient. A regional cancer center with a GI department can be a good place to consult, as they tend to have experience with a broader set of unusual cases, and they also usually have an associated bariatric department. I ran into an odd cancer situation a few years ago (thankfully fairly minor and early), such that even a major center might see one or two per year, and was a subject of one of the department's monthly meeting where the doctors all get together and discuss their "interesting" patients and brainstorm different approaches to the problem. You may need that level of "interest" to solve your problem hopefully not,) but it's good to be able to tap into that level of resource if it's needed. Good luck in finding a solution...

Eggs seem to be one of those foods that bother some people and not at all for others - I had scrambled eggs in the hospital and boiled eggs the first week home (on the plan...) with no problem. It's just one of those things - for some it may be lettuce (when it comes to that phase) or beef or who knows what. As suggested, try it again in a couple weeks to see how it does - that was one of our program's basic rules - test foods one at a time for tolerance and if one doesn't work, try it again in a couple weeks.

Yes, your body adapts to the changes made by surgery, and it will still want to gain weight, as it does now, but it is harder and slower to do so. This means that you have to adapt to to counter that tendency - the surgery will indeed help you to lose the weight that you can't lose now by yourself, but you still need to work at keeping it off. This guy gives a pretty good presentation of how it progresses, and some ideas on how to live with those changes to help maintain things. You don't have to follow all of his recommendations, (I'm not so sure about his green smoothie thing....) but it helps to understand what is happening so that you can develop your own plan that makes sense for you. My takeaway from him is that you will see increased ability to eat more at a meal, though not as much as pre op - his progression is consistent with my experience, though my wife maintains a greater restriction than I do, YMMV - is to fill in that increased ability/desire to eat more with bulky, low calorie veg to minimize and control the caloric increase over time. The salads that I make now for lunch have about the same amount of protein - meat and cheese - that they did early on, but a lot more veg than earlier. Our protein needs doesn't increase over time - our "high protein" post op diet isn't really all that high, but rather a maintenance level of protein while everything else is dramatically reduced at that time. I found that it really helps to work on your long term maintenance diet as early as possible - long before surgery if you can - to get used to how you should eat 5-10 years from now rather than just next month or next year. Learn how you should be eating for good weight maintenance (and satiety) and start developing those habits early - don't worry about rapid pre op weight loss, let the surgery do that. If you are seriously concerned about your long term prospects on weight maintenance - if you have had a long history of yo yo dieting, and/or are starting at a very high BMI, you should also consider the DS, duodenal switch, surgery as that has demonstrably better regain resistance than the RNY or VSG, which are very similar in that regard. There are more trade offs involved - what in life doesn't have them - but it is worth considering ahead of time rather than as a revision later on, as the bypass is a difficult thing to revise.

Do you even need to do anything? Programs vary all over the map from weeks of clear liquids to nothing at all other than the usual day before surgery thing. I expect that you have been told by now if your surgery is in October (or is that when they set the date for you?), as they tend to leave such bad news until it's too late to back out. Hopefully you have one of the more benign programs that does a better job of getting you ready for your long term life ahead.

I don't know what your phase 2 diet is, as post op diets and progressions vary all over the map, but things like tuna salad and flakey fish were on our initial diet out of the hospital, so it is unlikely to have done any harm if you aren't feeling anything bad going on. We had a lot of freedom to move between liquids, mushies and soft things at will that first month, with the general rule being to try things one at a time to test for tolerance and if something didn't settle right, then skip that for a couple weeks and try it again. Some programs, on the other hand, are very cookie cutter and hold everyone back to the lowest common denominator so that no one has a "bad" experience, other than being on a liquid diet a lot longer than necessary for them. If you aren't feeling bad, I wouldn't bother calling, but I would 'fess up to the doc when you see them next, let them know that you goofed and didn't feel bad, and didn't do it again. This is feedback that they can use, as often they don't really know how fast they can progress their diets - I have seen some come through here saying that their doc advanced them ahead of the published schedule, and when asked why, they were told that they had found patients cheating on the diet and not suffering from it, so they advanced the progression, and the guidebook will be updated next time they print some.

Most any sensible diet works post op and can be adapted for the immediate post op transition period as well. Vegetarian/vegan is tricky for a while because of the low protein density of most foods and the small amount that can be consumed for a while, but there are some veg protein drinks out there that can be used. Does this surgeon have an RD associated with the practice? They would be the most helpful in tailoring a diet for your needs - most understand that for a diet to be successful, it has to work for the individual. Some surgeons will jump on the latest fad diet, like keto, as a way of "tailoring" their program to the greatest number of potential patients while keeping it "one size fits all". When I went through this, there was a clique of patients on these forums who were all gaga about their surgeon because he was a strict low carb fan and they were all hooked on the low carb fad and many chose him specifically for his diet (Keto wasn't a thing then, more classic Atkins was the then current fad). A great marketing tool for the surgeon, and an OK diet for many patients, but hardly a necessity. Our program was quite flexible, aiming mostly to get maximum tolerance while keeping to the protein levels and textures required early on, Right out of the hospital we could have eggs, oatmeal, cream of wheat, sloppy mashed potatoes, refried beans, yogurt, etc. and it was quite successful for most everyone. So no need to get into any of those fad diets, or put up with docs who do.

Yes, likely ketosis, and basically means that you aren't eating your vegetables. It will improve as your diet improves and gains more variety. I never had any particular problem with it as I always maintained at least an homage to a varied balanced diet (no keto/Atkins stuff,) and let the calorie restriction do its job.

Yes, liquids basically go right through - the pyloric valve at the base of the stomach that closes to keep food in for processing remains open as there is nothing for your stomach to do when you drink. Some people will have a lot of inflammation in their stomach after surgery, so drinking is like pouring through a pinched soda straw, but many will not have that problem. So, measuring a portion size for liquids relative to our new nominal stomach size (maybe 2 oz or so for a typical VSG) is meaningless. Once you get to more solid foods it will make a big difference. My wife, when she went through this, could barely fit her nominal stomach size of protein drink through in one sitting, while I was virtually unrestricted. Both were within the expected result when I questioned our surgeon about it.

I don't know, and I really don't care - what's important is how your surgeon does the job and how are his typical results. The bougie is just a tool, or guide, and some may not use one at all. Similarly, I don't care if my mechanic uses Craftsmen, Snap On or Beta tools to fix my car. When I was early post op, there was a clique of patients from one particular surgeon who all insisted that if your sleeve wasn't a tightly oversewn 32F like their surgeon did, that you would never lose enough weight, or keep it off, and no one would ever love you again. Funny thing was that those whose surgeons used a 36 or a 40 did just as well. And some who had a 32 struggled and missed the mark. My wife had a huge sleeve (relatively speaking) with an initial capacity of 4 oz - typical of a DS sleeve and correlates to probably a 56-60F, while my stomach was initially 2.5 oz, which could come from any of the common VSG size bougies, 32-40F (height, and hence stomach length plays a part of that capacity, so a shorter person will usually have a smaller capacity stomach than a taller person, bougies and all else being equal. Despite those initial differences, our meal sizes are basically the same. Go figure. So don't agonize too much over what tool your surgeon uses.

The matter that you have a guy metabolism, and have had a relatively easy pre op loss if a good indicator of fairly rapid progress post op, but no guarantees, of course. I was also 335 at the start, lost about 50 fairly easily in the six month insurance diet/exercise effort (and then took a few years off before surgery - but kept the 50 off which led me toward the sleeve rather than something stronger like the DS, but I digress....) I was at 200 at six months post op, starting to ramp up the calories to slow things down toward my moving goal of 190ish (based upon body composition - fat mass, etc. - rather than BMI or scale weight.) Wight loss is usually a stair step affair, in a decaying function (rapid at first and slowing over time). The matter that you have lost "fairly easily" to date is a good sign that your metabolism is still in decent shape - those who struggle at this point seem to be fighting a bigger metabolic problem and tend to be "slow losers" and will often struggle to get to their goal weight, if they get there at all. Slow weight loss pre op would encourage me to look at something metabolically stronger like the DS, which may be overkill for someone with a better metabolism. In addition to general declining loss trends (mostly because it doesn't take as many calories to move around 200 lb as it does 300 lb, etc.) weight loss tends to be front loaded some by virtue that most of our initial loss has a large water weight component in it, and the body initially draws from its glycogen stores - basically stored carbs kept in the liver and muscle tissues, used for quick response energy needs. That needs the water to keep it in solution, and burns more rapidly than fat. Once we get through that - maybe 10-20 lb typically - we start drawing on fat stores, which goes slower. So, don't expect as big of a drop out of surgery as someone who hasn't lost anything pre op.

Second guessing and some regret is normal when one runs into problems. It is well to realize that whatever road you chose in the past was likely to be bumpy, even if the bumps might have been different. The bypass, in addition to having its own quirks (someone just showed up on today's recent topics column who is having reactive hypoglycemia problems - that's one of those quirks,) that can cause regrets, would not likely have been any better on helping you with your regain (RNY and VSG are very similar in that regard,) and is also more difficult to revise should you have had problems. So, there is (and was) no easy, straight answer. We follow what looks like the best road for us and take what life throws at us over time..

I usually wound up doing both - in the morning for weight (that's when it is most stable and less influenced by other day to day variations - and then before dinner to get the BF at its best time. So much for those who say we shouldn't weigh more than once a week! The key there is not to agonize over day to day variations and recognize that they are going to happen and are normal.

Ours was much the same as in the hospital, after getting through the leak test. Generally soft and sloppy but fairly varied - soups, strained of any chunks at first, yogurt, eggs, oatmeal, cream of wheat, chicken or tuna salad, flaky fish, protein drinks, of course, as that is a major protein source for a while. We could go back and forth between liquids and soft stuff as we could tolerate, some could progress a bit quicker than others and that was expected, Then most anything else added in after a month.

If the GERD is the result of a hiatal hernia, not an uncommon thing and a common cause of GERD, with or without WLS, then that can be corrected, though some surgeons may not be great at doing that with a sleeve - some can, some can't and will route you direct to a bypass instead. A resleeve might be appropriate if the original sleeve was malformed - that used to be more common 8-10 years ago when most bariatric surgeons were still learning how to do the sleeve (as one prominent surgeon put it, "twenty years of doing bypasses and they think they know how to do a sleeve....") but that is less common more lately, but something still to check out. If you are consulting someone who does the DS (particularly the "traditional" BPD/DS,) that's a good thing as they typically are the most skilled at working with sleeves, and can give a good reading as to what condition yours is in. If one of them tells you that the bypass is the way to go (even though they may normally prefer the DS,) then that's usually sound advice.

The first one I had was a Tanita, which are very good, they make a lot of the professional models that the doctors use, It was very stable and reliable for about twelve years when it finally burned out. They're pricier than the cheapos- $60/70 up to around 150 depending upon the bells and whistles included, so I wouldn't hesitate about getting another. I did replace it with one of the Omrons that has both hand and foot pads and that seems to work well. One of the errors in the technology comes from where the measurement is taken - across the feet or the hands; some RDs or personal trainers may use a hand held grip that does the same thing as the foot pads. The problem is that its accuracy depends in part on what shape your body is - it you are an "apple" shape, keeping most of your fat around your abdomen, then the foot pads will tend to understate your BF number, and the had grips will overstate it some. Conversely, if you are "pear" shaped, holding most of your fat in your hips and butt, then the foot pads will overstate your BF while the hand grips will understate it. A scale that has both will average the two to get a closer reading. Another error inherent in the technology is that it is hydration sensitive. As it is measuring your body's impedance (electrical resistance), that will vary depending upon how much water is present (just like standing in a puddle of water while changing a light bulb isn't a great idea....) Your hydration will vary during the day, and some from day to day, so you should weigh yourself at the same time each day, preferably in the late afternoon or before dinner, when you are fully hydrated and likely most stable in that regard; first thing in the morning tends to be more stable on weight, but you are more dehydrated then. One might see 4-5 points difference in BF from early morning to late afternoon, so consistency is key. One will probably also see some day to day variation, so don't take them as too significant - trends are more important than individual snapshots. I typically weighed myself daily before dinner and kept a mental track of the BF number, It would typically vary, say, between 32.0-33.9, so any differences in there were not treated as significant; however, as time progressed, I would start seeing readings in the 31's, and stop seeing 33's. so that I took as notable progress. Call it an informal moving average. If one is so inclined, then record them daily and do a real moving average of maybe ten days. That should smooth out the day to day noise.

Likewise, I don't see the sense of it The ESG by its nature is more limited in what it can do by virtue of its limited surgical procedure - they just can't do as much endoscopically as they can do by going in laproscopically. And, from what I have seen the ESG doesn't have as good results as the basic VSG, either. A few other random considerations: Revisions of any kind tend to have less performance than a virgin procedure - my simple minded picture is that you have already had your stomach reduced from 32-64 oz capacity down to 2-4 oz and you have learned to eat around that; even if it has stretched out some, cutting it back to 1-2 oz isn't going to do much. The RNY isn't markedly different than the VSG in weight loss or regain performance, so don't expect a lot from that, maybe 20 lb would be typical, mostly from a return to the extreme dieting one has to go through around surgery time. If you have had significant regain, first step is to evaluate the cause and treat that; as noted above, the RNY isn't markedly better than the sleeve, so unless you correct what went wrong in the first place, you will be back here again in a couple of years, but with fewer options (the RNY is a trickier thing to revise once you get it, so consider it to be a one way street.) Are you insured, but not covered for WLS, or not insured at all? if you have a significant GERD problem, then correcting it may/should not be considered WLS. but correcting a threatening health condition, possibly the result of an earlier surgery. Check it out before giving up on that avenue. How severe is your GERD? have you had it evaluated? If it is beyond treatment with meds and lifestyle changes, then surgery may be called for. It might be an RNY type procedure (don't refer to it as an RNY to your insurance as that will guarantee a negative answer if they don't cover WLS; there are a number of procedures that derive from the same procedure that gave rise to the RNY, and they are used for treating multiple problems; but they may go under a different name, so let your chosen surgeon work that out with the insurance company. Again, have your issue evaluated - if surgery is needed, a resleeve may do the job without going to the RNY, or it may not as it depends on what's going on with your sleeve.

If it's significant enough that you are bringing it up here, then it is enough that you should call them on it and not wait. Beyond unpleasant, it can cause damage if left un/under treated. And yes, it is unlikely to be a hiatal hernia, as while common pre-op, they are commonly fixed during the surgery, sometimes without comment.