RickM

Resleeves are done occasionally, either by themselves or as part of a revision to a duodenal switch. They tend to work best if the sleeve was somewhat defective - a stricture and/or too much fundus left behind at the top or bottom (the VSG is done by removing the major curvature of stomach, following the minor curvature of the stomach - problem is that the cutting/staple tools are straight and it takes lots of practice to get the curved profile right to avoid the above issues.) Often the resleeves are done open rather than lap due to having to work around the existing staple line. If the resleeve is being done due to normal capacity increase, the results tend to be less successful as there are often dietary issues as the root cause and cutting back capacity short term won't solve the longer term problem. Have they done any imaging to evaluate any shaping issues?

Neither dieting nor surgery works well if you are doing it because someone else is pushing you into it - it takes a personal commitment that this is what you need to succeed in life. Overall, for those of us heavy enough to be considering WLS, dieting has about a 5% success rate long term, and it doesn't matter what style of dieting is done. Low carb is the popular diet these days but is no better than the low fat diets it supplanted. After all, doing what's popular is what got most of us fat in the first place. This is a good video that presents some of the factors that can push a decision towards WLS or trying dieting again. He also has some other presentations on how the WLS works metabolically that makes it more successful than just simple dieting (something you may want to share with your parents to help them understand and gain their support), and some on things to expect from WLS and how to use it to best advantage. I don't agree with everything this doc presents, but over the years of working at this, I am closer to his perspective than the average or common WLS process. We often see people coming into these forums after giving dieting "one last try", and we often have to do some kind of diet/exercise program for insurance approval; which often does work to the degree that surgery comes along before any regain can occur. The way I approached it when my wife and I started getting serious about WLS some fourteen years ago was to look long term and work to adjust my living patterns toward what was needed for long term healthy living rather than jsut simple weight loss - I would take whatever loss that I could accomplish, and if I could be one of those lucky 5%, so much the better, but I was more focused on the lifestyle changes. I went with a very strict "no fad diet" regimen - no low carb, low fat, keto, Atkins, South Beach, Pritikin or any other "book" diet. Rather I minimized the junk foods and processed/packaged foods while moving towards more fruits and veg, whole grains in place of the refined and processed white grains, all to the extent that I could do sustainably. It wasn't perfect by anybody's book (and still isn't), but it was what I could do long term. It was a somewhat evolutionary process as I sneaked more veg into things that I ate I lost about 50lb over six months or so, which was about 1/3 of what I needed to do, At the time, we were still working to get my wife on the table through serial insurance denials, so I just went into a sustaining mode - working to lose more if I could and continuing to push the diet in the right direction. I never really lost more but I did maintain that loss for several years until insurance started covering the sleeve which seemed a better fit for my needs. The discipline that I established early certainly helped going through the surgery and weight loss process, and most particularly into the maintenance world - many who adopt some of the more extreme or radical diets in conjunction with their WLS struggle with regain or yoyo dieting later on in maintenance as they never established the dietary habits needed to sustain their loss in the long term.

You may never have to count those things, though post-op protein is usually counted because it is the most important thing to get in (after water) and is often a struggle for a while. Carbs and fats don't matter much post-op because our diets are so limited in volume that it's very difficult to consume too much of either - the type and quality of the food is a lot more important than the macro counts, though because of the popularity of some fad diets, some really go crazy counting these things. Pre-op, if you are following your nutritionist's plan, that should have the protein, carb and fat levels built in. However, you may find it useful to track your intake and see what those levels are for future reference - tracking apps such as My Fitness Pal are quite popular for doing this, and it is a powerful tool for understanding what you are doing nutritionally, and for making future changes as things evolve, particularly in your post-op and later maintenance phases. Some programs, like Kaiser's. will have a series of distinct classes for their pre-op patients while others will do educating via their nutritionist appointments or support group seminars.

It's fairly common to not have any special pre-op diet (other than the usual day before surgery thing) - it's maybe a 50-50 split between docs who do them and docs who don't. It's hard to tell from online feedback as those who don't have any special diet to do don't have anything to complain about while those who do have lots to talk and post about! There also doesn't seem to be any correlation with overall success of the program - it's more a matter of whether one can follow the program guidelines that lead to success than what exactly those guidelines are.

Yes, it is very common. It may be too early to wean off of them (some never get off of them, unfortunately) but for many it just takes more time. Many surgeons keep their patients on them six months as a routine practice, others it's just an individual thing. Using H2 blockers like Pepcid or Zantac is a good intermediate step - cut your PPI in half and introduce the H2I. Hint - H2I's are often considered to be particularly good at overnight reflux, so try them at night with the PPI in the morning. Then try cutting your PPI in half again or cut back the H2I. Work on getting down to just the H2I and then ultimately nothing if possible. Play around with it and see what works in your case.

It does sound like something isn't right if you are having these problems at 3 months - some will vomit if they overeat and there's no place for the extra food to go, which is what's happening to you except that your volume is way too low for that to be happening. Hence the suspicion that something is wrong, such as a stricture or twist in the sleeve. As a rough calibration of what should be happening over time, this video gives a pretty good idea of what to expect as things evolve over the years, and to prepare for them to avoid regain. In short, you will wind up being able to eat roughly half of what you could pre-op. https://www.youtube.com/watch?v=3_aahPETzH0

The general practice is to go from your weight when you started the pre-op games, but that can vary by company. There should be a policy bulletin online for your insurance that spells it out, or you can all them and hope to get a right answer. Starting at such a low BMI, I would be disinclined to lose much weight at all as the surgery is plenty powerful to get the job done without any pre op weight loss. What I did (starting closer to 50 BMI) with that 6 month insurance requirement was to work on my long term diet and lifestyle (since that's the hard part - anyone can lose some in the short term!) and take whatever weightloss happened as a bonus. It wound up being about 50 pounds and for a variety of reasons (my wife being number 1 on the runway being the primary) I didn't go through with the surgery at that time, some 13 years ago. But I did maintain that loss up until I did undergo the WLS, and have maintained that loss for about six years now, so the exercise was successful from that perspective. So, check with your insurance as to how they calculate things, and maybe readjust your focus over the remaining time until surgery. Good Luck...

Just the semi-usual day before GI surgery clear liquids and a clean out in the evening (in case they have to go into the intestines for anything.) Other than than there was the insurance mandated six month speed bump to WLS that was just a non-specific physician supervised calorie controlled diet exercise program.

That's a fairly common practice; we just don't hear much about it on these forums because there isn't as much to complain about as there is with the longer pre-op diets, particularly the all-liquid ones which generate a lot of online traffic!

There are several ways to approach a problem like this, and generally surgery should be a last resort - the more you cut the more you get backed into a corner and remove future options - but such revisions are possible. Have you consulted with your surgeon, or another bariatric surgeon? The RNY has been around for a long time (the basic procedure has been around for some 130 years!) and is the most widely performed weight loss procedure, so there is considerable experience in the field with the various complications that can arise, so your problems are not going to be unique. An RD (registered dietician) would also be appropriate to consult. Many on these forums poo-poo nutritionists/dieticians because they usually aren't falling all over themselves to recommend the latest fad diet someone saw on YouTube, but problems like these are right up their alley. A bariatric or hospital RD can be a good choice - many are bored stiff dispensing post-op diet plans to discharging patients who really don't care and want to get out of there, but they really thrive on someone bringing a real problem to them. They are worth a try. On the surgical revision front, since most revisions are done because of poor weight loss performance or regain, and the sleeve and RNY have similar performance, there usually isn't much to gain by revising an RNY to a sleeve from that perspective, and most surgeons aren't going to have a lot of experience in doing so. There is a small group of surgeons around the country who do perform RNY to DS revisions which does involve revising the RNY pouch to a sleeved stomach in addition to all of the fiddly work in altering the intestinal configuration (which you don't particularly need.) Two docs that I can think of in your region that do such revisions and would be worth consulting if you get that far are David Greenbaum in north Jersey and Mitchell Roslin in NYC. Both should also be well up on the nutritional problems that people can have with these different procedures as they tend to work with the more difficult case. Good luck in getting this worked out, whichever way you go.

Initial loss can be all over the board due to a number of factors, but is usually the fastest that you will experience during this process, and will taper off over time. Initial loss is heavily biased toward water weight, but after about three weeks (and the typical "third week stall") you will actually start burning fat and things will slow down considerably. (My first month's loss was 32lb, with 15lb in each of the next two months, then 10lb per month, and that is a fairly typical progression.) Give it a couple months before deciding whether you want to slow things down - most will struggle to get all the weight off that they want as things slow down over time. My basic rule of thumb is that if you are approaching your goal weight (say, within 10lb) within the first six months, then look at slowing things down.

It does sound like a different doc may be in order. Either a Gastroenterologist or Hepatologist (liver guy) would work in this area (my bariatric surgeon is also a biliopancreatic - liver/pancreas - transplant surgeon, so those are overlapping areas of expertise.) Pancreatic enzymes can be taken orally to counter the malabsorption - some DS patients need to take them for a time if they are losing excessively until things adjust, so there is no need for serious malnutrition while they work things out. Ask around on one of the DS forums as to what ones are used as a suggestion to your doctors if they aren't familiar with them. There are specialists who understand and deal with these things, but sometimes it takes some effort to seek them out, particularly if there isn't one in your PCP or bariatric surgeon's network of referrals. Good luck in working this out.

I haven't personally needed to do that, but it is sometimes done either as a planned two step DS procedure, or as a revision/completion of the VSG to continue the weight loss or counter regain. The point that my doc stressed in considering using it as a "plan B" in the event of inadequate results from the VSG is that the revision/completion works best if done before any substantial regain occurs. One of the points that we have discussed over the years in our support group is that with the DS, the majority of the weight loss is due to the sleeve while the switch helps keep the weight off, implying that you may have already used the majority of the weight loss power available. If I were considering a completion or revision in similar circumstances, I would want to know whether there is any problem or defect with the sleeve or something about how I used it as a tool that has left me with less results than I may have expected, so that such can be addressed and corrected as part of the revision process. Is there something about my diet or other habits that has caused a shortfall in performance of the original surgery, which is something that I would want to address, or is there a metabolic problem that the switch would address that the sleeve alone does not? Good luck in finding your answers and with decisions....

I will take a crack at some of these: 1. Yes - some do frequently, particularly if they overeat. Personally, I haven't in the past six years since surgery. 2. Yes. Ingested air or gas from digestion has to get out someway - there are two routes. 3. Post op tolerances vary widely with some not able to eat some foods for varying lengths of time, and some have no issues at all with anything. 4. Depends on your surgeon's program. Mine was soft foods and liquids from the get-go. 5. Depends on surgeon's program and individual needs and inclinations. Most are protein centric as our bodies need certain minimal amounts and can get by with little else. Some follow one of the many popular fad diets while others concentrate on learning to eat sustainably for long term maintenance and weight control. 6. No idea, but it shouldn't hurt. 7. No experience. 8. No, more like T-giving dinner after seconds, thirds and fourths, only with a small fraction of the amount. Some may experience what they call foamies or slimies when things come back up but I have never experienced this. 9: Water goes right thru; capacity of the stomach is irrelevant. Eatiing/drinking limitations are variable but usually settle out at no drinking for 30 min after a meal. Before a meal doesn't matter as the fluid flows right thru the empty stomach, though a limitation of 15-30 minutes is often used initially to account for post surgical stomach inflammation that may impede fluid flow. 10. As before, with a sip of water. For a while it was one pill at a time with a sip rather than a handful of pills with a gulp, but that settles out over time. Some RNY oriented practices like to use chewies or gummies to avoid pills getting stuck in the stoma, which is irrelevant for sleeve patients who don't have a stoma. Some large pills may work better split or crushed for a time. 11. See Above - fluids flow right thru the empty stomach. Drinking immediately after eating may result in things coming back up. 12. With the sleeve, nutrition is largely up to the patient as there is no significant malabsorption effect. Early on, much of our nutrition other than protein comes from supplements but that decreases as our diets improve over time. 13. For a time, yes, and some do more than one. Some choose to continue using them for the long term out of convenience. 14. you aren't going to do much to damage your stomach by exercising too much/early, but you can induce incisional hernias. 15. Choose better parents and don't get fat in the first place. Seriously, it's a matter of genetics, age, and how much fat is stored where.

It is quite common and physiologically normal - it would be abnormal for one to lose more in the second or later months than in the first month. What is happening is that when we go on to a serious caloric deficit, we that deficit is made up mostly from our short term energy reserves of glycogen (basically stored carbohydrates), which burns quite rapidly (around 2000 calories per pound lost.) Once the glycogen is depleted, the body needs to replenish that supply to a functional level and we frequently stall or pause for a short time - the "three week stall" that we often read about here. Once the glycogen stores are back up some and our body gets the idea that this caloric deficit thing that you are doing to it is a serious thing, it starts drawing from our longer term energy stores of fat - which is what we are really here for. However (there's always a "however"!) fat burns more slowly than glycogen (around 3500 calories per pound lost) so the weight comes off more slowly now, but we are doing what we came here to do - burn fat. Note that this has nothing at all to do with "ketogenic" diets or miracle "fat burning" potions - it's strictly the result of being in a prolonged caloric deficit. As a side note, I lost 32 lb the first month and 15 each of the next two months. with roughly the same caloric intake, so right on profile.

walking is the normal first step for the initial 2-3 weeks or so, most docs don't want you doing any lifting or abs work for six weeks - mine says 12 weeks which arguably is still too soon. One of the things that learned from orthopedics and the PT that goes with it is that our connective tissues (which would include the fascia that holds our abdomin together under the muscles) don't have nearly the blood supply as our muscles, so they heal a lot slower. We can readily find our muscle strength returning and feeling good before those connective tissues are ready to take the load, so slow and easy is the watchword. Incisional hernias are not uncommon in our post op population (though they can provide partial payment for plastics!) I started doing some light resistance machine workouts after three weeks, keeping the weights light (about half of what I had been doing) and isolating the core. The main intent was to start regaining some range of motion and just reestablishing habits. As BigViffer indicated, you are going to lose some muscle mass both from caloric deficit and the simple matter that you won't be carrying that excess weight around 24/7. But good quality protein and continued strength training can minimize that loss. Heart rate is a funny thing. After 2-3 months, a good brisk walk, just short of a jog which my knees still don't like, could barely get my rate to break 100 whereas before it would easily be in the 130-140 functional range. To get my rate up to any reasonable level I could no longer do it along the shoreline paths and had to take it to the hill trails to get the elevation change. These days my resting rate still hangs around 50 so I'm still maintaining that extra cardio capacity to feed that extra weight that I no longer have; still gets questions from doctors, too! On sex, the humorous answer is that the hospital nurses agree that you should wait until you get home. My doc's answer is when you feel like it. As long as you are comfortable with positioning, an orgasm isn't going to bother anything done by the sleeve surgery (just getting there might if you are particularly adventuresome.)

I can't speak from direct experience since I haven't had that revision done (yet) though such a procedure is on the table as there are differing opinions on my particular issues. A second (and even third) opinion is a good thing to get when considering a revision, particularly when it is due to some complications. One of the dynamics that exists in the bariatric world is that most surgeons have more experience doing bypasses than sleeves, so there is some natural inclination for many of them to revert to their comfort zone and go bypass when things get complicated. Most are sufficiently competent making sleeves these days (more so than 5-6 years ago when it was just starting to get routine insurance approval,) but the lingering question is how good is any particular surgeon at correcting problematic sleeves. Is a recommendation for a revision really the best solution for a particular problem, or is it merely the most convenient for the surgeon? Certainly, there are situations where a bypass is the correct solution and the trick here is to find whether or not that is your particular case. A second opinion from a surgeon who is deeply experienced with the sleeve would be a good start. I often use the DS as a starting point in establishing VSG experience as the DS is based upon the VSG and has been performed for some 30 years now, so those longer tenured DS surgeons tend to have a lot more specific sleeve experience than the average bariatric surgeon. (and there are a few who broke off from the DS world early on to specialize in the sleeve.) Further, a good number of them get involved in some of the more complex revisions (like RNY to DS) so are more capable than average in correcting sleeve problems. I have been rather impressed with readings and conversations that I've had over the years that as a group, while they may prefer the DS as their primary offered procedure, they have no problem recommending a bypass when it is the appropriate solution to a patient's problems. While DS docs tend to be fairly few and far between, there are several good consult prospects in the bay area. They are well worth seeking out for that second opinion. We can PM if you want to discuss further details. Good luck in getting this resolved.

This is quite normal. When doing a low carb diet, one's glycogen (short term carbohydrate energy stores) levels are being kept at their minimal level in the hope that the body will burn fat instead. On average, the body will keep around 2 lb of glycogen on board, which is kept in solution by about 8 lb of water. The body wants to get those glycogen levels back where they should be if tehy are low, so any additional carbohydrate consumption beyond ones normal minimal "low carb diet" level will result in some quick short term water weight gain. The amount is limited, and doesn't happen if one is on a normally balanced human diet. I never ran into this particular issue as i kept the carbohydrates and fats in relative balance throughout the whole process, so my glycogen levels, and associated water weight, never yo-yo'd all that much (that, and I couldn't afford the side effects of the overly low-carb/keto type diets.) The flip side of this is when marathoners carbo-load before an event by loading up on pasta, etc. - they are trying to maximize their glycogen levels to improve their endurance.

For best resuts, most surgeons want to wait for about a year after ones weight is stable before undergoing reconstruction, as thing can shift around some after the weight loss stops. There can be exceptions for different circumstances - for instance for those who have a severe problem with the overhanging flap one might do a quick pannilectomy to get rid of that flap, even if weight loss is not complete, and touch things up later when doing a total abdominoplasty or lower body lift.

I guess it can be for some, but we are at such different levels that there really isn't any, She needed to restore basic functional strength after anemia induced atrophy after plastics while I had been working out and swimming for years. I mostly tagged along to get a bit of professional guidance and be with her through the process. I never thought I would ever see her doing two minute planks though!

There are a number of considerations in choosing what procedures go together including individual preference on recover times and number of procedures, surgeons preferences and time on table, compatibility of different operations (as Stella indicated) and relative ease of recovery for different combinations. The play that your surgeon lays out makes sense from the perspective of isolating upper and lower body (much easier to get out of a chair or bed when your upper body is healing if your legs are unimpaired, and vice versa.) You probably wouldn't want to go through the thigh lift if you couldn't pull yourself up with your arms and pecs. I had an abdominoplasty and moob reduction together, though didn't need the brachioplasty, and it worked OK (none of this is easy!) The most memorable part of the process wasn't the recovery pain (that's expected,) but the scrotal inflation - I had a grapefruit down there for a month or so (doesn't always happen, but we have a convenient built in drainage path from the abdomin down left over from our infancy that can still work despite all the drains they install - it's a guy thing.) Have some loose shorts and sweats handy for post op, and maybe some good support may work better in some circumstances.

My wife and I used one for a year or so who was a referral from her physical therapists as one who they worked with to do follow on work after one is beyond the physical therapy level, which is what she needed, and I tagged along to work at my level (I think it was an additional $10 per hour to do both of us.) I have also known some post ops who have hired kinesiologists to specifically help them with balance issues, as that can be a problem for some with the rapidly changing center of gravity that we can experience as the weight comes off (I used to joke with my wife that it was like going through puberty in reverse....)

Clinically, HFLC diets are used for non-WLS gastrectomy patients who need to avoid weight loss and ultimately regain unwanted loss and indeed, this does present one of the challenges for WLS patients who adopt this approach. During the early weight loss months (when we are relatively insensitive to diet due to the enforced restriction courtesy of our WLS,) many will proudly proclaim that they "do full fat everything". This works fine when we are largely consuming "condiment" amounts of fats early on, but often bites people when they carry that practice into maintenance and allow the higher calories to get away from them. It can be done for whatever reason you may want to do it, but you do need to be watchful of your overall consumption to avoid regain. Philosophically, in the absence of a specific medical condition that warrants it, I'm not a big fan of diets that are "low" or "high" of anything as that implies deficiency or excess. One might do a short term very high or low diet to counter an existing imbalance (such as treating insulin resistance with a very low carb diet,) and then moderating that extreme to a more balanced state as the body's chemistry corrects itself for the long term.

One can make a good argument in either direction. I went with the sleeve because I was at a similar low 40s BMI at surgery time but without the diabetes. Further, I had already lost about a third of what I needed to lose while my wife went through her DS and effectively worked myself into a WLS maintenance lifestyle, maintaining what I had lost for several years, so I didn't feel that I needed the extra kicker on regain resistance that the DS provides. So far, so good after six years.

From a strictly weight loss perspective, there is a lot of overlap between the two, with the DS being better for those starting in the higher BMI ranges. The sleeve works well in the moderate BMI ranges (35-50) and also works well above that with somewhat more intensive dieting and greater discipline needed in the long term. The DS is stronger in regain resistance than any of the other mainstream procedures, so is particularly good for those with long term yo yo dieting patterns. From a diabetes perspective, the sleeve is similar to the bypass, with remission/resolution rates of around 85%, while the DS typically sees 98-99% rates. This should not be overly surprising as the DS started as a procedure specifically targeting diabetes, to which the VSG was added to make it a WLS procedure. Longer term, the sleeve is still relatively new with only some five year data available for any kind of significant patient populations. There are some indications of somewhat significant recurrance after five years, though it is not clear how well correlated that may be with whatever regain problems some may be having. The DS does seem to show more significant staying power in the face of regain, which in itself is less of a problem due to the long term malabsorption, compared to the VSG or RNY Note that this only applies to the "classic" DS and not the newer SIPS/SADI/"loop DS" which is a different procedure for which there is little long term data. There is a fair bit of experience that indicates that the longer one has been diabetic, the longer it takes to knock it out even with the DS. My wife had been under treatment for it for some twenty years when she had her DS and it took the better part of a year for her to be off of all meds for it. Others, even long termers, will walk out of the hospital free of meds with either the sleeve or the DS - YMMV. She is still off of all diabetes meds after twelve years. My feeling is that for a younger patient, particularly one whose obesity problem is only "moderate" in WLS terms can do very well with just the sleeve, particularly if they concentrate on learning long term weight control. If necessary in the future, a move to completing the DS (which is based upon the VSG so one is half way there already,) if the diabetes comes back again can be done. Last year at one of our support group meetings i was chatting with a gal who was some 25 years out on a RNY and by all measures has been successful in her weight maintenance until some of life's stresses hit a few years ago and brought on some regain (not the total regain we sometimes read about,) - enough to bring her diabetes out of remission, so she was lining up to get that revised to a DS to knock it out again (she would have done the DS originally had it been available then.) All of these procedures can give you something of a "do over" and let you start relatively fresh, but one has to take that opportunity to learn how to manage oneself in the long term and not go back to whatever got us here in the first place. Good luck on whatever path you choose.