RickM

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.

https://www.youtube.com/watch?v=3_aahPETzH0 This is a vid that we have been discussing on another forum that relates to what you are experiencing. Basically, the doc is discussing how our stomach will increase in capacity over time (as in years, not just the few months post-op), and we need to expect and accommodate that. His main solution is loading up with more veg, which isn't far off from what I have been doing these past few years - I have a decent sized salad most every day for lunch and while it only has a couple ounces of meat in it, it is still very satisfying most all afternoon. It may not be for you, but it is a good way to accommodate increased capacity with minimal calories to avoid regain.

There are several issues with alcohol and WLS that will apply to varying degrees to different people. Healing time for the stomach is the first, which may not apply to those with the band which doesn't cut directly on the stomach, but will vary from a few weeks to several months or a year or more depending upon individual surgeons' perspectives. Transfer addiction, which BigUtahMan discussed, wherein an addiction to foods, to the degree one is afflicted, is transferred to another medium - alcohol, drugs, gambling, shopping, etc. This can affect anyone who is severely limiting their ability to indulge in an addictive behavior (i.e. any WLS patient irrespective procedure.) From this perspective, some will take a "never again" stand on it. The other alcohol biggie is liver condition; going into any WLS our livers aren't in the best of condition due to our obesity (witness the "liver shrinking" pre-op diets that many surgeons impose on their patients} and is further taxed by its role in metabolizing the fat that we are rapidly losing. The last thing that the liver needs is to be further stressed by metabolizing a known liver toxin - alcohol (that's not a moral judgement, just a physiological fact.) On this basis, some surgeons will suggest no alcohol during your weight loss phase. With my surgeon, this is part of the contract that we sign with him - that we will not drink as long as we are losing; it comes from his alter-ego as a biliopancreatic (liver/pancreas) transplant surgeon who doesn't want to see any of his bariatric patients coming back onto his transplant table.

The first thing that you need to determine is whether the sleeve is a problem or your usage of the sleeve. Sleeves can be defective, particularly when the surgeon is new to doing them as most were 5-7 years ago; sometimes they are mis-shapen with too much of the stretchy fundus left behind (often in conjunction with a stricture, but not necessarily. Some imaging tests can determine how things are doing in there. If the sleeve is nominally shaped and a fairly normal capacity for a mature sleeve, there is little benefit to re-doing it as it will be back to this same condition within a couple of years. It is no surprise that the pouch test didn't do anything, as they don't typically do anything (even for those who do have a pouch, which we don't.) A better test is your capacity to eat meats - how much steak or chicken, by itself, can you comfortably eat? That is much more telling than those liquid/sloppy pouch tests fad diets. Have you fallen back to old habits, eating more high calorie junk food that slides on thru your sleeve, drinking calories, etc. or is your diet still largely compliant with standard WLS recommendations? If the sleeve is defective, it can be resleeved, either on its own or as part of a DS, though I would think carefully about letting the original surgeon do the job - if his experience was marginal for doing sleeves five years ago, he may be doing consistently serviceable sleeves by now, but probably hasn't yet developed the skills to competently repair them.

I don't have any direct experience with the Mx docs, but I'm sure others will chime in with their experiences; the only one that comes to mind who has a good following is Dr. Sauceda. My perspective on this is that with plastics it is preferable to keep it local if at all possible. This is not a MX vs. US thing, but rather a travel vs. local thing. Plastics, particularly getting into body lifts and the like, have a much higher chance of minor to moderate complications than your original WLS. Things like incisions that don't heal promptly or open up again, lingering drainage issues, seromas forming, etc. Much of this can be handled via pictures and email but other things are better handled with an office visit. It's usually much better to have the original doc handle these things than trying to find a local third party to do the pickup for him. It's one of the things to consider when weighing the costs of travelling vs. local care.

The general consensus from the chats in our support group, with and without they psych in attendance, is that WLS is a stressful time for couples, but that it tends to make a strong relationship stronger while seriously testing, or breaking, weaker ones. Still at it here 12 years post op for my wife and 6 years out on mine - so it does happen!

Six weeks is a fairly typical number, as you can see, but there are variances, too. My doc's instructions is for 12 weeks before crunches, etc. and that is arguably too soon for many. The problem here is that most of the connective tissues (like the fascia that helps hold your innards into your abdomen along with the muscles,) don't have the blood supply that muscles do, so they heal a lot slower than the muscles. This is one of the reasons that hernias around the incision sites are fairly common with us. This is why a lot of orthopedic procedures are slow to heal, and it applies here too. You, and your muscles, may feel fine and strong enough, but those connective tissues lag behind.

Stages and progressions vary widely from program to program. I, too, was on purees and soft foods in the hospital on out, with liquids in there as needed (particularly things like protein drinks, but also to fill in as needed if firmer things aren't tolerated well yet.) It's a big YMMV thing, just like pre-op diet regimens, or lack thereof.

Indeed, the sleeve provides more options down the road if necessary, while the bypass's options are limited to minor tweaks within the basic bypass architecture. It can be revised to a DS, but that is a complex procedure that only a half dozen or so surgeons can be trusted to do. One should be as certain as possible going in as to which procedure is the best fit for one's needs. Revisions typically don't work as well as a virgin procedure, so they should certainly be considered a "plan B" if other actions don't work out, but nothing that should be planned on "if I don't like" the first one. I know several who have gone the RNY to DS route and while they are generally doing better with the change, they would have done better still had they gone to the DS originally (most didn't know, or know enough about, the DS when they were sold the bypass in the first place.) Research, research, research. The sleeve can just as readily be revised to a DS as to an RNY but still usually has that performance deficit relative to a virgin procedure.

Finding doctors to provide post-op treatment as needed can sometimes be a problem as most docs are wary of taking on the liability of other doctors' patients (this can apply whether the original surgeon is in Mexico or the US). Routine follow up like labs and such are not usually a problem and can be done thru ones PCP and are usually covered by insurance as routine health care. As to which procedure to get, do as much research as you can on them. I'm no expert on the bypass or mini, but there are reasons why the mini bypass has never been accepted by the ASMBS or the insurance industry in the US. It has been around for a long time - some docs were promoting it when my wife and I first got into the WLS game some fourteen years ago, and in the meantime both the DS and the VSG have been accepted as mainstream procedures, but the mini has not. This also plays into any "plan B" that one may have in that since it is not well known in the general bariatric community, this makes it more difficult to treat and/or revise in the future if such is necessary. I would certainly stick with a more mainstream procedure (though a case can be made for a newer procedure like the SIPS/SADI which hasn't gained acceptance due to its novelty and a track record hasn't been established, as opposed to the MGB that never gained traction despite it having been around for a while.)

You may not be ready to come off of your diabetes meds yet - while may leave the hospital not needing them any more, others may take several months to get fully off of them. My wife took the better part of a year to be fully off of her diabetes meds, and that's with the more powerful DS surgery. And, while it's too early to be thinking such things, the sleeve and bypass resolve diabetes in around 85% of cases, so there is some chance that it may not put you into total remission It's probably worth running this by your surgeon and working out an appropriate dosage, if needed, for your needs now, and keep track of things as they change. If you do wind up being one of those whose diabetes does not go into remission, you can consider converting your sleeve to a DS (duodenal switch) which typically sees remission rates in the 98-99% range

If you are getting in only 500 calories (or even 600 or 700,) and an appropriate amount of protein, do carbs matter at all other than hitting some arbitrary number? I never worried about carbs and just concentrated on getting the best overall nutrition within the protein and calorie restrictions. One of the reasons that WLS has been the most successful weight loss therapy for the past few decades is that it gets your calories down to a functionally low level irrespective what diets are in fashion at the time - low fat, low carb or whatever else the diet industry comes up with.

Lots of good advice here. Call the doc's office and check - like many of us, you may not have to do anything until the day before (some docs don't want you fasting before surgery!). There's nothing standard with these procedures and protocols.

I suspect that it is a long stall leading into maintenance. Maintenance happens when your average daily intake equals your expenditure through living and activities. It can sneak up on some if their weight loss diet is calorically similar to their maintenance metabolism, while others will have to increase their intake to stop losing and drive themselves into maintenance. The tricky thing here is that typically, our overall metabolism declines as we lose weight - it doesn't take as many calories to move us around all day long when we are 100, 200 or whatever pounds lighter than when we started, so our loss rate on average tends to decline over time. A diet and calorie level that worked for us well at the beginning may not be enough to get us through to the end, particularly if we increase our consumption as we progress (some can get away with that while others can't.) If you are bouncing around the same weight for the past couple of months, this indicates that your intake isn't far off from your overall metabolism - you may have a few pounds more that you can squeeze out of there, but 30 lb is very unlikely unless you significantly reduce your intake. A drop of 500 calories from where one is stable should yield a loss rate of pound per week (or 4-5 lb per month). That should give you an idea of the size of your challenge here. There is nothing magical about a liquid diet for weight loss, other than most of the products used are very low calorie so you are dropping your calories a fair bit for a few days. One can do the same thing with a basic meat and vegetable diet - just cut the calories to the same level as the liquid program - and you will probably be more satisfied and tolerant of it. There are a number of liquid "reset" and "pouch test" diets out there that are based upon the idea that when we first had surgery we were (usually) on a liquid diet and lost like crazy for 2-3 weeks, therefore if we go back to a liquid diet we will lose like crazy again. Reality check here - those of us who never did a liquid diet also lost like crazy right after surgery, because it wasn't that liquid diet that stimulated that loss in the first place, but the dramatic drop in caloric consumption.

In the intermediate to long term, Protein first is the basic rule to help maintain and prolong our weight loss, however, dehydration will get you back in the hospital a lot quicker than low protein. Listening to your body is fine when it is sending the right signals, though early on many of those signals aren't there, or we don't recognize them because they may have changed. You may have significant swelling in the stomach post op, which can impede the flow of things going through it - you won't cause a leak by having a bit too much as much as it will just come back up, which is why we just go slowly until we get the hang of things. The usually wind up sip, sip, sipping the day away to get our liquids in - my doc's general rule (and the math works this way, too) is to sip away at a one ounce shot glass or medicine cup of Water every five minutes that we're not having a "meal". That will get you 12 oz every hour, or 64 oz over five hours spread over the day. If you can't do an oz per 5 minutes, go for 10 minutes... It does indeed get easier as the swelling goes down. I didn't have any particular problem with it, but my wife did, and both are considered to be normal outcomes. It's just one of those things we have to get through while striking a reasonable balance between all these sometimes conflicting requirements.

The short answers are no, and no. No, the "pouch test" isn't necessary, and no, it isn't sure to work. Beyond the matter that you don't have a pouch to test (assuming that you have a VSG, which is why you are posting to this forum,) these diets are premised on the idea that when we first started out and were on a liquid diet we lost weight like gangbusters, so if we need to get that loss started again, we should go back to that liquid diet. Newsflash - even those of us who never did a liquid diet lost weight like gangbusters those first 2-3 weeks, simply because the composition of the diet (liquids, mushies, solids, etc.) is irrelevant to our loss. That initial loss is a reaction to the dramatic reduction in the calories that we were consuming immediately after surgery (or maybe at starting a pre-op diet for those who did one.) If you indeed have not lost anything for two years (or even several months at the two year mark,) that's not a stall - it's maintenance. The only way to really get things moving again is to dramatically cut your calorie consumption consistently (around 500 calories per day to make it noticable - about a pound a week rate) rather than some quickie fad diet for a few days. The long term "back to basics" approach would be going back to basic lean meat, veg and little else that's caloric. That will do all the "resetting" that needs to be done from whatever junk may have crept back into your life, and is a lot more sustainable than any liquid and mush diet will ever be. Getting back to tracking your intake (assuming that you did once before and stopped, or never did,) with an app like My Fitness Pal or equivalent is a powerful tool to staying on track. Try diligently tracking your intake for a couple of weeks without doing any special "dieting" to get a baseline of what your current consumption is at, so you can tell where to go from here. Then look at where you can cut back on unnecessary calories. You can do it, but it takes more than a quickie "pouch test" or reset to do the job.

.Absolutely - a BMI requirement is not unusual and some like my doc don't do any special diet prior to the day before surgery for any of his patients, and from what I have seen, neither do most of the other long time DS surgeons. Further, the purely liquid diet is not really as common as one would think by reading these forums, as there is some adverse selection going on - those who don't have to do them don't complain about them! More commonly, those docs who do pre-op diets beyond the usual day before surgery thing, do some kind of low carb diet as that is the functional aspect of it from the liver condition perspective - a purely liquid diet provides no particular advantage; typically we see something like a meal or two per day of lean meats and veg and a Protein shake or two.

Beyond meeting whatever insurance requirements that you have, the surgeons office will give you the instructions that they want you to follow prior to surgery. Diet will vary from liquids only the day before (or even simply nothing after midnight) to several weeks of some kind of low calorie, carb or liquid diet. It's a big YMMV thing, so just do what your surgeon wants you to do and don't worry about what others may have to do - it will drive you batty.

I give them a twenty and tell them to keep the cookies. My sister was a GS when we were kids and one year we were the regional distributor - crates of cookies stacked up in the living room. It does good work if you keep the cookies away from your insides!

Initially, yes, as you are recovering from surgery and probably adjusting to new dietary norms. Some nutritional issues can cause problems - low vitamin B12 can lead to a form of anemia (many programs supplement this initially,) and diets that are overly low in carbohydrates can cause some lethargy from the low energy intake. But usually after two or three months and a good part of your weight has dropped off, you probably won't know where all this extra energy is coming from.

The 'gas' issues with the DS is bariatric surgeon code for "we don't really do that procedure even though we may list it on the website to get you interested in us." Yes, the DS does have some issues with smelly gas and stool for a while due to the incomplete digestion from the malabsorption - you may have experienced some of the same things early on with your bypass, and for the same reasons. It is something to consider, but not really a reason to avoid the procedure as it is something that is managed and treated. Even those of us with the VSG and no malabsorption can run into some of these problems simply because our diets have changed and out gut flora (all those nice little bacteria that live in out intestines that help digest our food) haven't yet adjusted to the new diet. Probiotics can help with those adjustments. I would be wary about sending any deposits until you establish that they can do the procedure that you want, which I doubt that they can (or that you really don't want them to try.) The DS is a more technically challenging procedure to perform than the other mainstream bariatric procedures, which is why relatively few practices offer it - it takes resources to develop, and particularly to maintain, the requisite skills. The revision from an RNY to a DS is another step above that in complexity, which is why only a few of the experienced DS surgeons offer it (half a dozen or so.). For a long time, Dr. Gilberto Ungston Beltran was the only surgeon in Mexico that one would consider for a DS. Dr. Aceves was training with him to offer it in his practice before he died, so I would be wary of others that say they offer it - do they really have the experience to perform it, or will they do something else once they get inside? A distal RNY is sometimes offered as an alternative to the DS by surgeons who don't have DS skills - look carefully into that as to whether it would be a viable alternative (though one needs to ask why it is not routinely done?) If you haven't run into it yet, a good information resource on the DS is dsfacts.com. It doesn't undate that often, but they do have an incomplete list of DS surgeons and a listing of various support sites and forums (including BP!) to check into, as you are pursuing a fairly rare procedure so you should cast your net widely to find others who have been through it. I know several who have done this revision and are quite pleased with the results, mostly thru Drs. Keshishian or Rabkin in California. My best advice would be to save your pennies and scour whatever financial resources that you have to do it stateside with one of the guys with the demonstrated experience to do what you want done - this is not a straightforward sleeve or bypass job. Good Luck