RickM

Physiologically there is no reason not to have a chunky soup pre-op, but you need to check with your surgeon's team as to what their specific rules are - only they can tell you why they are doing a liquid diet at this point and what they allow.

That was about five and half years ago, and my wife was on the same basic program for her DS eleven years ago. As far as I know, they still don't impose any such diets, even on very high BMI patients. Talking with another DS surgeon in a different practice, the reason he doesn't use them is that he wants his patients as strong and healthy as possible when they go into the OR, and fasting for weeks ahead of time doesn't do it. I can see where some surgeons vary the requirement by BMI and others by procedure - many are very experienced with the bypass but still relatively new to the sleeve, so they may need the extra help that such diets are supposed to provide. Also, the sleeve does more work underneath the liver where things are crowded while the bypass operates more at the top of the stomach and avoids some of that crowded space down there. Also, docs who have been doing the DS for some years, which is a sleeve plus intestinal rerouting, tend to have more experience doing sleeves and working around a lot of the fiddly bits under the liver where the switch occurs, so I suspect that they may have developed techniques that negate the need for such diets, which the bypass guys haven't found yet. Whatever their protocols, you want to follow your surgeon's directions as you want them to be as comfortable as possible when they are fiddling around with your insides!

Most need to take something (as do most non-WLS people, given the quality of the average American diet), typically at least a multivitamin and then others depending upon which procedure one had, diet and lab results. The DS and RNY will usually need more supplementation than the VSG due to their malabsorption.

I'm no expert on this (I leave that to the surgeon, who is a liver guy...) but rapid weight loss does tax the liver, so that increase in diet severity could lead to altered numbers. This is a good part of the reason that my surgeon has a strict no alcohol during weight loss policy - the liver is stressed enough as it is metabolizing the fat that we are losing. My suspicion would be that it is just the dietary change, but it would be best to run that by your surgeon to see if he has any concerns about it. We didn't have the pre-op diet so it wasn't an issue then but I suspect that my numbers may have been a bit out of whack post op while losing but it was never brought up as an issue by either my PCP or the surgeon.

Some of the devout carb counters would have total apoplexy at the thought of the bananas and strawberries in there, but even ignoring carb counts (as I did) you need to watch the calories and make sure that they fit in with your needs. I found that in making shakes with fruit like strawberries in them that the amount of fruit needed to make a notable difference in flavor wasn't worth the calories when in weight loss mode. My wife throws a pound of frozen strawberries in the Protein smoothies (which makes a couple of good sized servings) but she isn't counting calories or trying to lose weight. Making shakes from powders is my preferred approach as I can alter the flavor and consistency as I choose. Whether you need to add the milk powder to skim milk and Protein Powder is up to you - run it through a tracking app and see what it does on protein vs. calories to see if it make sense to do.

Deli meats, dark meat poultry and seafood are usually well tolerated early on, soft cheeses, greek yogurt, SF pudding made with greek yogurt and/or Protein powder, try alternate Protein drinks (I was never impressed with RTD drinks and found that I could do a better job of adapting the flavor with the powders and other added flavors to taste. I wouldn't be overly dependent upon that GENEPRO stuff as the main thing it can be guaranteed to produce is expensive urine. While they may not have been shut down as a fraud yet, it sure checks all the boxes of a typical nutritional supplement scam (too good to be true - 30g protein in only 15g of product, just what is "equivalent" protein?, proprietary product - nobody knows what it really is and they aren't telling, no independent verification of their claims...) 0

AFAIK, Dr. Rabkin (Pacific Laparoscopy) still has the Kaiser Norcal contract for the DS, at least he did when I had my sleeve done with him, and the last time I went to one of his SF support groups (I'm in socal, so don't get up there often) there were several Kaiser people there on one side or the other of surgery. You might give PacLap a call and get their current take on the matter.

We do see some variance with many practices, primarily in the form that women should get 60-ish (or 60-80) g of protein while men should get 80ish (or 80-100) g, though given that women have long been the primary demographic for WLS, it is easy to see how some practices have simply settled on something around 60g in their published documents, and them might pull the guys aside and tell them to get more. As to phasing the protein in or out as one progresses from surgery, my conclusion is that it probably doesn't matter much. Classically, protein demands can increase by 50-100% after major trauma, including major surgery. Since we haven't seen the bariatric world take to this, my main conclusion is that what we are going through really isn't "major" surgery. That is, after all, one of the prime benefits of laparoscopic surgery. There may also be a factor that getting the basic maintenance level of protein in is hard enough early after surgery that they didn't bother, and found that patients healed fine without the added protein. When I went through plastics, they did make sure that we got the protein boost, as that is indeed much more traumatic surgery than our basic WLS. Our basic protein maintenance requirements are most closely based upon out lean body mass, which is why typically guys need more than the ladies - guys ideally carry less fat and more muscle and are typically taller than women. That is the primary variation that needs to be addressed, and most practices do so in simplified form by using the 60/80 rule. The model promoted in the article (and noted for not being good for overweight people) is a very gross simplification - the better models use "ideal" weight, such as so many grams per lb or kilo of ideal weight, with ideal weight varying by gender and height and sometimes age, though age doesn't seem to be a major factor beyond puberty; the elderly often have problems simply because they don't eat as much as they use to, so should alter their protein/fat/carb balance. The model that I like best so far works to estimate actual protein demand, with the basic assumptions being that our muscle mass is replaced every six months, so how much protein is needed daily to satisfy that basic maintenance requirement? In general terms, it works out fairly close to the basic gross guidelines that we always hear, with the smaller ladies typically in the low to mid 50's with taller ladies in the 60's and guys tending to be in the 80's and 90's. My 150ish lb of lean mass (which is a little higher than average for my 5'10" frame) takes about 105g to maintain, according to this model. Then, if one is wanting to build muscle mass (and do the work required,) adding 10lb over six months would require another 40ish or so g per day.

We hear this claim a lot, but I can never find a legitimate source for it. To me, it doesn't pass the "smell" test of reasonableness. From an evolutionary perspective, it doesn't make sense that we would have evolved (or were created, if one is of that mind,) that way, as in the good old days we might chase down an antelope and gorge on it for dinner, and then not have any substantial protein for several days. I can certainly buy that after 30g, or some such amount, that the next 30g might only be 80% absorbed, and the next 30g maybe 60 or 70%. That would be more consistent with nature and our general biochemistry. I can also buy that rapidly absorbed supplements may have a limit, with excessive amounts just overwhelming our body's ability to absorb in the time allotted, but such limits on real food sources just don't make a lot of sense.

At that point I was getting 100-110 g per day (it's a guy thing), which is still what it is at five years later (as it should be - these are generally maintenance levels of protein we are trying to hit.) Doc added veg to my diet at the 10 day mark since at 90 g I was at a more than satisfactory level at that time.

In US vernacular, the biliopancreatic diversion with duodenal switch (BPD/DS) is the same thing as what is commonly called the DS. Back in the good ol' days there was a European procedure developed by Dr. Scopinaro that was called the BPD, which was a similar intestinal rerouting combined with a large pouch like stomach similar to the RNY gastric bypass, only larger. Typically the common channel was fairly short (50cm, IIRC) for a high degree of malabsorption, but low restriction, and typically the nutritional problems that went along with it. The BPD was never adopted in any numbers in the US, but was used as the basis of what is today the DS, which combines a sleeve gastrectomy with the switch type of intestinal bypass, typically with a common channel length of around 100cm, give or take, for a moderate level of malabsorption along with moderate restriction and milder nutritional impact (the DS typically uses a larger sleeve than the stand alone VSG.) When seeking approval from the industry (ASBS, precursor to today's ASMBS), Dr. Scopinaro insisted that the DS be referred to as the "BPD with DS" as a link to his BPD, hence maintaining credit for his contribution. The early DS docs generally agreed to keep him quiet, but this caused no end of problems with patients trying to get approval for the BPD/DS after most of the US insurance industry had soundly rejected the BPD due to its nutritional problems. In short, BPD/DS=DS, just two different names for the same thing, much like we have the VSG, sleeve, VS. and VG all referring the the stand alone sleeve gastrectomy. However, the BPD/DS or DS should not be confused with the new kid on the block, the SIPS/SADI/"loop DS" which has its own merits and de-merits and should be considered on its own as a distinct option to the VSG, DS and RNY.

Trying to keep this as short as I can, here is my perspective on this problem. After researching alternatives, my wife and I went to our first WLS seminar in mid 2003, targeting the DS as the most likely procedure - she was short woman w a 64 BMI and I was an average height guy w a 48BMI. The sleeve wasn't a routine alternative then, as even the DS was still considered investigational by many insurance comanies, including our. We went thru the usual insurance mandated 6 month diet/exercise roadblock to approval before the ultimate denials for her - she was no. 1 on the runway with her size and diabetes, and it took us a couple years to get her on the table on a self pay basis. The philosophy we took with our PCP for that med supervised diet was primarily sustainability - what do we want our diet to be long term that will promote weight control and general good health, not a quickie short term weight loss diet which typically leads to regain. I wound up losing 50lb. about 1/3 of my excess weight, over the six months or so which was great - can I actually be one of those 5% who can lose it all and keep it off? No, but despite making tweaks here and there and working to improve things, I maintained that loss over the years and effectively worked into a WLS maintenance lifestyle with my post op wife. Once the sleeve was being approved by our insurance and it was apparent that I wasn't going to get to normal on my own, I went with the sleeve. Had I regained what I had lost, I would have been inclined to go for the DS as that regain, had it happened, would have shown me that I needed the extra power of the DS to maintain the loss; since I was maintaining what I had lost, I felt that the sleeve would be adequate for the job. Five plus years later; it still is for me, and the DS is working well for my wife after 11+ years. With the DS, it's the regain resistance that is its' greatest asset - I have seen many lose 2-300 lb or more with the sleeve or the bypass, but it is keeping the regain at bay that is the challenge with them. My wife needs the extra help that the DS provides while I am getting along fine without it. There are some metabolic issues at play here too, that are usually more critical at the higher BMI levels. My general observation over the years (and there are always exceptions....) is that if one is still gaining weight going into a WLS program (the start of it, including whatever dieting, etc is part of the program, not the surgery itself) or continuing a yo-yo dieting pattern and expecting the WLS to break that pattern long term, go with the DS as you will probably need that extra power and regain resistance. Look at WLS as a do-over. You can likely attain a normalish weight with any of the mainstream procedures, but then you have to keep it off. Can you learn the healthy eating habits during your weight loss period - many go on various popular weight loss diets during that time which puts off learning the long term skills until maintenance, and that is where many falter. I agree with Alex and others about second opinions, and learning as much as you can from the surgeons as to what they see as their critical success criteria, and why they recommend what they do. You have a number of good DS/sleeve surgeons in your area (BTW, which one have you been talking to so far - the DS community is fairly small so we all tend to know who most of the players are?) but they often have somewhat different perspectives.

From what I have seen over the years, this is one of the more common shape related issues with the sleeve - with or without a significant stricture, sometimes too much of the stretch fundus is left at the top and/or bottom of the stomach leading to excessive stretch over the long term. Whether it comes from quirks in ones' specific anatomy or surgical technique is anyone's guess for any specific case. As I have had it explained, the cutting tool/stapler that they use is a long, straight tool, with which they need to make remove the greater curvature of the stomach, following the general shape of the minor curvature on the inside - think of cutting a piece of paper or cloth into a circle with a long pair of shears - lots of little cuts rather than a few big ones - which isn't easy via the remote laparoscope, it takes lots of practice. The result with a sleeve if they make just a couple of large cuts instead of 3-4 smaller ones is something shaped more like an hour glass than the banana that it is supposed to resemble. I can understand from a liability perspective that others are shy about correcting the problem. Unfortunately, this is a big problem as those who may be relatively new to the sleeve and are more prone to these issues are in less of a position to correct the problem. Often the recommendation is to revise it to a bypass as that is what they are most familiar with. Other surgeons in the area may also be apprehensive about correcting it as they themselves may be too low on the learning curve to make such repairs. The best shot that I can think of is to find a well experienced sleeve/DS surgeon who may be willing to tackle it - the guys who do the DS as their primary procedure tend to have a lot more than average sleeve experience as the average bariatric surgeon - dsfacts.com has an incomplete listing of DS surgeons, though conveniently there are several good ones in your vicinity. The two most likely guys to check with would be Dr. Roslin in NYC or Dr. Greenbaum in Moorestown are well regarded for doing complex revisions (like putting bypasses back together and revising to DS) so if anyone can in the area can put your sleeve back the way it should be it would be one of them.

It sounds like it could be an incisional hernia, which can pop up months after the fact. If you have an appointment with your surgeon or PCP soon, bring it up with them - it's something that they can usually feel since they know what to look for. Certainly bring it up with one of your docs to eliminate the simpler things before going for an expensive test that may or may not show the problem.

I never had a problem with peanut butter (creamy, of course,) early on and sometimes had some on a couple of saltine crackers (which are basically liquid by the time they hit your stomach) but my program didn't distinguish between "full" liquids, purees or soft protein foods. Where PB would fall within your doctor's spectrum of phases could be anybody's guess, so best to check with the doc if it isn't spelled out in your guidebook.

I suspect that it is because aspirin and NSAIDs are a very big NO-NO with the bypass, due to specific problems with that anatomy that don't apply to the sleeve, but most bariatric surgeons are still feeling their way around the sleeve after years of bypass experience - an abundance of caution on their part until their experience catches up. Surgeons who have been doing the DS (sleeve with intestinal rerouting) as their preferred procedure, such as the OP's surgeon, usually have more sleeve specific experience under their belts and tend to have a better understanding of the tolerance differences between the different procedures. One of the long held selling points of the DS over the bypass is its' NSAID tolerance. I was told to use ibuprofin or naproxin of any post surgical pain once the narcotic pain relievers were no longer appropriate (not that I needed any.) That said, they are still serious medications with significant potential side effects even for normal people, and consistent use of them should be done under medical supervision even if they are an OTC product (there are potential liver and kidney issues with them.) In the OP's case where this is prescribed, presumably by the surgeon, if the script has refills specified on it, that would be tacit approval to continue its use, but it would be good to double check with his staff on Monday.

The sleeve is generally more tolerant of NSAIDs including aspirin than the bypass, which is where most bariatric surgeons get their experience and recommendations from. I suspect that Dr. Roslin will be more liberal than average on their use as he is coming more from the DS world, but it is really his call. It's not normally something that is a big deal to skip a day or two on, so you should be able to wait to talk to them on Monday and get their word on it.

And take the results with a few grains (or kilos...) of salt. The problem with these metabolic calculators is that the formulas they use are typically set up for normal weight people, and don't handle unusual body compositions (like extreme obesity) well. They do OK for someone needing to lose a few pounds of holiday bulge but not for someone needing to lose hundreds. Resting metabolism is most closely associated with lean body mass; fat mass does virtually nothing to resting metabolism (though does have some influence on our active metabolism as it does take calories to move all that excess weight around.) When I first started this WL venture years ago using a precursor to MFP, their calculator said that I should be eating around 4500 calories per day. Fat chance (so to speak) - maybe if I were a Marine doing 20 mile hikes with an 80lb pack...My actual stability point with moderate activity was around 26-2700 calories, based upon weight stability. An average height woman will usually have a resting metabolic rate somewhere in the 12-1500 calorie range. Add to that the problem of metabolic damage from which we all suffer to varying degrees from our journey through obesity - this is the problem where we tend not to burn calories as readily as our normal weight counterparts, even when we attain normal weight ourselves. and is one of the factors that tend to keep us fat even when we do all of the "right" things. It may be a minor issue or a major one depending upon number of factors that the experts are still trying to figure out, but I have seen a few cases where 6-800 calories is their stability or maintenance point - anything more and they gain. Makes it real tough to lose weight in those cases. These are certainly outliers, but they are out there. Short answer here is not to take these calculators too seriously, they are a rough guideline at best, and don't be surprised if you don't lose weight, or even gain, by following them. Final point - absolutely track what you are doing on MFP or similar tracking program/app. They can really help in guiding choices ("oooo, that's way too many calories for what it provides, I'll choose something better...") and in documenting your efforts. If you are really struggling getting some weight off even at fairly low calorie levels (say, 800-1000) that could be an indicator that you have some significant metabolic problems, and influence your choice of procedure - a VSG or RNY may not be strong enough for that need and something like a DS might be a better choice. Having good documentation of your efforts to discuss with the surgeon can help convince him that you aren't just blowing off the effort needed, and may have a more serious problem.

Any of these procedures can create some bowel issues for a while. It all gets back to the dietary changes we go through and how the bacterial flora in our guts respond to those changes. With our old crap diets, a certain group of bacterial species evolved in there to live off of, and help digest, what we were eating. With the change in diet, those buggers aren't of much use and we need a new group of buggers. Add to that the antibiotics we usually get with the surgery that kill off much of those good bacteria, and then the digestion changes from the intestinal rerouting of an RNY or DS, plus the continually changing diet those first few weeks as we go from liquids to purees to mushies and soft foods ultimately to semi-normal foods, and we are in a dynamic time, digestionally speaking. It's no wonder our bodies can't always decide whether to be constipated or have diarrhea. Probiotics can help in re-establishing the gut flora after antibiotics, and help your system evolve to better digest your new diet, whatever it may be. But don't be surprised if you digestive system provides you with surprises occasionally those first few months as things get stable again. As they like to say in the RNY (and DS) world - never trust a fart (shades of the classic Al Roker White House shart story!)

Yes, I have a sleeve, but progressions can vary widely depending upon how much inflammation you have in your stomach. With minimal inflammation, fluids should go down fairly easily (sip, sip, sip!) but with a lot of inflammation it can be like feeding it through a pinched soda straw - sip a bit, let it settle through, sip a bit more..... I had little problem with any fluids or even soft things like yogurt, puddings, Jello, etc. so I apparently had little effective inflammation. My wife, on the other hand, had significant inflammation and had a hard time moving Protein shakes through her system for a while. Both results are within the spectrum of normally expected results. Are you having problems with just getting the liquid down, or is it more the taste and consistency of the Protein Shakes? If liquids and semi-liquids like yogurt are difficult, then firmer things like eggs will probably be harder still, unless you make them reeeeaaallly runny. If it's more of a gag reflex thing (and some of those Protein drinks are gag-worthy,) try a different brand, diluting it with some other flavors, or as suggested, mixing it with Water or one of the fake milks (almond, soy, etc.) if milk seems to be a problem. Temperature can make a difference, too, some can't take them too cold or warm.

This is really something to check with your surgeon's team about. With the sleeve, we can generally tolerate soft foods early, and many of the long experienced sleeve/DS programs start out with soft foods as tolerated, and more are following suit as they gain experience with the sleeve. The bypass is a somewhat more delicate structure, so this doesn't really apply to that, so check with your surgeon to be sure.

Correct - while statistically they both end up in about the same place, they may take a somewhat different route to get there. The bypass, with its' temporary caloric malabsorption may provide somewhat quicker initial weight loss, but that caloric advantage disappears after a year or two, so metabolically you wind up in the same place in maintenance - if you maintain at 1200 calories with the sleeve, you will maintain at about the same point with the bypass (only the DS gives you a long term caloric malabsorption so that you will maintain at a higher caloric level.) That said, the procedures do have somewhat different "personalities" which may be more compatible with some patients vs. others; some people may do better with one vs. the other.

I had scrambled eggs in the hospital and boiled ones later that first week (part of our plan, at least,) and they were fine in my system (one of those big YMMV things, particularly early out.) If protein drinks aren't working well, maybe try cutting back on the powder (assuming that you are using them rather than RTD products) and adding a raw egg in the mix to bring the protein back up.

A pre-op diet unto itself is not such a big deal, though I certainly question those who do the fully liquid diets as those don't seem to offer any benefit over a simple low carb diet, but do present potential negatives to the patient. If they have other reasons why they may want to do such a diet, other than selling a product through their practice, I have not seen them expressed - it's always the 'shrink the liver' thing. If it is the policy of the practice or hospital, I would question the seniors involved in establishing their policies; if a hospital recruits a respected surgeon to practice in their facility, it is the surgeon who establishes such policies, one way or another. It is really tough evaluating these guys - the surgeons themselves have a hard time at it unless they actually see their colleagues at work in the OR, or have occasion to see their work after the fact (not a good sign if another surgeon has to revise their work!) Some guys may be good at settling claims before they become official, so their record remains clean even if their skills may be marginal, others may have a clean record because they never do anything challenging while another may be more skilled and experienced but have some bad marks on his record because he takes on challenging cases and may have lost one or two. Which is better? Who are you most comfortable with? Patient reviews only scratch the surface (we aren't awake during surgery, and most of us aren't qualified to evaluate them if we were) only touching on tangential issues like bedside manner and office staff and rarely on long term outcomes - which is the most important thing. We need to look for indicators where ever we can. My preference is to look for DS qualified surgeons (those who actually perform them routinely, not just list them on their CV and then sell you something else,) for the reason enumerated in the post above, but also owing to the DS being a technically challenging procedure (that does use the sleeve,) such that those who adopt it as a primary procedure tend to come from the top half of the class. They also tend to have broader experience, as most started out doing bypasses and moved to the DS in search of a more effective procedure, so they don't have a problem recommending an RNY if that is really in the patient's best interest; with most other bariatric surgeon, if they recommend a bypass over the sleeve (or wanting to revise a sleeve to a bypass,) there is always a question as to whether they are looking at the patient's interests, or what is most comfortable for them to perform. Given that the DS has maybe a 5% market share, at best, this leaves another 45% or so of other surgeons who are also in the top half of the class that I have excluded. I don't know how to evaluate them, other than the basic number of specific procedures under their belt, and that isn't particularly helpful if you don't live near one of them, or can't travel to them. My surgeon is about six hours away from me, even though living in southern California there are bariatric surgeons on almost every street corner (though there are a couple of others I have found in the area since then that I would go to, though they came more from networking than from the usual vetting methods.) It is certainly an imperfect selection process, but it beats randomly picking whoever is local that's in the insurance network.

You might post in the general or RNY forum as it is a more common problem with the bypass and fairly rare with the sleeve.