RickM

The "no NSAID" rule is a legacy of the RNY, where is it a big NO-NO due to fundamental problems specific to that procedure, and is then usually carried over to the surgeon's sleeve practice along with their other protocols, many of which eventually get updated as they gain more experience with the sleeve and learn the differences. NSAIDs are not the friendliest class of drugs, even for "normal" non-WLS people, and some will argue that they never should have been taken off of prescription status, With a sleeve or DS, we may be somewhat more sensitive to them than normal, non-WLS people, but nothing like bypass patients, so caution should still be used with them, but occasional or incidental use is little problem. My surgeon suggests their use once narcotic pain relievers are no longer appropriate post-op. Many suggest the use of a PPI in conjunction with them to minimize potential issues with the stomach. So, as usual, check with your surgeons team on medication issues, but you aren't in any particular danger from this one slip up. For those who have chronic pain problems, it is something that is certainly worth investigating further for your use, as even non-WLS folks should use caution with them, and have medical supervision if they are going to be used consistently.

The building consensus amongst the surgeons is that no amount of short term dieting will make a marked difference in the size of a fatty liver; what it can do is reduce a slime coat that forms on the surface of a fatty liver, which can make it somewhat easier to handle during surgery. Some surgeons need that extra help while others have developed the tools/skills to negate that need. What is needed to make such changes as can be done is a low carb diet leading up to surgery. Typically what most surgeons who do this recommend is a couple of Protein shakes a day, and a lean meat/green veg meal or two. The shakes aren't really necessary other than as a bridge to get the patient used to using them post-op (which is a good idea, whether one has a pre-op diet requirement or not - explore the different products ahead of time so you don't get stuck with something that you can't stand when you have no alternative post-op.) What the pure liquid diet that some surgeons impose is any body's guess - it's the low carb and restricted calories that is the functional aspect of the diet, not the liquid consistency. Some surgeons make their patients buy a specific product through their office as an additional revenue source. The stomach only needs a few hours to empty to be ready for surgery (which is why the minimal requirement is usually no foods or liquids after midnight before surgery, though most push that back some and make it liquids only the day before in case they need to switch to a bypass during the operation.) Some surgeons vary their diet requirement based upon the patient's BMI or liver tests, which shows that they are at least considering the patients' condition rather than just a one-size-fits-all approach. This is certainly better than putting everyone on a liquid fast whether they need it or not. Most of the surgeons that I am familiar with who specialize in the duodenal switch (which is a sleeve plus an intestinal rerouting which includes some rather fiddly work directly underneath the liver) don't require any extensive pre-op dieting, which leads me to conclude that they have developed tools and skills that negate the need for such diets. They have typically been doing sleeves for 10-20 years or more vs. five or so for the average bariatric surgeon, who typically has been doing them part time along with bypasses and bands. Those DS guys are the type of surgeon I prefer to have on my side.

How many VSG's have they done (it should be several hundred to be comfortable that they know all the in's and out's of the procedure.) Do they impose a liquid pre-op diet (other than the usual day before thing,) - I would be disinclined to deal with a surgeon who does as it implies that they still aren't comfortable doing the procedure; the most experienced guys out there don't do any at all as they want the patient as strong and healthy as possible come surgerytime, and fasting for weeks before doesn't do it.

I wasn't prescribed anything for it. Some docs do while others don't. I never had a problem with it, though if the doc had felt stones in there when he was working on me, then he would have taken it out.

Generally, the no sugar advice is the norm for those who have to do some kind of diet - however there is no "the" pre-op diet as the procedure itself doesn't have any such requirements (it only takes a few hours for the stomach to empty to be ready for surgery,) but some surgeons require more than that for a variety of reasons. It is best to check with your surgical team as to what they want you to do, as no one here can read your doc's mind as to his intentions.

A sleeve as a stand alone procedure - very few as they were rarely done by themselves back then. My wife has a sleeve as part of the DS that she had done 11+ years ago and is doing well, as are several others in our support group we have dinner with every month, most of whom are 10-15 years out.

This is highly dependent upon what the surgeon's program calls for - some are a simple low carb calorie restricted diet, others do a combination of protein drinks and low carb meals, and yet others are nothing but liquids only (some are only clear liquids,) while other require nothing at all until the day before surgery. What does your plan say?

It looks fine to me - my program was purees and soft Proteins, along with liquids of course, from the hospital on out. I was served things like yogurt and scrambled eggs (along with pureed lettuce - ewwww!) in the hospital. The basic rule was to try new foods one at a time to test for tolerance, and if you had any problems with that one, try it again in a couple of weeks. This is from a program with over twenty years of experience with the sleeve, so I had little problem questioning their experience on this. Things like Protein shakes are still a staple initially to ensure adequate protein intake, but their preference is to move away from them as tolerances permit - their general finding has been that patients tend to do better as they move toward more real food. I have found this to be a fairly common practice amongst the more experienced programs (most particularly the DS oriented practices that have more sleeve experience than the average bariatric practice.) The main reason we see most programs being more conservative and going with liquids, sometimes for weeks on end, is that they are transitioning their experience from bypasses to the sleeve and they haven't gained enough experience and confidence in the sleeve yet. We are seeing more programs advance their progression schedules as time progresses and their experience builds. How well you will handle heavier liquids into purees and beyond is heavily dependent upon how much inflammation you experience in your stomach - it may be minimal which will allow things to move through relatively easily or it may be significant where liquids have a hard time passing. There is no real way to know ahead of time where you will stand in this spectrum. Take things slowly and try small amounts of new things while sticking with the tried and true Protein drinks for the basic needs at first.

The basic rule for these questions is, what does your doc's program say? My experience has been that dairy is no problem at any point, and had yogurt in the hospital, and had milk based protein shakes, yogurt, eggs, soft cheeses, etc. from the day I got home (which is on our plan, but more advanced than many). Of course, some will wind up lactose intolerant, so that needs to be handled by either avoidance or using Lactaid products. Sour cream may be a bit caloric and low protein for use in any quantity, but should be tolerated ok.

Indeed - this is why some surgeons specifically avoid these liquid pre-op diets that are imposed by some programs - fasting like that isn't the greatest way to prepare for major surgery.

My wife has a DS from his older brother, now retired, done about 11 years ago, and Dr. John did my VSG around 5 years ago. Unless things have changed radically in their program, things tend to be a lot more straightforward than many programs. There is the usual clearance from your PCP, and maybe a specialist or two depending on your particular health issues (cardiac, pulmonary, etc.) and the typical surgical pre-op tests (EKG, blood draw, etc.) and then a liquid diet (probably clear, don't remember) the day before and a bowel prep/clean out the afternoon/evening before. If you want to be particularly conservative, you can have your "last supper" two nights before and go with a mushy/liquid diet the day before the day before surgery but that isn't required as things flow through and out well enough on their one day program. Our PCP has been impressed with their practice ("my other WLS patients don' get this kind of follow-up..." in regards to their annual lab draw,) and after my surgery, Dr. John gave him a phone call with a post-op report ("surgeons never do that - I;'m lucky to get a fax of the surgical report...") Good luck, and have a pleasant trip through all of this (ours has been boringly routine!)

It's difficult to get to toxic levels of B6 from food (particularly for us post-ops with our small stomachs), but supplements are where the problem usually lies. Our surgeon has gotten sensitive to this issue as most of his patients (the DS guys in particular) take lots of supplements, and it can sneak in where you least expect it. The one that they warn about most is the Costco/kirkland Calcium citrate which adds B6 to their mix in addition to the usual D3 (and probably mag.) Combine that with a Multivitamin or two (check the levels on those - they sometimes load those up with much more than 100% RDA) and sometimes a B complex and it's easy to get to toxic levels. .I haven't heard of B1 being much of a problem, other than the occasional deficiency from the low carb diets that most are on.

A couple of surgeons in your region to look into is Dr. David Greenbaum in NJ snd Dr. Mitchell Roslin in NYC. Both are well regarded in complex revisions such as RNY to DS (there are only a half dozen or so in the country qualified for that one, including Paul Kemmeter up in MI that RJCS197, who posted above, used. Their preference may be to go with the DS as that overall tends to provide better results, but they usually have no problem doing RNY when that is the appropriate solution for the patient (be open minded when dealing with these complex revisions - the bypass may have worked well for you, but your mother may be a better match for another configuration.)

Purees and other soft type proteins (eggs, yogurt, etc.) in the hospital and beyond for the first month. I ignored the pureed lettuce (ewwww..) they served there.

The general rule that I have heard these days is that saturated fats should 1/3 or less of your total fat intake. I don't think that it makes much sense to try to set goals for the poly- and mono-unsaturated fats as they are so poorly documented in most of the foods that we eat and record that one can never reach such a goal on paper (look at most food labels and see how many list the poly- and mono- numbers.) Philosophically, I never worried much about fat and carb levels while losing since between our Protein minimums and caloric maximums, there isn't room for much of either - our diets are defacto low carb and low fat, and generally nutritionally deficient in both. I just tried to get the best overall nutritional balance that I could with that remaining "non-protein" segment of the diet, supplement to make up the deficiencies as best I could, and look toward meeting those more specific goals in maintenance when I had more calories to work with.

The liver shrinking thing is something of a debatable point within the bariatric community these days, with the current concensus being that no diet of a couple weeks makes a notable difference in the size of a diseased liver. What can be improved is the reduction of a slime coat that forms on the surface of a fatty liver, making it easier to handle for some. The normal protocol for this is a low carbohydrate diet, typically consisting of leaner meats and non-starchy vegetables. Some programs will substitute a meal or two per day with a Protein Shake to get patients used to them for their post-op world, but an all liquid diet provides no real benefit toward this goal. The surgeons who impose these all liquid diets seem to have something else in mind, but I have never found any good reference to it. It might be a belief in it helping get patients ready for weeks of post-op liquids that some use or may simply be a legacy of past practices ("that's the way we've always done it.") My experience has been that the surgeons who routinely do some of the most complex bariatric procedures and revisions generally don't need their patients to do these diets, even the very heaviest, implying that they're bringing tools and experiences to the table that negate the need for such pre-op treatment. These docs also tend to have more rapid post-op progressions as well, often starting with soft foods in the hospital or after only a few days of liquids rather than weeks; our info binder states that their experience has been that patients tend to do better the sooner they move from the supplements/shakes into real food. This is why I tend to look a program's pre- and post-op dietary practices as a window (one of several) on their skills and experiences. Congrats on your routine surgery and recovery, and keep up the sip,sip,sipping and the walkies!

Check with your surgeon or program director, as many programs are set up to handle remote appointments. Due to some of the specialized procedures that they do, my doc has a fair number of travelling patients, so he can handle everything past the initial 10 day/2 week appointment remotely via phone/email/fax. Certainly, it is preferable to find a surgeon in your new area that can take over - check with your surgeon to see if he knows anyone in your new area that he can refer you to; while not always necessary, the availability of a hands on check up is nice to have available should some complication arise (and it would also be good to get involved in a support group in your new area.)

What, if any, pre-op dieting regimen do they use? Surgeons vary all over the map on what they require, from nothing at all beyond the usual day before pre-surgery thing to weeks of liquid only fasting. Personally, I would avoid any of these guys that do the weeks of liquids only dieting as you want to be as strong as possible going into major surgery, and fasting for weeks doesn't do it.

Caution - www.dhmo.org

As noted, check with your surgeon's team, as only they can tell you specifically what your diet is and why you are doing it.

The catch with this (there's always a catch!) is that it only really works if you self pay for your surgery, or have other substantial medical expenses that, in total, exceed 10% of your adjusted gross income. It all adds up (parking & travel expenses related to medical treatment, too) if you can pass that threshold; otherwise it's a wasted accounting effort. My sleeve was covered by insurance, so none of these things were deductible, but a couple years later when plastics came along, this medical expense deduction totally offset our tax liability for that year.

The best Protein shake is, first and foremost, the one that you will drink; tastes vary widely so take others' opinions with a grain of salt - try different ones for yourself. From an absorbancy/bio-availability perspective, 100% whey protein isolate is generally considered to be best for us - they are more expensive than the cheaper whey concentrates/blends, but you get what you pay for (they probably work out about the same when you consider how much protein actually gets absorbed.) A whey blend that you will drink is better than a whey isolate drink that you won't. I prefer the protein powders over the RTD products as I find them easier to alter to suit my tastes (higher/lower concentration, added flavors, blend with other protein powders, etc.) At the moment, the one I like best is the Optimal Nutrition 100% Whey Isolate powder sold through costco, in either chocolate or vanilla flavor as appropriate.

By all means give them a try if they fit within your plan's pureed stage. We had them served up to us in the hospital, so it shouldn't be too early overall sleevewise (I'm not real big on scrambled eggs, but had boiled eggs a few times those first couple of weeks, and they settled well with me.) As noted by others, they may not settle with you - tolerances can vary widely between people, so try a small amount at first to see how you do with them.

Best of luck in getting through this, I have also gotten quite familiar with the trials and tribulations of dealing with offbeat medical problems/combinations of problems. If this opportunity doesn't work out, try contacting Dr. John Rabkin in San Francisco (yeah, a bit of a commute for you, but that's sometimes what it takes to resolve complex issues.) He did my sleeve about five years ago, but more specifically for you, his background and alter ego is that of biliopancreatic transplant surgeon (his brother brought him into the bariatric practice some years ago as a means of treating the liver problems early.) Since he is qualified in both disciplines that you need, he may just be the ticket to get you through this. Although a rare combination of skills/qualifications, he may also know of other similarly qualified surgeons closer to you, so it may well be worth contacting him. Best of luck to you in getting through this...

Talk to your doctor about this - PPI's such as pantoprazol, omeprazole, etc., usually need to be weaned off of rather than simply stopped otherwise you can experience a snapback reflux condition (which apparently you are.) Cutting the dose in half for a couple weeks and/or switching to an H2 Inhibitor such as Zantac or Pepcid is the usual protocol. The H2I's are usually considered a friendlier medication for the longer term, though may not be as effective as the PPi's but are often just the thing for weaning off the PPI's.