RickM

Overall, it's a coin toss, and which procedure is best suited to your personality - both the sleeve and bypass show diabetes remission rates of around 85% - some practices will show marginally better results with one procedure than the other and vice versa. One thing to consider is that most bariatric surgeons are most experienced and comfortable doing bypasses, as the sleeve is relatively new to them, and they tend to recommend what is most comfortable for them to perform. Look at the positives and negatives of both procedures, if possible talk to surgeons who specialize in each, then decide which fits you best, and choose a surgeon who is most experienced with that procedure. An additional note - if diabetes is your primary concern (as it usually should be,) then also take a look at the Duodenal Switch, which typically shows diabetes remission rates of around 98-99%. It is a more complex procedure, which is why most bariatric surgeons don't offer it (it takes time and resources to develop, and most particularly maintain, the necessary skills,) but it is the best available for addressing the diabetes problem, and should at least be on the radar of any diabetic looking at WLS.

How much you lose is largely up to you, though surgeons' programs vary widely on their expectations, which can strongly influence your outcome - some expect and settle for the quoted average of 60% excess weight loss while others expect their patients to lose 100% - which practice do you expect has better overall results? Even if you are in one of the more pessimistic programs, you can still go beyond their recommendations and exceed their average results. Also, being young(er) and a guy tilts things in your favor on both amount of loss and speed. After losing 50 lb around 12 years ago and maintaining the loss for several years, I lost the remaining 100ish lb that I needed to lose with the sleeve in about 7 months; I could have done it somewhat quicker had I been interested in doing so. Quite variable, depending upon age, genetics, weight history, how you hold your fat, and who know what other factors. Another big variable. The sleeve has some predisposition towards this, like most any medical procedure or medication that will have some predisposition towards a negative side effect. The bypass generally considered to avoid this particular problem but at the cost of its own problems and limitations. We look at all the potential risks of the different options that we have (including doing nothing...) and make a choice. As with other aspects of complex procedures such as this, the skill and experience of the surgeon can be a big factor - a poorly shaped sleeve as one may see from a surgeon new to the sleeve can exacerbate the problem. I can't say that I have noticed much of this, but then, being a guy, I'm probably less sensitive to such things (more clueless?) than the ladies are on average. Not really, though the fat pad around it shrinks, so more of your gentleman will be hanging around outside now (better locker room image...) which also means that there is more of him available to explore more deeply whatever he is inclined to explore. There's no right or wrong reason for improving your health; overall, you are interested in improving your life as a whole. As we get older, mortality grabs more of our attention as we can see the significance of our health issues and see more of our peers leaving this world. It's never too early to get a handle on blood pressure, diabetes and other chronic diseases that come along with our weight. and the sleep apnea can sure get in the way of overnight dating! Good luck on this venture,

Clear liquids and a clean out the day before surgery for the surgeon; 6 months of monitored diet and exercise for insurance.

It sounds like the psych is telling you more about them than you - that this is what you can expect from their program. Many of these WLS programs are geared for 50-60% excess weight loss as their goal (it's a lot easier to be "successful" with moderate goals,) while other programs push for 100% EWL. Some do get down to normal-ish weights with these moderate programs by exceeding their recommendations - many of these programs target 1200-1500 calories per day during their losing phase - and the psych is telling you their results - while the more aggressive programs target 6-800 calories per day - overkill for some, but necessary for many/most to achieve the more challenging goal. The docs in these moderate programs are often "amazed" at how well these patients did (by ignoring their advice.)

It is probably more correct to say that it can be difficult to handle liquids early on, but it not necessarily will be difficult - there can be quite a variation in results, primarily due to how much inflammation one may experience in the newly reworked stomach. It may be significant, impeding flow through the stomach, or it may be minimal allowing relatively normal drinking. I, too, had little problem with liquids even in the hospital, while my wife could barely down her nominal stomach size in a sitting - both are within the range of normal expectations according to our doc.

Typically, those docs who require these diets do so for an average of two weeks, though three or four is not unheard of; neither is none at all or something in between - it depends upon the surgeon's preferences and prior experiences. Many who do these diets just do a low carb, low calorie diet (which is the essence of what the liver needs to improve its' condition for those surgeons who are concerned about that,) and many do some combination of liquids and low carb meals. If you are self pay, then you can choose any surgeon that you want. I've never found a good explanation of the value of these purely liquid diets vs a general low carb diet for these pre-op concerns, so you can look for a surgeon who is a bit more patient-friendly in that regard. Hint - look for surgeons who have substantial experience with the DS (duodenal switch) as from what I have seen, most don't require anything beyond the typical day before routine. It seems that experience with that procedure provides skills and tools that negate the need for these diets (DSFacts.com has a listing of some of the well-regarded DS docs around). As a bonus, since the DS uses the sleeve as its basis, the average DS doc has been doing sleeves much longer than the average bariatric surgeon, so you get additional sleeve experience on your side.

I make my protein pudding with both protein powder and greek yogurt. To me, using strictly protein powder (in the normal one scoop per cup of milk ratio,) had too much of that protein shake taste to it, so I cut it back to on scoop powder, one cup milk and one cup plain greek yogurt. This yields a pudding without any whey powder taste and just a hint of tartness from the yogurt and isn't overly sweet like many things can be post-op.

I was having small salads, including some meat and cheese, at a month out. I found that if I cut back my normal serving of about 3 oz meat to only 2, I had room for another 3 oz of salad veg - chopped spinach, tomato, avo, pepper, green onion, etc.

You seem to be incredibly, boringly, normal - liquids tend to go through with little restriction. Some will have more inflammation in the stomach after surgery than others, which can restrict the flow of liquids (hence the usual advice to sip, sip, sip your liquids or they might come back up on you if you are suffering from that level of inflammation.) People who are having problems tend to post on these forums more than those who don't, so the problems "seem" to be normal and we get concerned if we don't have them. And, you aren't going to gain weight with the very small amounts that you are consuming this early out, and the matter that you aren't having any problems on your liquid phase has no bearing on how much you will ultimately be able to consume later on.

I don't know what an MGB is (other than an old British sports car,) but pre-op diet protocols for WLS in general vary widely from surgeon to surgeon from weeks of liquids to nothing at all. My doc only requires the semi-normal day before GI surgery of clear liquids and a bowel clean out (same basic thing as is done before a colonoscopy,) for his sleeve and DS patients. From my perspective (and his as well,) the less of that the better, though from the long term success perspective, the sooner that you can adopt/re-adopt an overall healthy eating pattern the better.

I would second Dr. K as one of the best in the business (besides, I don't know who else in the LA area does them, at least anyone that I could recommend.) Call his office and explain your situation (probably to his insurance coordinator) and ask which of your options would work best.

It seems like the docs can define things differently (and whether it really makes much of a difference is anybody's guess.) My doc didn't discriminate between liquids, purees, mushes and soft Proteins, but just let us move between them during that first month as our tolerances dictated. It sounds like your interpretation is reasonable, though yogurt isn't usually pourable (except for some of the yogurt drinks.) If in doubt (beyond checking with the doc or nut), you can thin things out a bit with Water or milk, or just see how the thicker consistencies go as they are acceptable on some programs and there is so much overlap between the different programs. Don't be afraid to call the doc's office with any such questions, as if things aren't clear to you, they likely aren't clear to lots of other patients on the program, and the instructions should clarify such things, and if they don't they should be rewritten so that they do.

Is it a no-no based upon your doc's program, or based upon what other people do? Surgeons' programs vary widely as do peoples' opinions of different foods based upon various diet fads. Mashed potatoes have long been an acceptable early soft food (depending upon what phase one is in - it was fine for my doc's program at five days) but some consider carbs to be evil because that's the way the diet industry swings at the moment. Many things that are on ones' program at whatever point one is at may make you feel a bit off or worse, but that's just normal variations between people - count that particular food out for a couple weeks or more and then try it again.

While specific insurance policies may differ, typically the industry standards of 40BMI (or 35 with co-morbidities such as hypertension or sleep apnea) still apply. I have seen some that cover the revision with lower BMI if there was a mechanical problem with the band - slippage, erosion, etc. Any chance that you have developed any of those co-morbidities since your last surgery? It would be a shame and counterproductive to have to gain weight to qualify to lose weight, but that is sometimes how the game has to be played (ankle weights, anyone?) The psych evaluation is pretty much a standard provision, though the requirements for nutritional and exercise programs vary widely. Somebody in the process (the hospital or surgeon's practice typically) will usually want the deductible up front and sometimes an estimate of the copay as well.

The Protein levels that are typically recommended are our basic maintenance needs, or a little above - the amount needed to do the normal replacement of our muscle and organ tissues over the course of our daily living, plus what's needed to supply the amino acids that drive various biological functions in our bodies. These maintenance levels generally correspond to our lean body mass, so most women are fine in the 50-70 gm per day range while most guys need in the 70-100 gm per day range (more if one is particularly muscular, and still more if one is actively trying to build muscle mass.) Think about it - 100 gm protein is 400 calories, or 10-20% of our typical pre-op couch potato diet, so hitting those basic levels is largely incidental amongst all the other things that we are eating. However, post-op, we still need that basic maintenance level, plus a bit more for healing, etc., so we work to minimize most everything except protein in our post op weight loss diets - we may be running 50-80% protein, representing the dramatically lower proportions of carbs and fats during that time. Also, protein tends to be more satisfying, and longer, than carbs or fats, so there is another emphasis on protein there - it's easier to eat less overall if we eat protein forward so many eat more protein than the minimum for that reason.

I'm sure that he has seen holiday weight gain before. That said, surgeons are quite variable as to what they expect or want of their patients pre-op. Some are really into pre-op diets and "proving you can do it" efforts while others are not. My doc takes the view that "if we could do it on our own, what do we need him for?" and doesn't go in for any pre-op dieting. YMMV Does your doc even require a pre-op diet, or are you going off of what others here online go through with different docs?

This often happens early on - we naturally have a big loss the first two or three weeks as we use up our short term energy reserves of glycogen (basically stored carbs,) before moving on to living off of our fat reserves. Glycogen burns very quickly while fat burns more slowly, so we experience a slowdown (and often the dreaded third week stall,) when we go through that transition. Since that is often around the same time as various diet programs are moving from one phase to the next (Clear liquids to "full" liquids to purees to soft Proteins, etc.,) people often associate those different diet or food progressions with a slow down in their loss. However, those of us who don't go through discrete diet progression phases experience that same slowdown at that time.

It's nothing that I have ever found - real milk in protein shakes, greek yogurt, cheese, etc. I guess that there could always be some outliers that might respond like that, but they would be just that - those well outside the norm.

I think that whatever you tell him, he will know, as the rapid weight loss will tell him. Perhaps you can come up with a credible alternate procedure that would produce those scars (and most any abdominal lap procedure will produce similar scars, gallbladder perhaps?) but in the absence of WLS, the rapid weight loss is usually a red flag for something being seriously wrong - the most immediate concern to most who see us after a few weeks or months without knowledge of our WLS is cancer.

The default is to do the procedure open if they can't do it lap, and we usually sign something to the effect that we understand that and approve of it. If you have any doubts (and it would be worth checking with the surgeon to make sure that you understand what he said, or meant) a second opinion would certainly be in order. Even amongst surgeons who are similarly "experienced" (like ten or twenty years of bariatrics,) they can still vary widely in what those "experiences" are - for some the potential complication that you present may be very concerning to him while to another with a somewhat different background it is no concern at all. We get a hint at this by looking at all the posts here on these forums about pre-op diets to "shrink the liver" - some docs are very strict about everyone doing two, three or more weeks of heavily liquid dieting to give them more space while working in there while others require little or nothing at all as they are comfortable working with those issues.

By the time Aetna got around to paying the surgeons fees, we had hit the max out of pocket level, so they covered that 100% even though he was out of network. The hospital was in network so that was 80%, so maybe that was $1000 or less (don't really remember now.) That's something to consider if scheduling works toward later in the year. If insurance is covering it, even if is winds up being a bit more than some of the cheaper MX docs, it's usually worth the extra cost if you can possibly afford it as the aftercare and post op support programs that are usually included can add a lot of value to the process.

I suspect that this is a holdover from RNY practice, as their stomachs don't work the same way as a normal stomach (or a sleeved one, for that matter, which is a lot closer to ":normal" than an RNY pouch,) I have had no problem with gelcaps and the like, and it was never brought up as being a problem in our education process, but then my doc doesn't do bypasses anymore.

No OTC supplement does potassium well, as 3% of RDA is the legal limit in the US, so I guess they figure, "why bother?" Most multivits have that 3% in there so that they can all themselves "complete". The best non-prescription supplement that I have found for it is the low sodium variety of V8 juice (I guess they figure that it's harder to OD on V8!) Vit K, while essential for us, is also a big influence on blood clotting, so possibly they figure that it may not be desirable for bariatric patients to take a lot of K (particularly if you are taking their vit pills pre-op) without specific direction from their surgeon. It plays havoc with blood thinners that some may be on, and many surgical instructions call for minimizing K before surgery. Fish oil is great, but the horsepill sized capsules can be hard to manage for a while post-op until the inflammation in the stomach recedes.

There are a couple of things that are pretty easy to do. One is to add some plain greek yogurt to the mix- the yogurt's tartness helps tame the sweetness. Another is, as you suggest, dilution - I like my shakes thick, like a real milkshake, so I blended it up in a blender with the milk and added ice to thicken it up; then if the flavor was too weak, add unsweetened cocoa powder or vanilla extract to boost the flavor without added sweetness.

Congratulations on your progress. As I noted to my wife when she was going through this years ago, it's like going through puberty again (to the cries of nooooooo! not again!) with having to get used to the changing sizes and balance. One of the things that I did that she didn't (as her WLS was 10+ years ago while mine was just 4+ years back) that seemed to help was to get a Wii Fit system. It has a lot of balance games in it along with a basic balance evaluation each day when you log in and weigh up. Exercise-wise it's pretty "gym-lite" but some of those games do seem to help in getting back in touch with where everything is. Another possibility that a couple we know did was to hire a kinesiolgist to help them with their balance issues. I don't know how specialized that may be vs. a general physical therapist, exercise physiologist or trainer, but that is another avenue to pursue that has given good results for some.