RickM

I don't know how standard it is these days, it seems that some groups have them and some don't. My doc's group didn't have one, as they provide that function on their own via their RN program director, surgeon and PA's transmitting their combined experience in the craft. I saw an RD associated with my PCP a couple of times, and she used the surgeon's guidelines to help me tailor a program around it that fit my needs. You can usually find an RD (Nut) on staff at any hospital. The main thing to watch for with them is that frequently the primary bariatric experience they have is with the RNY, which is somewhat different from the sleeve in nutritional requirements (RNY patients are often given more calories per day to account for their malabsorption that sleevers don't have, which can lead to slower or inadequate weight loss). If your surgeon has guidelines (they usually have some kind of booklet of instructions published), take that along when you see the RD.

Do a lookup of the vagus nerve - that sucker connects lots of things including most of the abdominal organs to the brain, and many more things along the way, and is usually (temporarily) damaged in the process of the stomach reduction. The most common side effect that people notice is a runny nose or sneeze sensation as a full signal, but I expect that sweating could also be symptom (it does control that, too.) All the funny things that we learn our bodies can do!

My wife and I are about six years apart, her having a DS (which is a sleeve, plus) ten and a half years ago and I had the VSG four and a half years ago (it takes me a while on some things.....)

It's tough evaluating these guys for us non-medical laymen (and it's not even easy for the surgeons themselves to evaluate each other if they don't see them in action in the OR, or can evaluate their handiwork after the fact). The usually suggested tools of state medical boards, yelp, online forums, etc. can give some indications but are ultimately of limited value - much of our legal system of settlements, arbitration and mediation comes with gag orders that keep many negative reports out of the public eye. In this imperfect world, what I have found to be one of the more effective filters for VSG surgeons is whether they have extensive DS experience. As the DS is one of the more technically challenging procedures around, it tends to attract the more skilled surgeons, and as the DS uses the sleeve as its basis, these guys are the most experienced with the sleeve with most having done them for 10-20 years or more (as opposed to most others who have been doing them for maybe 3-5 years, adding them to their RNY based practices, which involves a somewhat distinct skillset. Observing these forums over the years, and chatting with lots of patients around the country, one notices a pattern that these DS surgeons generally don't do require these extensive pre-op "liver shrinking" diets that many surgeons require. One can conclude that these guys have developed skills or tools that negate the need for these diets, and that the OP has likely fallen in with one of these more experienced surgeons (or one who has been training with them.) We also see similar disparity with post-op dietary progressions, with some limiting their patients to liquids for a month or more while others have progressed to steak by then - guess which programs tend to come from these more experienced DS/sleeve guys? Given that the DS only has a 1-2% market share in the bariatric world, this filter leaves out a lot of surgeons who can be considered "great" or top drawer (say, top quintile, or 20%) but I don't know how to properly evaluate them against those who are merely "good" or "so-so" (though if one is considering a surgeon who has been changing jobs/practices every year or two, I would keep looking....)

A few random thoughts on the DS vs. VSG, but first my relevant background - my wife and I have been in this game for about twelve years now, from when we first went to one of the support group/seminars and started the common insurance mandated six month diet/exercise roadblock to approval deal. It took us close to two years to get her on the table after the serial insurance denials (DS was still "investigational/experimental" then) and getting our ducks in a row to self pay the job. Her history since has been boringly normal, losing 200+ (350 into the 140s) and regaining about 20 from her (too) low - not uncommon to overshoot the mark some with any of these procedures. In the meantime, I lost about 50 over that first 6-8 months or so from basic diet clean-up (wanted it to be sustainable, no fad diets, just what I could change a do for the long term - cut out/down the junk food, more fruits/veg started tracking and monitoring calories/nutrition, etc.); kept tweaking and trying different things and lost a bit more here and there, but overall simply maintained that original 50lb loss and fundamentally worked into a WLS maintenance life along with my wife (but without the WLS on my side.) Maintained that state for 5-6 years, not comfortable with the DS if I could maintain what I had lost, so was in a holding pattern until finding that the VSG was then being covered by insurance, so went ahead with it. Four and a half years out on it and so far, so good. To the random thoughts: supplements, Vitamins, etc. - you should be taking some with any procedure, or even no WLS at all given the state of our food chain, so at least a Multivitamin and probably more as we age. Calcium is likely with the sleeve just from our overall lower intake of food - I take one dose a day to keep my total intake including food in the 1500-2000 range, so that is no great inconvenience (I take it with my normal evening pills.) The DS will typically require more due to the malabsorption: Iron will probably need to be supplemented with the DS and the other "typical" DS supplement is an ADEKs tablet (for the fat soluble vitamins A,E,D &K in a "dry" or Water soluble form as the normal fat soluble forms are not well absorbed due to the fat malabsorption of the DS) or some subset of that group depending upon your labs. Supplementation with the DS is moderately more complex (or PITA) than with the sleeve, but periodic (annual typically) lab testing is critical as things can skew out control much more easily if not watched. Most of the DSers that I know are healthier than the general population, in good part because they become amateur nutritionists and are much more aware of their body's needs than average people (and often better than their family doctors - some keep spreadsheets of their lab results to watch trends more closely than their PCP.) One of the common problems with the sleeve is the prospect of reflux or GERD - it's a function of a small stomach with potential acid production that is not proportionately reduced along with the stomach size coupled with the pyloric valve closing things off at the bottom. PPI medications like Prilosec or Nexium usually keep things in check, but are not desirable long term as they can impair absorption of minerals like calcium and iron (so there is potential malabsorption there without the intestinal work.) The DS is less prone to this problem as they typically use a larger sleeve with the DS (though some surgeons these days like to use smaller, VSG sized sleeves with their DS's). This is a point to ponder when considering the "VSG and revise to the DS if I need to" approach. This is a subject to discuss with your surgeon. When we were first getting into the DS world 10-12 years ago, our doc's figures for needed revisions was around 5%, roughly split between adjustments needed for inadequate weight loss and those needed for excessive weight loss that couldn't be resolved with diet and enzyme supplements; since then, the DS world has gotten much better a tailoring the DS for individual needs rather than the one-size-fits-all that it used to be, so the uncontrolled losers are much less common now. I understand your surgeon's concerns about metabolic issues stemming from your previous loss/regain history - yoyo dieting can really screw up our metabolism (though if it was only one cycle as you indicate, it may not be as big a deal as those who have been serial yoyo dieters.) Have you, or are you now, tracking your intake with My Fitness Pal or some similar app or program? Tracking, beyond being a good tool for controlling our weight and understanding our dietary needs, is one of the best means of getting a handle on your metabolic rate (given that the calculators are useless, most particularly for us fatties/former fatties, and even the active VOx tests are suspect for us.) If you have decent idea of where your metabolism is, that is a good guide toward deciding on a procedure. For instance, if you are keeping yourself under 2000 calories (as a guy) and still gaining, then a DS is a good bet as it will allow your long term diet to be more "normal" and easier to maintain. With a sleeve, you would likely be maintaining in the 1200 or so calorie range which is hard for most guys to stick with long term. OTH, if you are stable in the mid to upper 2000's, then a sleeve can be a good fit. Before surgery, I was maintaining my weight in the 26-2800 calorie range, and now do so in the 2000-2200 range (it just takes less energy to move <200lb around than it does 300+.) The prospect of doing a DS as a back-up if the VSG is a tricky one. Beyond what I mentioned above about the prospect of using a larger sleeve with a "virgin" DS, there are some other considerations or risks that I discussed with the doc. It is generally considered that a virgin DS works better than a 2 step or revision DS. Like your doc, his experience has been that the second stage should come fairly soon after the first, but certainly before any significant regain occurs - it works much better to allow the "switch" part do mostly the maintenance job rather than depending upon it to get significant weight off. So, if one is starting to lose control and regain, when does one pull the trigger - 10lb up? 20? 30?... Adding to the conundrum is that insurance typically doesn't cover the revision unless one has regained back up to the normal 35-40 BMI level, which reduces the effectiveness of the revision. In my case, with the weight stability that I had been experiencing, I thought it was worth the risk. YMMV I'm sure there are more points I can think of, but this is enough bytes for now (and it's time to get the steaks on the fire,) but good luck with the decision and hopefully I have not obfuscated things too much.

No pre-op diet here, either, just the semi-usual day before surgery clear liquid thing. It's not that unusual, but it tends to come from the better surgeons in the craft, so rejoice that you got one of the good ones!

Each company should have a policy bulletin somewhere on their website that will spell out all of the requirements and limitations for WLS. If you already have a surgeon picked out, check with their insurance coordinator to see which company is easier to work with or has more generous coverage. Also, make sure that whichever plan you choose does indeed cover WLS - Aetna and BCBS will both cover WLS in general, but your employer may choose plans from them that exclude that benefit, so watch out for that trap.

You might get lucky and find someone here that has recently been through this with that insurer, but the two best sources are the insurance company themselves (check their WLS policy bulletin online to see what they say about it, or call one of their reps (and hope they know what they are talking about...) and the insurance coordinator in your surgeon's office. Since they are dealing with this issue every day, the insurance coordinator is usually the best source, and they can probably tell you off the top of their head that this company is easy on that issue and that company is tough on it, etc. Good luck - this isn't the most rewarding part of the process!

It seemed to reach a critical mass around 5-6 years ago when several insurance companies started covering it along with the other approved procedures. I had been in the background considering for several years - lost about a third of my excess weight by cleaning up the diet/lifestyle as part of my wife getting a DS ten years ago, wasn't heavy enough to be comfortable with the DS, had maintained the loss for several years and was spurred on to get the VSG when I saw that Aetna had started covering it. So there was a convergence of events - ASBS/ASMBS position changes accepting it, more surgeons offering it as it is much simpler for them than the DS, along with a growing disenchantment with the bands - and the start of insurance coverage that really accelerated the sleeve's acceptance,

The DS is sometimes done as a two-step procedure for patients not healthy enough to undergo the longer combined procedure (time under anesthesia is particularly critical for those in marginal health,) with the sleeve part done first and then the intestinal rerouting (the "switch" part) after they have lost enough weight to withstand the second surgery. It was noted that some lost enough weight on just the sleeve part to not need the second switch procedure, so it started being offered, and optimized, as a stand alone procedure. The VSG's relation to the DS is one reason why I have a preference for using DS surgeons for VSG's when possible, as they have longer experience in crafting them than the surgeons who have more recently added the VSG to their RNY and band practices.

When my wife had he DS ten years ago, the go-to guy for those who couldn't afford US self-pay rates was Dr. Baltasar in Spain. I'm not sure if he is still practicing (he could be retired by now - he's been at it long enough!) but for the VSG, I prefer working with DS experienced surgeons as the VSG is the basis of the DS (with added intestinal rerouting) so they tend to have been doing sleeves a lot longer than the surgeons coming at it from the RNY or band perspective and that usually shows in their results. Good luck on your search!

Quite a bit of it, if not most, is the excess weight. In So Cal where I am, we are as warm as anywhere, though without a lot of the humidity (usually.) I haven't needed to use deoderants, etc., since I had plastics and he cut up into the pits and got out of the habit, and never found a need to go back. I perspire minimally when I do my strength training routine at the gym, though my heaviest work is usually swimming which takes care of itself in that regard. But for daily life, it's a non-issue. Somewhere around the third month I noticed that the shoreline walk (as fast I could go without breaking into a jog or run - knees still aren't going there!) that used to get my pulse up into the130-140 range was barely getting me over 100. Since then, I've needed to head to the hills to get the system working to any degree. Having cardiovascular and cooling systems with 50% excess capacity is a useful thing now!

No, not a med pro, (was actually in aircraft structures for a while, before moving over to the aircraft-as-targets end of the business,) but have been at the WLS game for a while. My wife had a DS about 10.5 years ago, while I had my VSG about 4.5 years ago. Even after living an effective WLS maintenance life for several years with her (I lost about a third of my excess weight in the "let's see what we can do without surgery" phase, and keeping it off for 5-6 years (hence the decision to go with the VSG rather than the more powerful DS), I still didn't fully appreciate how sensitive we can be to different foods and food compositions - things that don't really matter when you have a normal, full sized stomach. It's somewhat like understanding what sex is like before you experience it. Your concerns about over-doing the loss is an understandable one, and particularly common amongst those of us starting in the lower-to-middling BMI ranges (I was about 42 at surgery time.) We also tend to put a premium on quality rather than quantity (have a really good prime steak rather than a merely "good" one, as we can't have all that much of it in the first place - the cost difference isn't that great; even with a restaurant meal, we usually get 2-3 meals our of one, so enjoy the good stuff when you can) One of your challenges is going to be travel food, which tends to be on the low quality, junky side, which challenges anybody's weight control. And, if you are always on the move and not able to save those doggy bags from the good places, it tends to reinforce the desire to go cheap and not waste the good stuff. As your diet evolves as you lose and move toward maintaining things, you will devise a strategy that works for your lifestyle, with some combination of foods that are high density nutritionally that are readily available in your travels possibly along with some portable take-along items (like some high-quality Protein bars to fill in as needed between formal meals, perhaps?)

Welcome aboard, Captain, and enjoy the flight. Generally, we have little problem overshooting the mark on our weight goals with the sleeve; indeed the more common problem is to fall short of the goal, though as a guy with a low/moderate BMI, rapid loss is more common. The typical loss pattern is for declining loss as we progress, since we have less excess mass to move around and that burns fewer calories (think of having to retrim to maintain altitude as your fuel burns off.) Occasionally someone will get over-hyped on exercise, working toward marathon goals or the like and will experience stable or increasing loss as they progress, but they are the exception. Assuming a nominal sleeve (one without defects like a stricture or twist that blocks things up,) after things are fully healed and flowing smoothly (a few months' time) it is fairly easy to adjust our diet to meet our needs. The restriction that we get varies with the composition of the food that we eat. Your basic meats will still be fairly restricted, 3 ounces, give or take an ounce or so, as the pyloric valve in the bottom of the stomach closes up to let the stomach process it. However, there are lots of "slider" foods out there that require minimal stomach processing and slide on through with little restriction; unfortunately, most junk food fits into that category, but so do a lot of good things like fruits and many vegetables. Drinking calories, using "meat lube" (gravies and sauces) along with slider foods can be used, in the negative sense, to "eat around your sleeve" or in the positive sense to help you get in the calories and nutrition that you need to be stable. These are variables that we learn to play with attain stability. Given that our sleeves mature to be of similar size, (there's variations depending upon surgical technique, starting point of the patient, etc., but we are all much smaller there than we started out at,) some people will wind up maintaining at 1000-1200 calories, while others will be at 2000 or more, and anywhere in between. Yet these variations can be accommodated by how we adapt our eating technique. As a reference, I can eat about 4 oz of meat if that's all I have, but cut that back to 2 oz and thrown into a salad, that salad can be around 10 oz and often pushing 500 calories (quite a bit of avo and some cheese in there boosting that count, and I could easily make it more caloric if I were so inclined.) Isolating other variables, as a tall guy, your stomach is typically longer than average to start with, which leads to a longer and overall larger stomach capacity once the surgery is complete and things have healed, so you will likely be able to eat somewhat more than average. Compensating some is that your metabolism is likely higher than average, and will remain above average. In short, overshooting the mark for any length of time is rare with the sleeve (more common with the DS if they get a substantial mismatch between the malabsorption part and the patient's metabolism.) Typically the only time we see such problems are when the patient develops an eating disorder where they are so afraid of regain that they can't stop dieting - but that's a psych issue rather than a physiological one. Enjoy the ride an please remain seated until the captain brings the plane to a screeching stop at the terminal.

It basically sounds like you are in maintenance, and to change that you need substantially decrease your calorie intake over the long term from what you have been doing. Some people can get away with losing on 1200 calories or more per day (and some plans reflect that and use that as their basis - these plans tend to have a lot of early maintainers in them as 1200 calories is a common maintenance level for many patients, particularly women. Other plans that show better success limit themselves to the 6-800 calorie range, but even those are not enough for a few outliers for whom that is a maintenance level. The various things that you have been trying are minor tweaks that have little long term impact on weight loss and mostly show up as minor ups and downs via Water retention and release. When you have logged/tracked, what has been your average calorie level? That will give you the best clue as to what your metabolism really is despite what various online calculators, etc. say that it should be, and where you need to go from here.

I would have a couple of saltines - it's one of our doc's recommendations for upset stomach as it helps to absorb the excess acid and gives the system something gentle to work on. Both my wife (when she went through this) and I kept a packet of them on the nightstand for months in case something soured up overnight. We never got into the whole low carb thing, which never bothered our weight loss (it's really rather irrelevant if you look at the numbers,) and while saltines are not the best, most nutrition packed food around (and yes, one of those "white" carbs that should be avoided in preference to complex carbs, it does serve a viable purpose so one shouldn't agonize over having a couple. If they trigger you to scarfing the whole package at a time, then steps should be taken to limit that, or find and alternative, but otherwise, don't worry about it.

I slept under a pillow after plastics due to our cat's (only a ten pounder!) jumping off the headboard onto me, or the chase games through the bedroom with the other cat. Or you can try sleeping under a scat-mat (watch what you touch in your early morning fog!)

It couldn't make it worse, and may improve it (added Probiotics?)

I never worried about carb (or fat) counts, as they tend to be a distraction from developing/maintaining healthy eating habits. With our low calorie and high Protein requirements to successfully work our sleeves, it's hard to have too much of either. Better to work on eating real food as much as possible - the closer to what comes out of the ground (or what eats what comes out of the ground,) the better, rather than what comes out of a box. There are so many accounting tricks that can be used, particularly in packaged foods, that carb counts are nearly meaningless. Quality definitely trumps quantity.

It's quite variable depending upon the doc and their experiences and philosophies - some do a few days, some a couple of weeks and some none at all. My doc is in the none at all camp, starting with liquids, purees, mushes and soft Proteins as tolerated and progressing to everything else after a month. YMMV Best thing is to keep up what you are doing until you can contact your doc's staff and find out what their progression schedule is. They may have a set schedule or they may advance things as they see fit at each follow up appointment.

It depends upon how much inflammation you have in your stomach which leads to how quickly fluids pass through it - you may have only the equivalent of a soda or cocktail straw sized passage going through so things may go fairly slowly, or you may more of a passage the size of a marking pen where Fluid pass fairly quickly. My wife, when she went through this years ago could only move her nominal stomach capacity of 4 oz of Protein shake through in a sitting of a half hour or so, while I could pass a cup and a half or more of fluids through in that time - both were within the "normal" range of expected results that first week or two according to the doc. Sip as much as you are comfortable drinking for now - guidelines from different docs vary from sipping an ounce every five minutes to an ounce every fifteen minutes; even at that lower five minute guideline, that would take you an hour to drink that shake. If you can do it quicker than that comfortably, that's no problem, but likewise it's no worry if it takes longer for now.

Approved by whom? FDA? ASMBS? wlsolutions? The manufacturer?

With significant metabolic problems, it is also worth checking out the duodenal switch (DS), which is a sleeve combined with a malabsorptive component somewhat similar to the bypass, though generally more effective. The bypass, with its' malabsorption, will give you an edge over the sleeve in losing, but sadly that caloric malabsorption dissipates after a year or two (though the nutrient malabsorption remains long term,) and you are still left with your metabolic problem while trying to maintain your loss, just as you are with the sleeve. Trying to maintain that loss on 1000 calories per day (or whatever your metabolism allows,) is a challenge for many which ultimately leads to significant regain. The caloric malabsorption of the DS lasts for the long term, effectively resetting your metabolism back towards normal, which significantly aids in maintaining the loss. It is a more technically challenging procedure to perform, which is why many surgeons don't offer it, but it is well worth seeking out a surgeon with the appropriate skills and considering it.

My program could have them (preferably with some added protein powder) anytime during the soft phase, which was the entire first month for us. Likewise, rice and beans were on the list, but docs vary so much on what they allow when that you really need to look at your own book rather than depend upon others here (I know that doesn't help under the circumstances!) I would go ahead and get them and if you can't have them yet they will keep until next week or the week after.

My wife is a little over ten years out on her DS; doing well overall and still the choice for her needs over the RNY or VSG. What do you want to know? Ask away.