RickM

The usual preference is to wait a year or so after attaining a stable weight before doing plastics, as things redistribute some once you stop losing, and the skin can tighten up some as well. This isn't an absolute rule, but is for best results, so there is some flexibility if things need to happen faster.

I would be inclined to go with the DS, as it's the more straightforward revision (at least to a DS surgeon, where it is basically completing the DS) and it offers the best shot at countering the metabolic damage that you have suffered. With the RNY, the caloric malabsorption dissipates after a couple of years, so it may help you get the weight back off in the short run, but in the longer run you will be back where you are now, trying to get by on 1100 calories. Another thing to consider is that with the VSG, the revision to the DS is straightforward, and something that most any qualified DS surgeon can handle. However, if the RNY doesn't work out and you ultimately need to revise that to the DS, that's something for which only a handful of surgeons in the US are really qualified (maybe a half dozen.) That assumes that the RNY doesn't permanently screw up the sleeved stomach in making the pouch - I know quite a few who have had the RNY/DS revision (and even a couple who started with a band, revised to RNY, revised to DS) but don't know any who have gone the VSG/RNY/DS route yet.

A good reference for anyone looking into the DS (or any WLS for that matter, as the DS should at least be on everyone's radar along with the other mainline procedures) is http://www.dsfacts.com/ My wife had a DS around nine years ago (and I'm three years out on a VSG.) What is the protocol to get to surgery? It should be the same as any other WLS, though you do have to find a DS qualified surgeon as it is a more technically challenging procedure than most other WLS, so many surgeons don't find it worthwhile for them to develop the requisite skills (but that also means that most of your experienced DS surgeons tend to come from the top of the class!) Go to a surgeon's seminar and become familiar with them and what they need to get the ball rolling; some insurance may require a PCP referral, so it pays to be knowledgeable about the procedure so that one can educate their PCP on it. Pre-op and post-op diets/experiences (I know this will be different for all depending on doc) As you note, there can be wide variation between docs' programs. Our doc doesn't do any pre-op diets other than the semi-usual day before bowel cleansing diet (similar to what's done before a colonoscopy.) Post op, progression is more rapid than many docs prescribe, with liquids, purees and soft Proteins like cheeses, yogurt and many seafoods for the first month and most everything else after that. How long is the surgery? IIRC, typically 2-4 hours, though can be longer depending upon complications that the patient may bring to the table (extreme obesity, adhesions from prior surgeries, etc.) How long were you in the hospital? 3-4 days would be typical. How was your recovery? How long before back to work? IIRC, my wife took a month off, but she always milks these things - some may take longer while others may be able to get back to it sooner, depending upon the work. Are there foods you can/cannot eat? She became lactose intolerant, which is not unusual, and that has become worse over time - lactaid tablets with dairy don't do quite the job anymore. She has also become gluten sensitive, which may or may not have anything to do with the DS. Side effects from surgery? Similar to the RNY in that one needs to keep up on supplements and follow up labs, though the profile is somewhat different. Gas and stool can be rather aromatic at times as one would expect from incomplete digestion, though most work out what foods trigger problems so they can be avoided, and Probiotics can also be useful in helping the system adapt to its new reality. Why did you chose this surgery? Of the procedures readily performed at the time, neither the bands or bypass offered sufficient weightloss performance relative to their complications and side effects. The DS (and VSG) allows use of NSAID pain relievers which are a giant no-no with the bypass. The DS offers better regain resistance than any of the other mainstream WLS procedures, along with a generally more normal diet long term than most (no place for things to get stuck like there is in the bypass.)

I have a number of patients in their early 70s over the years go thru WLS in my doc's practice (my wife had a DS 9 years ago, so I've been around this game for a number of years before my own VSG,) who have done well. They have primarly gone with the DS, which is a more significant procedure than the VSG alone, both from the immediate time-on-table and early recovery perspective as well as from the longer term nutrition and compliance standpoint. I have also seen a number of others who, while younger, had significant health issues to the extent that they felt that the WLS was their last hope to make it more than another couple of years, and they have regained basic normalcy in life. The main issue that I see in your parents' case would be dedication and compliance - they have to want to do it to make it a success, so be the best example that you can be for them.

I didn't have any noticeable swelling after the VSG, but certainly did after plastics and inquinal hernia repair. It may be, as Sportcub suggests, just residual Fluid from all that they pump in during surgery, or it may be a bit of drainage from the surgical site up above. As the plastics guy explained it, the ducts that our testes descend through from their original position at infancy to their ultimate destination is still there, and make a wonderful path for any abdominal fluid build up to drain downhill. Yes, bag of peas time, and if it doesn't clear up in short order, keep in top of the doc about it - mine got up to grapefruit size (not pleasant or convenient carrying that around!) and ultimately developed a hematoma that took months to resolve. May your journey be shorter and more pleasant!

Generally we should not increase calories since our weightloss tends to slow over time automatically - it doesn't take as many calories to move our lighter bodies, so the caloric deficit (which is what we are really interested in - calories burned less the calories consumed) is normally declining as we get closer to goal. The exceptions to this would be those who are seriously ramping up their exercise as they proceed, and hence are burning a lot more calories to make up for that lower weight, and those who already have a fairly high caloric deficit and are losing rapidly (say, closing in on goal within six months or so of surgery.) I started increasing my intake some at six months as I was within 10 lb of goal and losing at a consistent 10 lb per month rate, so I wanted to slow things down a bit to ease into maintenance mode.

Some would say so based upon the popularity of low carb diets in the weight loss industry and amongst some docs these days, but unless you are carb sensitive or diabetic, there is no particular reason to go to any great effort to minimize carbs beyond what our minimal intake already provides, particularly for relative lightweights like the OP. I was rarely, if ever, as low as 65g and did just fine, as do most of the people in my doc's program which doesn't put any particular emphasis on carb counting. Given our limited intake, quality of the food and nutrition is much more important than carb counts in the long term.

There aren't any major things that I can think of after some ten years in this game (three years since my VSG and nine from my wife's DS and all the pre-op games before that....) The colonoscopy shouldn't be a big deal as we can drink pretty normally after a couple months or so (quite a few here are marathoners and other endurance/hydration intensive folks) though some of the DS guys have problems getting properly cleaned out with the standard protocols due to their altered intestines, but nothing that really applies to us with the VSG, People do get their sleeves and lower downs checked by contrasts, so the procedures are there - best thing is to make sure that the doc ordering the tests is aware of your condition so he can make adjustments as needed. Some docs don't want their sleeve patients to take NSAID pain relievers while others have no problems with them (they are a giant NO-NO with the RNY, and some docs carry that over to the sleeve, but to the docs on the DS side of the trade, NSAID use is a big selling point of the DS and related VSG.) This last issue with the NSAIDs is probably the most common issue that we will encounter in our post-op lives as they are so commonly used for most any inflammatory issues - the laundry list of orthopedic problems, arthritis, etc. - and to most physicians, WLS=RNY=no NSAIDs due to the recent market dominance of the RNY in the bariatric world. Irrespective which side of the fence your surgeon sits on this point, it pays to be conversant on the topic for your own well-being (we have to be our own advocate in our health care!) since their are divergant and changing opinions on this within the sleeve community - one's surgeon may be advising against their use currently but may well have a different view in five years time. And, while NSAIDs can have their issues even for "normal" people, Tylenol/acetometaphin as the typically recommended alternative, beyond not usually being as effective, can have its own problems when used to excess.

On the limited basis that you are talking about, particularly during your weight loss phase, this should present no particu.lar problem - many of the diets that are used along with WLS are highly deficient and they are tolerated well for the short to medium term that they are used while we get the weight off. Labs at the recommended points should catch most deficiencies before they go too far. Having some veggies as you can while there (to have something to munch on) along with what fish and eggs are available and then getting the majority of your Protein from the shakes would not be an unreasonable approach One of the things to consider is to think of your long term dietary needs once you get to maintenance - the type of dietary habits that will sustain and control our weight for the long haul rather than what got us into trouble in the first place. Think of what that will look like with your work situation and how to transition to that both during your loss phase and your move to maintenance once you get to your goal weight. This is one of the trickier points of the process, where most non-WLS diets tend to fail and where many post-ops also have the greatest difficulty. Good luck, and welcome to the game!

The main problem with this idea, beyond the weaknesses of the medically supervised liquid diets when one tries to come off of them and adopt a more normal diet, are a variety of nutritional deficiencies that come from not come from lack of variety and balance in the diet. Typical vitamin/mineral supplements are limited in what they provide - the commonly supplemented vitamins and minerals are those that were known and established in the 1950's when the gov started publishing RDA's, but there's a whole laundry list of antioxidents, flavinoids, phytosterols, etc. that have been discovered since then that don't have established RDA's and aren't found in our typical supplements. There are also a few nutrients, such as potassium, that have significant legal restrictions for OTC supplements. This is why we can get away with these diets for a short time, but not for the long haul.

The two procedures are very commonly done together, and this is a common way for people to get partial insurance coverage for their TT's - the hernia repair can pay for a good part of the OR, hospital and anesthesia overhead cost while the patient self pays the delta cost for the TT. I had an umbilical hernia (that was non-symptomatic, but the plastics guy could identify it,) and an inquinal hernia (the 'turn your head and cough' type for us guys...) that were both repaired along with the TT.

From the future sleeve's perspective, it doesn't matter at all what you have three days before surgery (I probably had steak, but don't really remember,) but different surgeons have different policies for pre-op dieting for different reasons. Those that do such diets can vary between liquids only for some weeks before to some combination of Protein shakes and low carb meals to meat, veg and salads only. A real big YMMV

Nothing special here until clear liquids the day before surgery. Docs vary all over the board on this between virtually nothing to four weeks or more of liquids.

Hi Joe, I'm three years out (wife is nine years out, so been in this game for a while!) and up in the north valley, if you're that part of town. The others have it right about following your doc's guidance on what to expect from their program in those early days. Slow and easy on the early exertions and you will be amazed at how quickly things progress and you feel better and stronger. Within about three months I could barely get my pulse over 100 when walking as fast reasonable (running is still out of the question with my knees; 140 bpm would be what I was doing before at that level of exertion.) Sweating is almost a thing of the past on my strength workout days (can't tell on my swimming days tho!) Good luck and enjoy the ride!

It depends upon the type of insurance that you get - some will require a referral from the primary care doc, and some do not. If you don't need a referral, then your doc may recommend a bariatric surgeon he is familiar with and you can start there, but there is no reason to stop there - most family docs know little about bariatrics beyond what it presented to them in seminars from the bariatric department of their associated hospital, and they may or may not be any good. It is time for you to do your own research - about the various procedures available (if you haven't already,) and surgeons in your area. Go to some of their seminars and learn about them, what they offer and see who you are comfortable with.

I was also a bit concerned when I found that I could down a bowl of broth (6 - 8 oz?) and a half cup of juice within a sitting (30 min or so?) in the hospital while my wife when she went through this some years ago could barely put away her nominal stomach size in liquids in those early days (and I had a 2.5 oz VSG stomach measured at time of surgery while she had a 4.0+ oz DS stomach) I was assured by the doc that these are just normal variations, and indeed over the years here I have seen reports from both ends of the spectrum. Some people will experience more inflammation from the surgery, restricting flow thru the stomach, and some people's pyloric valve will be a little looser in allowing fluids through than others. A cup of Protein shake in a half hour or so was no problem for me the first week. The real test of your restriction will come when you get into solid foods and see how much your stomach holds when the pyloric valve is closed while things are being digested.

Yes, this is a pretty normal thing - there are almost no end to things that can cause some water retention (hormone changes for everyone and TOM for the ladies, sodium changes in the diet, etc.,) and you are hitting on at least two more exercise related ones - water needed as part of the muscle repair mechanism and you are likely behind the curve on hydration so your body is playing catch up. To see if you are hydrating adequately during your workout, try weighing yourself immediately before and after to see if you are losing more to sweat than you are drinking during the workout (preferrably weigh naked so you aren't weighing sweaty clothes!)

Most docs limit drinking the first few weeks or months out of concern for healing the stomach, which you are past. My doc is one of the stricter ones like yours, forbidding alcohol during the loss period, the reason being that our livers are typically diseased to varying degrees simply by our being significantly overweight, and it is further taxed by its' role in metabolizing all the fat that we are losing - it doesn't need the added stress of metabolizing the alcohol (which is a toxin that the liver normally handles in moderation, but not so well when it is overtaxed as it is when we are losing massive amounts of weight.) As my doc is also a liver transplant specialist (I guess bariatrics just doesn't keep him busy enough...) he is a bit anal on the liver health front, but I tend to take his opinions on such things seriously! On that basis, since you have stopped losing, an occasional drink would be OK at this point, though one might want to give the liver a bit more time to recover before indulging much. The other main issue, where some docs will advise "never again" is concern over transfer addiction where whatever degree of food addiction that we had gets tranferred to something else - drinking, gambling, shopping, etc., and a casual or occasional drinking habit can lead to total alcoholism. The thing to watch there is for the every week or two drink becoming a daily thing. Good luck, and congrats on the loss!

In general, once the sleeve has healed and is matured, there is nothing that you can't have due to the sleeve - which i not to say that there are things to avoid in order to lose what you want to lose, and to maintain your loss once you get there. Nothing is going to get stuck in a stoma as can happen with an RNY or band, as the pyloric valve does its' natural restriction job. There can always be some individual variations in results - some may become lactose intolerant, for instance, or tastes may change, but nothing that is inherently sleeve related.

It is normal or not normal depending upon the surgeon's philosophy and experiences, but generally the guys who are more experienced with sleeves don't require them (other than some kind of day before surgical prep diet.)

Band to sleeve revisions are very common, as the bands are so problematic and the sleeve does what the bands promise to do, but don't. RNY to sleeve is less common (I can't think of any specific cases, but there probably are some out there,) as that revision is a lot more complex, and the sleeve and RNY overall have very similar weight loss performance, so there is usually little to gain from such a change; RNY to DS is a more common revision as the DS generally performs better than the RNY, but that is a very complex revision for which few surgeons are genuinely qualified. The sleeve is becoming the preferred procedure as (noted above,) it does what the bands promise but fail to deliver, and it offers similar performance to the RNY at a lower cost in lifestyle and medical treatment limitations (fewer dietary restrictions, lower supplementation needs, no major drug restrictions - can't use NSAID pain relievers with the RNY.) If the sleeve is not a powerful enough tool for a patient's weight loss needs, the RNY is unlikely to provide any better result, and the DS should be considered.

The nurses usually recommend that you wait until you are out of the hospital. Beyond that, it's when you feel up to it (and you should generally avoid swinging from the rafters for a while!)

The "No NSAID" (Motrin/Ibuprofin, aspirin, Aleve/naproxin, etc.) thing comes from the RNY world, as the bypass has specific weaknesses that contraindicate their use, problems that don't exist with the sleeve. Since most bariatric surgeons come from the RNY side of the business, they tend to transfer that advice to their sleeve patients, at least until they (the surgeon) gets enough experience with the sleeve to really know its' characteristics (this is why we also often see RNY diet/nutrition/supplement advice copied for the sleeve rather tailored for its' specific needs). If you ask a bariatric surgeon who has substantial DS (sleeve with intestinal rerouting for malabsorption) experience about NSAID use, they will tell you that it's no problem; indeed, NSAID use is one of the major selling points of the VSG/DS over the RNY, and is often used in overturning insurance decisions favoring the RNY. My doc has over twenty years of DS/sleeve experience behind him and recommends NSAID use as soon as the narcotic pain relievers are no longer appropriate - but certainly wouldn't suggest such things for an RNY patient. As usual with medical advice, it's best to go with your doc's advice - many take a middle ground and restrict NSAIDs for some limited time post-op while things are healing. And, consistent use of any of these drugs (even these notionally "safe" OTC drugs) should be done under a doc's supervision as long term use of any drug can cause problems (indeed, there are some studies finding that bypass patients have a greater than average incidence of acetemetafin - Tylenol - poisoning as they are so dependent upon it for pain relief since NSAID use is a no-no for them. Nothing is completely safe in this life.

A 60 bougie would be consistent with a DS (duodenal switch, where they combine a larger sleeve with intestinal rerouting/malabsorption) while for the VSG we typically see numbers in the 32-40 range. Docs have differing philosophies as to what works best for them and their patients, and there can be substantial overlap between patients where the same bougie was used (the sleeve can be made tighter or looser around it, and stomach length is another variable.) I have no idea what bougie my doc used (if, indeed, he used one at all...) but my nominal stomach capacity at surgery time was about 2.5 oz. In comparison, my wife's starting stomach size when she had her DS was about 4 oz. Adding to the confusion is variabilities in inflammation and recovery times, and who knows what other variables that may be involved. When my wife was going thru this, she could barely consume her nominal stomach size in liquids during a meal sitting (which was tough on her Protein intake,) while I had no problem with liquids and had very little restriction with them - I put away a bowl of broth (maybe 6-8 oz) and a half cup of juice in relatively little time in the hospital; both extremes are quite normal, and the doc had no concerns about such variability. I had no problem with consuming a Protein shake in 20 minutes or so as long as needed them, but have little problem with inadequate restriction at 2.5 years out.

NSAIDS such as ibuprofin, naproxen and aspirin, are generally acceptable to use with the sleeve, though some docs whose experience has been primarily with the RNY gastric bypass don't make the distinction between the two procedures in that regard (the RNY has specific structural problems that preclude the use of stomach irritating drugs such as NSAIDs, which the sleeve does not have.) Indeed, need for NSAIDs has often been used to overturn insurance decisions favoring the RNY over the DS and sleeve. The best general advice for most everything like this (medical advice, etc.) is to follow your doc's advice and instructions over amateurs on the net. However, when there are wide differences of opinion or experience between professionals on a particular subject such as this, then we need to be more proactive for our own interests. Do some research on this yourself to become more informed and comfortable with the subject, and discuss this with your surgeon. A good place to start researching is to look up docs who are long experienced doing the sleeve and duodenal switch (which uses the sleeve as its basis and adds a malabsorption component) and look at their advice and practices - many will list the use of NSAIDs as an advantage of the DS and sleeve over the RNY. http://www.dsfacts.com/duodenal-switch-surgeons.html#.Uqv1KOJliIk is a good reference listing long experienced DS surgeons to look into, and check their views on the subject. My surgeon, with some twenty years of DS/sleeve experience behind him, suggests NSAIDs for post-surgical pain relief once the usual narcotic pain relievers are no longer appropriate. Some docs take a more in-between stance, allowing them after a few weeks or months post-op to allow for more healing, but long term there should be no general restriction on their use beyond the normal admonition that any consistent use of them be under the guidance of a physician as long term use of these drugs can cause some damage, even in normal people.