RickM

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.

3% of RDA is the legal limit for OTC potassium supplements here in the US; any more needs a prescription, so this is a tough one for those who are deficient. It's difficult to get much in with our limited solid intake that we have post-op, and most of the best sources tend to be fairly caloric - bananas, avocados, potatoes (they're about the best real food source on a per-calorie basis) oranges and tangerines (and their juices) are amongst the best. The best source that I have found is the low-sodium version of V8 juice, at about 25% of RDA per 11 oz can (and 70 calories.) I guess that it's hard to OD on V8 juice to any toxic effect, so the FDA rules for supplements don't apply to such a food product. If you were deficient in the hospital, then you may have to take prescription supplements for a while (or longer) until you can get enough in through diet. My wife, who tends to be deficient, uses a prescription liquid supplement, which is notionally orange flavored, mixed with some tangerine juice for her normal supplement and adjusts the dosing periodically depending upon her labs.

Tylenol you can certainly take, and ibuprofin, naproxin and aspirin (and the other classic NSAIDs) are also generally usable with the sleeve, though some docs who aren't yet very experienced with the sleeve stick to RNY protocols which forbids those medications. My doc, with some twenty years of sleeve experience behind him, is fine with any of those pain relievers as soon as the stronger prescription narcotics are no longer appropriate. The best thing is to check with your doc's staff to see what side of the fence he is on with that issue.

Think in terms of those who have the RNY gastric bypass, where the entire stomach is bypassed and set aside inactive. The stomach may atrophy over the years such that it is no longer viable, but that is over many years - people have the bypass reversed or revised to a sleeve or DS after several years and that stomach is entirely usable again.

I had no problem with standard pills after surgery, including the larger Multivitamin tablets within a week or so. The only chewables that I used was calcium as those tablets tend to be real horsepills (though there are some petite versions available for some brands - you just have to take twice as many of them,) and I used them for quite a while as I bought a big bucketload of the Bariatric Advantage chewables that needed to be used. Some may have a problem with normal pills for a while until the stomach inflammation goes down, but most of the concern over pills is a holdover from RNY practice where they can get stuck in the small stoma at the bottom of the pouch - a problem that doesn't exist with the sleeve.

Potassium can be one of the tough ones for us with our minimalist diets during weight loss (and low carb diets make it doubly so,) and the matter that it isn't supplemented well without prescription due to toxicity concerns (so do follow your doc's instructions with any prescription supplements!) Bananas, cantaloupe, potatoes, orange or tangerine juice and avocados are good potassium sources, but getting a meaningful amount from these sources is still tough when we're restricting calories. The best source that I have found is the low sodium variety of V8 juice which has about 100mg per ounce - an 11.5 ounce can (soda can size) has about 1100mg for 70 calories - that's still only about 25% of the typically suggested RDA but it gets us up into a useful range such that we may be able to avoid prescription supplements.

This is one of those big "it depends" issues - some docs would have you keep your calories constant until you hit goal and then figure out where to go, while others will be more flexible depending upon the patient's progress. My take (and my doc's,) on it is that if you are getting close within six months post-op, then slowing things down and easing into goal is a reasonable thing to do. In my case, I was about ten pounds away at six months, and still losing at a consistent ten pounds per month rate (which implies around a 1000 calorie per day deficit,) so I started loosening things up some (but as it was that time of year, I mostly let the holidays happen!) and between that, holiday travelling (when I usually pick up a few pounds from Water retention due to altered exercise regimen and increased sodium intake from eating out more,) that slowed things down enough that it was mid January when I hit goal. I did ultimately drop another five pounds or so which pretty much defined the lower end of my five pound maintenance range. How is your loss rate going - is it fairly consistent, and in range to hit goal within the next month?, two months? How firm is your goal weight - just a number, based upon BMI, or body composition, or lowest adult weight or other criteria? Some get to their goal weight and decide that they want to go another few pounds, so some flexibility there can be desirable - goal weight is ultimately up to you!

I had saltines a couple days after getting out of the hospital - they basically melt in your mouth so there is little bulk by the time they get to your stomach, and they are good at soaking up excess stomach acid if you feel a bit queasy. They can be a trigger for some people (most any food can be a trigger for someone....) and can be a slider, so some may find themselves going through a whole tube of them in no time, so be aware of that. And, of course, they are carbs if you are concerned about them. But early out, a couple of saltines with Peanut Butter fits in well with a soft diet and is usually well tolerated. As usual, check with your doc/nut or program instructions as they vary widely between practices.

Basically, they are a big no-no forever for the RNY due to structural weaknesses inherent in that particular procedure. Many docs who are experienced with the RNY but relatively new to the sleeve carry over that advice to their sleeve patients until they (the docs) get comfortable with the differences in treating the different patients (we see much the same thing happening with dietary restrictions and progressions, with RNY protocols often being applied to sleeve patients until the surgeons learn how the different patient groups respond.) Surgeons who come from the DS side of the craft have little objection to NSAID use and offen recommend them for use post-op as needed once the narcotic pain relievers are no longer appropriate. Note that the Obesity Help article linked above only mentions the bypass in limiting NSAID use, but does not discuss other procedures. This difference is well enough established in the medical world that it is often used in overturning insurance decisions favoring the RNY over the DS or sleeve, but as usual, follow your doc's recommendations as much as possible; if you have a specific need for these medications, as the OP does, and they are on your surgeon's no-no list, discuss them with the surgeon. NSAIDS have side effects that can be problematic for normal, non-WLS people, so their use should be monitored by your doc (surgeon or PCP) even though they may be OTC medications.

Much of it also comes down to how much sleeve experience the doc has - you have an old line DS surgeon like my doc (which means that they have been doing sleeves for a long time), and from what I have seen, they all tend to have more aggressive food progressions than those who are fairly new to the sleeve, even if those docs are long experienced with the RNY. Did Pomp have you do an extensive pre-op diet? That's another area where the old line DS docs seem to be less inclined to do them than the RNY guys.

Likewise, in the hospital the day after surgery - purees and soft foods including things like scrambled eggs, yogurt, cream of wheat, etc.

One of the problems that we can face with a procedure that is relatively new, like the sleeve, is that when problems occur, the natural instinct of most docs is to go back to what they know best, getting into their comfort zone, which in this case is the bypass. It may well fix your problem but it is a radical approach to something that may have a simpler solution to those with more experience in the procedure that you have had - the sleeve. Likewise, most gastro docs are going to mostly be experienced with solving problems with bypass and band patients simply because they are the most numerous of WLS patients. Try to find a surgeon experienced with the duodenal switch (DS), which is a WLS combining the sleeve with intestinal rerouting. Most of these guys have been doing sleeves for 10-20 years or more, so they are likely to have come across complications similar to yours and may have techniques that they can use that are less invasive than a revision to a bypass. A good place to start is at http://www.dsfacts.com/North-American-Duodenal-Switch-Surgeons.html#.UmvoWFP5mpo My wife has a DS, which thankfully has been without major complications, but over the past ten years we have learned that those in the DS world have to stand up for their specific needs in what is essentially a bypass dominated medical world. Those of us with the sleeve have to do likewise until the sleeve becomes the dominant WLS procedure (it's getting there!) and more of the medical world caters to our needs rather than forcing us to adapt to solutions created for a different population. Good luck in finding a solution other than just chopping out the rest of your stomach.

http://www.trxtraining.com/ I don't workout exclusively at home (I keep the pool at the Y!) but I use the TRX and resistance bands when I travel. The TRX uses your weight for the strength work, and the level of strength required is varied by the angles and positions that you use.

I was on soft foods along with purees/mushies and liquids from the first week - scrambled eggs and yogurt along with jello and broths in the hospital and progressing as tolerated from there.

50 lb over the first couple of months is a great loss. You will experience more rapid loss the first 2-3 weeks of any major weight loss effort with our without surgery - that initial loss comes from your short term energy reserves of glycogen (and the water that keeps it in solution,) which burns more quickly than your longer term stores for fat. So, you may not be seeing as impressive numbers at seven weeks post op that others may show who never did a pre-op diet and had their most rapid loss during their immediate post op period, but lost weight is still lost weight - enjoy it!

My doc's plan has that on their plan for anytime within the first month - we have no liquids-only phase. I think I had some cream of wheat (or was it oatmeal - can't quite remember what the hotel had for breakfast then) the day after I got out of the hospital. So, it mostly goes with whatever your surgeon's plan specifies.

Adding to the widely variable insurance requirements (or none at all, for those who self-pay) we also have widely variable surgeon's requirements - some want to see some weight loss over a few months prior to surgery, plus pre-op diets that vary from 2-4 weeks to none at all; then there are scheduling considerations where many surgeons are booked for weeks or months ahead, and sometimes cancellations happen where surgery can happen in just a few days after whatever requirements are met.

Maintenance calories can be all over the map depending upon factors too numerous to count (but including such things as lean body mass, activity levels, and amount of metabolic damage.) When I dropped to within 10 lb of my goal weight/body composition, I was still losing at a fairly consistent rate of 10 lb per month (and had been for the previous three months) which implies a caloric deficit of about 1000 calories, so I had a ballpark number to work toward (which turned out pretty close, as I was losing at an average of 1100 calories and am maintaining in the 2000+ range.

If this is a lactose intolerance problem, which is not uncommon post-op, then whey Protein isolate can be used as it has had the lactose filtered out of it as part of the process. Isolate is expensive, so the cheaper Protein drinks are usually blend of cheaper whey concentrates, isolate and other sources. Yogurt also has had most, if not all, of the lactose consumed in the fermentation process, and many cheeses are very low in lactose. One can also take :Lactaid tablets just prior to consuming dairy with lactose in it. On the minimum amount of protein required, that is largely dependent upon lean body mass. A small, light (will be light!) woman who may end up with a healthy weight in the 100-110 lb range will need somewhere in that 55-60 g range while a fairly muscular man may require 100g or more to maintain their lean body mass. Inclination towards increasing muscle mass or healing from major trauma can add 50% to those figures.

Pretty much immediately - scrambled eggs and yogurt (along with the typical juices and broths) in the hospital followed at home by experimenting progressively (under plan - try new things one at a time to test for tolerance) with other soft things like oatmeal, softer cheeses, progressively less strained soups, peanut butter, tuna progressing to dark chicken, etc.