RickM

Check into Ara Keshishian; he operates out of Glendale, but I believe that he does have an office in the South Bay area. He is one of the long experienced DS/sleeve surgeons around and would have been my choice had I not gone up to SF for my sleeve. Cirangle is great if you fit his ideal patient profile (SMO+/very high BMI), but if you don't, there are better choices. I went with the doc across the street (figuratively) from him as he fits my needs better. Look carefully at a doc's program to see how well it fits your needs, whether it can be tailored for your needs or is an assembly line operation.

The nurses prefer that you wait until you get home from the hospital, and that cross that they had me strapped down to in the OR wasn't particularly amenable to it, but it's mostly down to whatever and whenever it feels right.

Why do we have no choice? The sleeve doesn't care what kind of diet one uses - whatever works for one's weightloss needs is just fine, and we don't have any of the physical dietary limits that the bypass has. Granted, with the caloric restrictions and protein minima that we have, our diets are inherently low carb and low fat, but that's just a temporary thing.

Part of it is to make sure that your weight is stable, as you don't want to have to go through it again if you lose more weight, and it often takes a while for our weight to stabilize once we get to goal - overshooting the mark some and regaining a bit to get to our stable weight. Also, once we do stop losing, things tend to redistribute some, so for best results, it is good to wait for upwards of a year after reaching goal before getting into plastics. As with most things in life, compromises can be made to meet different circumstances - some have had a window of time to do it early before getting into longer term work or school commitments, or have had such an extreme panni problem that they needed to do that part early for functional reasons, and then go back later to finish things up with an LBL, thighs, arms, etc.

I hear ya on the boredom front, particularly when one has gotten used to being active. When I had a shoulder repair done last year, they at least got me into some physical therapy within a couple of weeks, but the reconstruction was just couch potato time for so long, and even once the drains are out, if there are any parts of the incisions that are slow to close (not an uncommon semi-complication) that can delay things further. Once they were all finally closed up, the doc was eager to get me back into the pool to start stretching things out again.

If anything, I may have dropped a bit on girth, (though that is not something I measured or tracked.) At least relative to my glans the shaft is now a bit skinnier - I was never much of a mushroom headed guy, but it is now to a greater degree. So, either the shaft shrank a bit or the glans is grew a bit.

Three of the four that I had were out by a couple days past three weeks, and the fourth was out by four weeks. The port for that last one took quite a while to finally close up (no significant drainage from it, just slow to close up so had to continue dressing and cleaning it.)

Pills are OK even early on, though the larger ones like calcium tablets are difficult and most use chewables or liquids for that for a couple months. NSAIDs are also generally OK with the sleeve - it's the bypass that has a serious problem with them and some docs carry over the same instructions to the sleeve (the ability to use NSAIDs and similar drugs is one of the major advantages of the sleeve, and DS, over the RNY gastric bypass.)

I had a TT, manboob reduction and a couple of hernia repairs (an incisional/umbilical hernia and an inquinal hernia - the "turn your head and cough" type,) in early March. It ran around $16k self pay, with about half of that coming back eventually from insurance coverage of the hernia repairs. I didn't have as rough a time as Aaron (at least not as severe), pain and mobility was manageable, but more in the way of minor discomforts and complications. Scrotal swelling was probably the most inconvenient/uncomfortable part - think in terms of grapefruit for the first month (apparently not that uncommon of a complication for surgery in the lower abs for us - excess drainage beyond what the JP drains pick up still flow downhill!)

The DS uses the sleeve as its basis (usually a bigger version), and adds an intestinal rerouting like the bypass, though of a different configuration. The net result is a more normal diet and eating style than the bypass (things don't get stuck in the sleeve as they can in a bypass pouch, and dumping syndrome is very rare), and the caloric malabsorption lasts for the long term so regain resistance is better than any of the other major WLS procedures. Diet is more forgiving with the DS than with the sleeve as the caloric malabsorption compensates for some of our sins, though my sleeve diet at 2 1/2 years out is also quite forgiving (so far!) due in large part to my fairly high guy metabolism; my wife had a DS 8+ years ago and she isn't as disciplined as I am, but she is maintaining her weight much better than most shorter women who have lost 200lb with a sleeve or bypass. The flip side of the DS is, like the bypass, that greater discipline in routine labs (typically annually once things have settled down) and appropriate supplements as indicated is required. The bypass is heavy on mineral malabsorption - Iron and Calcium in particular - which can be particularly problematic for the ladies as they get into the age when iron and osteoporosus problems come into play. The DS's malabsorption is less mineral intensive, but adds more malabsorption of the fat soluble Vitamins - A,E,D, and K - which overall tends to be easier to supplement than the narrower but more extreme profile of the bypass. A good short summary would be that the DS requires less eating discipline than the sleeve, but more supplement and lab follow up discipline. A good starting point for research on this is http://www.dsfacts.com/

It sounds like your first doc is simply more comfortable doing the RNY when things get a bit complicated, so your instincts are right with having a second opinion lined up. There are reasons that the sleeve may not be the right choice to replace a band. As they are both similar in using restriction to limit your intake to lose weight and maintain the loss, if the problem with the band was that you were able or inclined to eat around the band (and any surgery can be ate around if one tries!) but it otherwise worked as intended, then the sleeve may not work any better for you. However, if the sleeve failed in one of the many ways that they do - slippage, erosion, ulcerations, etc.- but you otherwise lost with it, then the sleeve will likely be a good move. Overall, there isn't much difference in the performance of the sleeve vs the RNY. The RNY might allow you to lose a bit quicker than the sleeve due to its malabsorption; however, caloric malabsorption is only temporary with the RNY, so after the first year or two, its regain performance is little different than the sleeve. Unfortunately, mineral malabsorption is lifelong with the RNY. When considering WLS revision, one should look closely at all of the various options to avoid having to go through this again. The different procedures have somewhat different personalities, and some are a better fit for some patients than others; that's one of the major reasons for revisions - a simple mismatch in character whereby the procedure fails the patient. As you are going through this research process, also look into the duodenal switch (DS) as well. It may or may not be right for you, and a doc who doesn't do them is unlikely to discuss it seriously, but it is worth considering and consulting a doc who does do them. I know several people who revised from bands to RNY and ultimately to the DS in order to get what they needed - it's best to avoid that if you can and get what best suits you, rather than the surgeon. Good luck in your continuing journey,

I didn't have to do one, either, beyond the usual day before surgery thing. Generally, it's the surgeons who are more experienced with the sleeve that don't need those diets, so be happy!

I never got along with Dr. Cirangle's high program fee, as much of it covers things that would be covered by insurance if billed separately, like the follow up appointments - those are routine Dr. consults. I have no problem with some of the nominal fees charged by some to cover expenses that insurance doesn't cover. Some of those things can be very useful long term if they get us started in directions we may not ordinarily go (like exercise physiologist consults, or body composition testing) while some of it may be fluff. My doc doesn't charge a program fee, but covers those costs in his surgical fee which he doesn't normally discount by being "in network" for the insurance companies.

It sounds like you are in the classic, dreaded third week stall - it's just early since you started early with your pre op diets. We typically lose quickly the first two to three weeks of any major weight loss effort as we burn off our short term reserves of glycogen, at which time our body gets the idea that we are serious about this caloric deficit thing and starts to decide that its time to start drawing from our long term reserves of fat, But that can take some time, as we have to rebuild the glycogen reserves from this initial fat burn, and that also involves retaining some Water to keep it in solution, so we start burning fat but retaining some water = no or little weight loss until the glycogen reserves are back to a workable level, even though we are starting to burn the fat. In short, don't worry, you aren't broken, and it will start moving again soon.

Quite normal. As usual, when you see this kind of distortion in the marketplace, you can bet that the government is involved - in this case, Medicare reimbursement practices are a major influence on this hokey accounting. "Normal" charges will be integral with your insurance contract with the providers (which, likewise, are not always the most rational things in the world, either.)

What one is "supposed" to be on when varies widely between different surgical programs - docs coming from the RNY world tend to specify much slower progression rates than those who have been in the DS world and have been doing sleeves for a long time; likewise, what we can tolerate when can also be very individual - I had scrambled eggs and yogurt in the hospital without distress. A couple bites of eggs isn't going to stretch anything out - if her stomach didn't like it, she would know about it. My doc's experience has been that most patients do better as they move into real foods, so it seems like she is experiencing this as well. We typically experience a fairly quick loss the first couple of weeks or so of any big weight loss effort (surgical or otherwise), and then have a bit of stall (it may be a couple days, a couple weeks or more, or none at all...), so if you had much weight loss immediately before surgery, like from a pre-op diet, that could be your initial big loss and now you are into the stall mode. The best thing to do to deal with these stalls is to keep up your protein and Water consumption needs.

Yeah, the insurance coordinator for your doc or the surgical center would be the place to start. It may take your suggesting to them that you pay them their standard self pay price for the sleeve and hernia and they rebate you whatever the insurance pays for the hernia repair. The plastics guys are used to doing this as their work is largely self paid but the bariatric guys don't do these deals as often. I paid upfront for my reconstruction surgery, and I will eventually get about half of it back from the hernia repairs that were done at the same time. Good luck in getting something out of all of this!

There is a good possibility that you could get a major part of the cost covered for repairing the hiatal hernia, with you covering whatever added cost is involved (additional OR time, probable extra day in hospital, etc.) This is done all the time in getting tummy tucks and similar reconstruction surgeries partially paid for by way of repairing umbilical or incisional hernias.

Welcome semi-neighbor - I'm a part-time peninsula resident (will be fulltime once my wife can finally retire.) I'm a little earlier than August, having been sleeved in May 2011, but overall had a smooth journey. I was also sleeved on a Monday and booted out of the hospital on Wednesday (it should have been Tuesday but the hospital dragged their feet in getting the leak test and results done.) By Friday or so I was outpacing my wife on our neighborhood, park and beach walks. The second week was when constipation hit and clipped my wings a bit, but by Thursday of that second week I was up enough to drive back up to SF for the 10 day follow up. Protein was doing well enough by then that they were adding veg to my diet. If you are living on pudding at the moment, try making a protein loaded version of the SF mixes - either add in a couple scoops of protein powder along with the milk (lactaid milk or soy/almond milk as appropriate for your lactose intolerance,) This mixture had a bit too much of that protein powder taste to it, so I cut back to one scoop of powder, one cup of milk and one cup of plain greek yogurt and that made if much better to my taste (YMMV) with a bit of the yogurt tartness taking the place of the protein powder taste. With your lactose intolerance, be sure to look for 100% whey isolate protein drinks/powders as they have all of the lactose filtered out in the process. I'm currently using (when I do, which isn't often these days,) is Performance Whey 100% Isolate from costco - it's vanilla flavor and works OK for me, though I usually flavor it up with some chocolate flavoring or use it in the puddings. Good luck on your journey and may it continue to go smoothly,

I would expect that Unjury's chicken broth flavor protein powder mixed into water or broth would do the trick; likewise some of the unflavored powders mixed into a clear beverage (or jello?) would also work. Since I'm not sure what the purpose of a post-op clear liquid phase is, you'll have to check with your doc's staff to make sure that these fit into their intentions.

Factor in your travel expenses when considering things - my doc has us stay in town for 10 days until the first post-op appointment if we aren't local (we travelled about 6 hours to SF for my VSG, and my wife's DS a few years ago.) The 11 hour drive home should probably be broken up into two days - I had no trouble travelling the six hours when I went home after the 10 days. My doc also has an office about an hour away from home for follow ups and support group meetings, so that helped in the decision to go with him instead of someone local. I fully understand the desire to get on with it once we make the decision to go the surgical route. Depending upon your history, etc. a decision to wait and go local can be a very good one if you take that extra time to work on improving your habits for the long haul. It is often stated on these boards and in the various programs that success involves major lifestyle and habit changes for life; however most programs say that and then go put you on yet another diet pre-op, post-op and loss phase, leaving most sort of hanging when it comes to actually making these long term changes once they get to maintenance. What I did in my somewhat circuitous route to my VSG (as my wife was already going thru the WLS process,) was to start making those habit and lifestyle changes when we decided to get serious about our weight problem. This was specifically not any of the fad or book diets that get the weight off in the short term only to experience total regain (or more), but was an effort to make the sustainable long term changes that we all know that we should make (cutting out or minimizing the crap, more fruits and veg, whole grains and lean Protein, more activity/exercise, etc.), and that worked quite well. I lost 50 of the 150 lb that I needed to lose, and most importantly, kept it off for several years until circumstances converged to get me into the VSG. I probably could have lost it all with one of those fad diets, but I would very unlikely have been one of the 5% or so that can keep it off. Was it perfect according to proper nutritional theory and the latest book diets? Of course not, but it was what I could do within my tastes and tolerances, and there were substantial changes that I was able to make within those limits. Once I decided to finally go for surgery (insurance finally covered the VSG and I concluded that I wasn't going to permanently lose the rest of the weight by the habit changes alone), the process was much easier as the dietary changes for loss, once beyond the initial post-op transition phase, were not such a major change to what I was used to pre-op, or to what I am doing now in maintenance; cheating on the diet was less of an issue as the cheats were fundamentally healthy fare that I was already used to. The bulk of the changes that I made occurred in the first six months with mostly continuous tweaking after that to improve nutrition and trim calories where I could, but most of the good habits were established fairly early and then reinforced thereafter. so that is a timeframe consistent with your needs if you go for the springtime surgery (and is still worthwhile if you can get a December date.) Short answer here is that even if you decide to wait until spring to go with the local doc, you can get a good start on your journey now rather than just waiting for some future date. Good luck on your adventure,

As a relative lightweight (for our population, at least- under 40 BMI,) 100% excess weight loss is very achievable. Some docs aren't very aggressive in their goal setting, either for themselves or their patients, and they are the ones that see only average results - the 60-65% numbers that you are being quoted - while other docs set tougher goals and have programs in place to help their patients achieve them. If, as it sounds, that your doc is one of those less aggressive ones, you can consider seeking out another doc who has a better program and success rate, or simply set tougher goals for yourself, depending upon your personality and need for that extra push to succeed. Seek out the advice of the longer term post ops here who have done well, paying particular attention to those in similar circumstances to your own. Good luck in your journey - you can do it!

It's nice that you are getting approval for this (sorta - even better if things weren't bad enough for the insurance to take notice, but that's life!) I had an extended TT (the panni taken a little farther around, plus muscle tightening) along with manboob reduction, partially paid for by a couple of needed hernia repairs. It certainly isn't as much fun as the original VSG typically is, particularly for the boys down there (the most disconcerting part of the whole thing); it seems that the channels through which our testes descend from infancy to their permanent location also make a wonderful drainage conduit for anything accumulating in the abdomin after such surgeries - and things flow downhill. Sweatpants may be the dress of the day for a couple weeks or more; I carried a grapefruit down there for the better part of a month. YMMV, and hopefully yours will vary to the better side than mine did. This is not to dissuade you from getting done what needs to be done, as the results are worthwhile, but it is a reflection that these procedures do typically involve longer and harder recoveries than is normal for our original bariatric procedures due to the amount of cutting and surface scarring that is involved, so that should be planned for (and hope for a better than average recovery!) I went into this after seeing my wife go through this, so eyes were wide open and that still doesn't completely prepare you. Good luck and smooth sailing with yours,

My wife was right around 60 when she had a lower body lift and thigh lift in two procedures. I'm 55 and just had an extended TT and manboob reduction. Overall, count on a rougher journey than with the average bariatric procedure due to the extensive amount of cutting and scarring involved.

Most hospital based nurses agree that you should wait until you are out of the hospital. Beyond that, it's up to individual doctors' opinions which vary from "when you feel like it" to some weeks. Basically, it's down to being able to do things without distress - you probably don't want to be swinging from the rafters, but any positioning that accomplishes things in comfort is fine.