RickM

20mg is the standard OTC dose in the US for omeprazole. Esomeprozole (Nexium) was more advanced in that it was a minimum change from omeprazole in order to establish a new patent when omeprazole (Prilosec) lost patent protection and they moved it to OTC. Physicians were hounded by the drug reps to change their patients Prilosec Rx over to Nexium, and there was a major marketing campaign to the public to establish demand for the new pretty "Purple Pill." Doctors who were overly aggressive in switching their patients were often chastised by their peers for "caving in" to the Pharma marketing push. The general advice then, as now, is that if there isn't any side effects noted with the older med, there was (is) no compelling reason to go with the newer, more expensive med. Pantoprazole (Protonix) was a different med in the same class by a different manufacturer that did have notably different characteristics that were often useful (ie, "better") but again, if the older, cheaper med works without problems, that's fine.

The VSG is somewhat predisposed to reflux, meaning that a greater proportion of those with that surgery will have that problem than the general population. The sleeve reduces the volume of the stomach much more than its' acid producing potential, and sometimes the body doesn't fully adjust to that. The bypass in comparison is predisposed to dumping syndrome, reactive hypoglycemia, marginal ulcers and mineral deficiency disease, so there are trade offs with whatever route one chooses (and with doing nothing, given all of the obesity related diseases that we are trying to avoid!) This is not unusual when we change things in our body - surgery of any kind changes things and sometimes there are negative aspects, or risks of, along with the positives. Medications change our body chemistry to solve a problem, but sometimes there are side effects that are negatives. It is routine for patients to be given a PPI for a while after any WLS, or even on GI procedures - I was put on pantoprozole for a month after a minor cardiac procedure I had a few months ago simply because when the body is under stress (like form surgery) it tends to over produce acid. So, being on a PPI at this point is normal, and nothing to worry about.

Pantoprozole (Protonix) is also available OtC. Depending upon insurance details, OTC may or may not be cheaper than Rx - OTC omeprazole is usually around $15 at Costco for 42, sometimes on sale for a few bucks less. Use the one that works best for you. Also try Pepcid, which is an H2 inhibitor and is generally considered friendlier to our systems long term than PPIs such as the -azole meds above. The PPIs are also known to have a problem with rebound reflux if you stop them suddenly, so it is usually better to wean off of them over a couple of weeks - cut the dosage in half or spread the dose timing, or intersperse a dose of PPI with one of H2I. Some may never have a problem with dropping them, but if one does, try tapering off the med.

I can certainly understand that, as they tend to be familiar with different dodges used to get around their exclusions. There are a number of procedures that are used to treat GERD, depending upon what the cause is. Fixing a hiatal hernia, for instance, doesn't require a bypass to accomplish, though such repairs are commonly performed in conjunction with WLS, either a sleeve or pouch type. When I had my VSG, it was just starting to be routinely approved by US insurance companies -some did, others still called it "investigational", As a legacy of that, insurance commonly excluded the 2 step DS (as the DS uses that sleeve as its basis, in extreme cases they would do a VSG first, and then once the patient had lost enough weight to undergo the longer switch part they would do that as a second procedure - that was the origins of the VSG, as some found that they lost enough on just the VSG that they didn't need to go through with the second part. Insurance got wise to the dodge of getting approval for the DS but only doing the first VSG part, so they blocked that approach. Of course, for those who really needed to go that route, it was still available but they needed to jump through more hoops to get there. Had your surgeon approached them, it might have flown (assuming that it was a justifiable approach for your GERD, as they would not be asking for an RNY WLS, but using different terms and codes. The same basic procedure (it's called a Billroth II) is used for treating several different maladies, and the rules and codes are different for each. The sizes of limbs and the pouch are different for an RNYGB WLS than they would be for a partial gastrectomy used in treating gastric cancer or gastroparesis, though they are the same basic procedures.

This is something that should be covered as a complication from an previously covered procedure, rather than a second WLS; it may takes jumping through some hoops to get there, but you should (eventually) get it. This likely got an automatic denial as claiming a second WLS and needs to be appealed, first through the BCBS internal process, and then, failing that, through your state insurance regulator. The first appeal step will usually involve a peer to peer review, where your surgeon talks to their staff doctor to explain the medical necessity on a doc to doc basis.. Once it is apparent the ramifications of your situation (and their liability for not covering it...) it should go through. Your doc should be able to discuss with them what steps have already been taken to resolver the (medical) problem - what meds have been tried and failed, what tests have been done, what your prognosis is without surgical intervention, etc. Good luck again, it should go through, they just need to be slapped around a bit to realize their obligation. Another possibility is that your surgeon's office coded it as a standard RNY, and there's a different code to use as a GERD treatment (the basic RNY procedure is used for several different maladies beyond its basic WLS function, but it goes by a different name (and code).

You are right to be looking around for second and third opinions when contemplating a repair and possible revision with a higher than average complexity. If indeed you are in the "gained it all back, plus" camp, then the traditional RNY fixed probably won't be strong enough to do the job, and adding in the hernia and additional scaring compounds things. The surgeon I would suggest looking into would be Ara Keshishian, who is in the Glendale/Pasadena area of So Cal. He is one of the handful of surgeons who can do the complex RNY/DS conversion, should that me necessary, and I have seen some on these forums who have had some fairly involved RNY reworks from him (though his preference is usually to go for the DS if it makes sense.) Rumor has it that he isn't dealing with insurance anymore (haven't verified that, though,) so if that is an issue, another good choice to talk to would be John Rabkin in SF, who is similarly qualified in complex procedures., As both have long drawn patients from around the country (and beyond) they have long routinely been able to do their early screening discussions and longer term follow ups remotely. Another doc I would talk to if you want to look East would be Mitchell Roslin in NYC; he also seems to have a very deep toolkit, capable of doing a number of different procedures as appropriate Most bariatric surgeons are pretty good at doing RNYs and variations of that, but don't go very far beyond that, and it sounds like you need someone with rather broad (and deep) skills to get what you need. Good luck,,,,

See above - many programs put all their patients on the same regimen, either out of their convenience, or because they haven't yet figured out what a VSG needs vs. an RNY, or they haven't bothered to update their guidelines yet.

It is probably overkill, and it does sound like more of an RNY regimen than one for a VSG, but many programs combine the two out of convenience (their convenience, not yours!), and then tailor things more as your labs come in over the next few months. Also, it's usually easier to start at high levels and cut them back than trying to play catch up later on. With a VSG, you really aren't malabsorbing anything like one is with an RNY, so you can usually cut way back on a lot of those as your diet improves over time. For instance, though I target 2000mg of calcium per day (which is above normal RDAs but appropriate for my needs,) I only need to take one dose (2 pills) to achieve that along with my normal diet, and I don't need any iron or B12 (which is more of an RNY thing) and B1 comes naturally from whole grains; it is arguable whether I need any multivitamin at all (but isn't bad insurance, just in case.) It's all a big YMMV thing that settles out over time, but likely you won't need nearly that much over time, but in the short term, with a protein intense and little else diet for a while, a bit too much is better than not enough.

With a sleeve, you really don't need anything overly special, as we don't have the malabsorption of certain nutrients that you get with the malabsorbing procedures like the RNY or DS; we mostly have to make up for the poor diet that we have during weight loss when we are concentrating on protein at the expense of the fruits, veggies, grains and legumes that typically flesh out our nutritional profile, so a good quality general multi if usually fine. To that we add some calcium and iron as needed (since they need to be take apart from each other) and whatever else we individually may need. With a sleeve, we generally don't need extra B12 (that's more of an RNY thing) but some programs specify it out of convenience, as many just use the same recommendations for their sleeve patients as tehy use for their RNY patients, and then make adjustments later on as labs indicate. Personally, I just use a generic Centrum from Costco, add one or two doses of Calcium citrate depending upon my other intake (I shoot for 1500-2000mg per day from diet and supplement) plus vit D3, K2 and magnesium citrate (al part of the osteo complex) as I have some history with osteopenia. Overall, the bariatric vits (or double multi vit as some programs recommend instead) are largely overkill for us, but it's generally better to start high and then whittle things down as labs indicate and diet stabilizes.

Going to your original surgeon, if you are still in the same town, is a good start, but that should only be a start. As Tomo suggests, getting a second (and third, even,) opinion is a good idea, particularly for a revision where the needs and solutions are more varied than the original surgery. Talking to a non-surgeon or two (such as a gastroenterologist) is also a good idea as there may be some non-surgical interventions that can do the job, and it is usually preferable to start there anyway, and then consider surgery if those don't work. Be suspicious of a surgeon who immediately tells you that if you have a sleeve, with GERD, that you need a bypass revision, without first doing some tests to find out what's really going on inside you. It may be a hiatal hernia which commonly causes GERD in WLS nd non WLS people alike, and that can be repaired without going through a revision (though some surgeons may not be comfortable or capable of doing so, or it can be a poorly shaped sleeve that inhibits good flow, and that can often be resleeved to correct that (though I probably wouldn't be depending upon the original surgeon to fix that, as it implies technique issues with the original surgery.) In short, don't be too quick to self diagnose - let the professionals do that (though it pays to be well educated on it,) and play the field to get multiple opinions - they all can have somewhat different background and experiences, and that drives their opinions; don't settle for the first one that you come across. goo luck in sorting this out....

Certainly, potatoes are about the most calorically efficient real food sources of potassium that we have (and potassium isn't supplemented well without an Rx. Many programs suggest mashed potatoes as an early soft food (along with things like oatmeal and cream of wheat) as a means of countering the common early to mid post op lethargy from a diet that's overly low in carbohydrate ( a popular thing in the fad diet world.) As with salads, the main dietary problem with potatoes is the high calorie junk that is often piled on them, rather than the basic food itself. Enjoy.

I used a straw in the hospital after surgery. This seems to be one of those "if it bothers you, don't do it, but if it doesn't, don't worry about it" things Some programs or docs claim they're death and you should never use them ever, while others are "huh? what's wrong with a straw?" I think that the worry is that you will suck up air, or too much air, when trying to get the last bit our of the cup, which might be a problem for some early on, in which case, don't use them, or don't suck up the last bit with the straw.

As you note, programs differ, (and sometimes wildly!) both in their progressions and also in how they define food types (what's a liquid, what's a puree, etc.) and also in how much they trust their patients and in their own communication with their patients. We had yogurt and scrambled eggs in the hospital - if we could tolerated them, that was great, but if not, liquids were fine too until we could do more. As to the OP, it is concerning that at three months there has not been more progress. A stricture does sound like a possibility - that's not uncommon with a bypass (scar tissue forming around the stoma overly restricting things) and from what I have seen, they're usually fairly quick to do an endoscopic dilation (or two) to open thing up - twenty years ago, this was so common that it ceased being considered a "complication". With a sleeve, it is less common, and more indicative of a surgeon who hasn't quite got the technique down yet, so they may be more reticent about correcting it (if they know how) and just seeing if it will fix itself. I would be a squeaky wheel and get after them to address the issue, as this isn't normal.

Do you even have to do one (many do not) and you are assuming by other posts that you do? Many programs that do them tend to wait until the last minute to tell their patients (for fear of scaring them off, understandably.) Some programs specifically don't want their patients doing any of those fasting diets, preferring that they concentrate on learning how to eat sensibly. If you do need to do one, then yes, playing with different protein shakes to find one that you like, or at least tolerate, is a good idea, but it's not worth going overboard on it. If liver shrinking/condition is their goal (it usually is) then simple low carb will do as well as anything - lean meats and green veg; the liquid aspect is pretty much irrelevant to that goal (and I have never understood why some insist on that, other than they don't have to do it themselves!)

Unfortunately, revisions tend not to do all that well for regain problems - I like to think about it as your stomach started out being able to hold 32-64 oz, and after WLS it can hold 1-4 oz typically; even after it stretches some and/or adapts, its capacity of maybe 4-8 oz is still just a fraction of what it was, and we have gotten used to living with that. So, going with a "do over" revision just doesn't have the same power as the first time around. Further, the bypass is difficult to work with, so typically the best they can do is to either put a band around the pouch to restrict it, or tighten up the stoma, neither of which have a great track record of success. Probably your best shot at getting on track again and losing a substantial amount in a revision is to look into a duodenal switch (DS) which has much better regain resistance than the RNY or sleeve. Unfortunately, that is a very difficult revision, that maybe a half dozen or so surgeons around the country can do. Fortunately, two of them are here in CA - Dr. Ara Keshishian in the Glendale/Pasadena area, and Dr. John Rabkin in SF. I have seen several patients come through our support group over the years that have had quite reasonable success with that revision, so it is definitely worth a look. The other approach that you might find is to convert your (conventional) proximal RNY to a distal RNY, which basically involves moving the pouch much farther down the intestine, bypassing more of it. It does not have a great reputation for being trouble free (from what i have seen, most insurance will not cover it as a primary WLS procedure, but will consider it for a revision.) I suspect that a big problem with it is that the surgeons don't really appreciate the nutritional/supplement differences with it, (it is much closer to a DS than an RNY in supplement needs) and the patients suffer as a result as they may not get the aftercare that they need over the years. The DS tends to be much less of a problem in this regard as the surgeons who do it do so as their primary or preferred procedure, so they know all of its subtle needs by experience. Good luck in finding a solution to your problems,

I've seen everything from 800ish to close to 3000, depending... One thing to remember (or learn, if they didn't tell you,) is that the caloric malabsorption tends to dissipate after a year or two, so you may need more to maintain a certain weight now than you will in a couple of years, so stay flexible, keep tracking what you are eating and make adjustments along the way.

Building on my comments above, if you got along well with your band - it seems like you did - but just had mechanical problems with it, then the sleeve is a good replacement as its' character is similar, being strictly restrictive, but without the foreign object problem potential of the bands. The bypass is a good procedure that has been done for over forty years as a WLS, based upon procedures that are about 140 years old developed for gastric cancer, so it is a well established and understood procedure, both the good and bad. There has been a continuing effort in the industry to develop better procedures (as there should be) and a number have come along, with some remaining and becoming established as viable alternatives (such as the BPD/DS and VSG) and others falling by the wayside, never getting traction (such as the mini-bypass,) and others where the jury is still out (the SIPS/SADI/Loop DS.) The BPD/DS generally works better, being stronger metabolically, but is also technically more challenging to perform, so few surgeons have adopted it; the VSG came out of the DS (the DS is based upon the sleeve, and adds malabsorption) and has established itself as being comparable to the bypass in average performance - overall weight loss and regain resistance - in a more straightforward procedure that has fewer long term compromises for the patient. GERD is the main potential bugaboo with the sleeve, which compares with the bypass's predisposition toward marginal ulcers, dumping and reactive hypoglycemia. The ulcer potential is what presents restrictions on some medications with the bypass, the biggest group being NSAIDs, but there may be others that one encounters in life that will also be off the table, or severely restricted, with a bypass. There is also the blind stomach and upper GI loop with the bypass, which makes those areas more difficult to monitor and evaluate through life (can't just stick an endoscope down there to take a look,) and there are an increasing number of endoscopic treatments for a variety of maladies available these days that would also be off the table. If one needs periodic monitoring in that region, for instance for a history of stomach polyps or family history of some cancers, the bypass becomes much less interesting. Another factor to consider is what I call the "Plan B" case - what to do if things don't work out as expected and things need to be revised? While the bypass is technically reversible, that is rarely done as that in itself is another fairly complicated procedure. The bypass, overall, is something of a dead end procedure in that it is difficult to revise into something else is need be. As weight regain is similarly possible with either the sleeve or the bypass, there isn't much to be done to correct that with the bypass - installing a band over the pouch or tightening up the stoma are the most common revisions, and neither has a very good track record for resolving regain problems. The VSG, on the other hand, can be revised (some would say "completed" into a DS fairly easily as it is the first step in a DS, or it can be revised into an RNY if GERD problems can't be resolved with meds (the RNY is usually reversed if an ulcer problem can't be resolved with meds. So, more options are available with the sleeve should a "plan B' be necessary. These are the reasons why the sleeve is building in popularity; there are good reasons to choose either, but one needs to take a close look at one's circumstances going into it to determine what is the best trade off for one's needs.

Generally, with the sleeve, we will have less need to supplement than with a bypass, all other things being equal; if one is inclined to try for the ideal of getting all nutrition from food, then the sleeve is the way to go - one may not quite make that ideal, but will be closer. The first couple of years, our diets are protein heavy and little else, so supplementing if a good idea, from a belt and suspenders perspective, if nothing else. Labs should be the determiner of how much supplementing is needed, and that takes some time to establish trends, rather than just a snapshot "my labs are fine." One of the problems that we have in going through this is that not everything shows conveniently in our lab tests. Some nutrients, calcium being the most notorious, do not show as deficient until one is in deep trouble, as the body works to maintain serum levels at nominal levels at the expense of body reserves. The body will leach calcium form our bones to keep the serum levels "correct" until it can no longer do so - they you're falling apart. There are other tests that can be done that give us hints as to our status - is calcium depositing or leaching from bones? Talk you your doctor about these things if you are not supplementing as recommended Many programs recommend the same supplements initially for both sleeve and bypass, primarily out of laziness, and then make adjustments over time as labs come in, and you can cut back as indicated. Again, trends over time tend to be more informative than simple "normal" levels. Surgeries do not always correct the need for some medications; After WLS, one may still need meds for BP, cholesterol or diabetes as well, though usually at lower levels. Bypass patients often take PPIs either for GERD that they develop over time, or for the marginal ulcers that are endemic with the bypass (marginal ulcers are to the bypass, what GERD is to the sleeve - you may avoid one potential problem with your choice of surgery, but it is usually at the expense of risk of something else - that's life!)

As noted, the patches seem to work OK for some, and not at all for others. I would stick with the pills for now, as much of a bother as it may seem. You probably won't need to be taking all that many for long - many programs overkill on their supplement recommendations for the sleeve, based upon their bypass experience, which is fussier in that regard. It usually isn't a big deal, as subsequent lab tests show what you really need, and you can probably stop taking many of them - most of us with a sleeve don't need to supplement as much as those with a bypass (but there's usually something that we need, so we need to find out what that is.) The problem with starting the patches now, is that when you start getting lab results back in a few months showing that you are fine,, that's great - but how do you know whether it is the patches that your are using doing the job, or that you don't need them at all? So, I would stick it out with the pills for a while to find out what you really need and get your labs stable on them, then try the patch(es) if the pills are still too much of a bother.

Yes, post and pre-op, vary widely from practice to practice. Ours was similar to above, with most anything in the liquid, mushy, pureed or soft categories acceptable for the entire first month, then moving to solids after that. Some may be on liquids only for a month or more; or anything in between. A big YMMV thing.

Yes, it sounds like reflux; do they have you on any anti acid medication for it (omeprazole, pantoprazole, etc)? Those are commonly prescribed for the first few months after any bariatric surgery (and many other surgeries, for that matter.)

I've had a number of them over the years, and haven't had any such problems; typically, one might have a bit of a sore throat for a while (can happen anytime they stick things down there, whether endoscopy, intubation, etc.) The jaw sounds like they may have been a bit ham-fisted with moving things around to get the scope in. Most of the time, I have had a plug that I bite on (like a baby's pacifier) with a hole in it that they pass the endoscope through, and they strap the jaw closed around it (so it doesn't move when you're under anesthesia). The bloating seems a bit odd - they do inflate the stomach to see around in there (same with the colon in a colonoscopy) but that usually comes out quickly with a bit of belching, if I have noticed at all. When they do the actual surgery, they do inflate your abdomen to give them working space, and that can take a couple of days to work out as there is no direct vent to the outside world as there is in your GI tract.

Keto is no better or worse than any of the other fad diets out there - it's just the one that's currently "in". As with the others, maybe 5% of people on it can lose, and most importantly, keep, a substantial amount of weight off. If it floats your boat and you can keep with it as a "lifestyle" (think vegetarian or vegan) over the long term - even after your loss has stalled and stopped - go for it. But, do realize that Keto in and of itself is not a weight loss/maintenance diet - you have to learn how to do that within the restrictions of the diet, just like any other lifestyle choice. Good luck

Have you ever had a colonoscopy? That's what ours was for the day before surgery. As noted, they're all different so ask your own program for tips and information on their specific requirements.

My surgeon will take the gallbladder of his VSG patients if he feels stones when he is in there; with his DS patients he takes it as a matter of routine as he feels the risk on another surgeon going in there and getting lost in the altered anatomy outweighs the benefits of leaving it there, That isn't an issue with VSG (and presumably the RNY, which he rarely does) as those are familiar to any general surgeon. He also doesn't routinely prescribe Urdusol, or at least didn't when I had mine done. Lots of variations in this world.