RickM

From what I have seen on the various forums (I can't speak from personal experience as the pre-op diets aren't part of my doc's protocols,) some is better than none, and you will have about a week of low carb prep between your 2 day pre-op diet and whatever you do from now until then. Some docs who do the liver shrinking diet will vary the length of diet depending upon patient BMI, with some doing one week, others two or more, so it seems like there is some value in a shorter diet. As a note, I didn't lose anything pre-op (actually gained a bit with all of the "last suppers" associated with all of the pre-op tests and appointments,) and have never been particularly low carb though my diet has long been sane and healthy - just overly-portioned - and my liver was in fine shape at surgery time, (doc tends notice and mention such things as he is also a liver transplant surgeon in his "other life") so YMMV.

I have been wondering things along the same lines - maybe within their experience in their practice, they don't have such good success with the sleeve with higher BMI patients. I would take their advice seriously, which leaves you with the choice of having an RNY with them, or going elsewhere for a VSG (which would certainly be my preference - I never seriously considered the RNY or bands.) There are other surgeons who have had good success with the sleeve and higher BMI patients, though you may have to travel a little farther than you had planned - SF seems to be attract top-drawer bariatric surgeons. Though I'm not a big fan, Dr Cirangle seems to have developed his sleeves and program to work very well with higher BMI patients; Rabkin and Jossart are both well experienced and capable DS and sleeve surgeons there as well. There is also Dr. Keshisian, who operates out of both Delano and Glendale, and is another top flight DS and sleeve surgeon. While with the excitement, stress and hassles involved in getting this close to surgery, it may be well worth taking a step back and re-evaluating things as either an RNY or a substandard sleeve could lead to substantial disappointments down the road, possibly taking you down the path of a revision that may never had been necessary had the correct surgery been done in first place (and if you need to revise an RNY, then you will probably be going to either Drs. Rabkin or Keshisian, as they are two of maybe a half dozen surgeons in the US and Canada who are actually qualified to revise an RNY to a DS. Further, at your BMI, it is worth researching and considering the DS (if you haven't done so already) along with the VSG as it does classically work better for high BMI patients, and has better regain resistance than the other mainstream WLS procedures if regain or yo yo dieting has been in your past history. Good luck in your journey, whatever decision you make,

It is not so much shrinking of the liver that is desired, but a de-sliming or improving its texture by depleting it of as much of the glycogen (basically carbs) that it processes as possible. Typically you see docs that call for these diets to be a couple of weeks of low carbs - some do liquids only but there is no real rationale for that. So, if you want to do what you can, keep it low carb for the couple of weeks before your 2 day surgical diet - heavy on meats and veg while minimizing the fruits, sugars, breads, etc. It wouldn't hurt to experiment with the protein shakes early on, too, so that you don't get caught up with one that you can't stand when that's your primary protein source early on post-op.

The RNY pouch tends to be around an ounce in nominal capacity (give or take half an ounce or so, depending upon the surgeon and patient) while sleeves can be anywhere from two to six or so ounces, though our stand alone sleeves tend to be in the 2-3 ounce range while DS sleeves on the larger side since they are paired with the malabsorption component. My sleeve started at about 2.5 ounces at surgery, while my wife's DS sleeve was about 4 ounces. Some docs like to make tighter sleeves while others prefer somewhat larger ones (it is thought that smaller sleeves may yield better regain resistance, but be more prone to reflux problems than larger sleeves, but that is still somewhat speculative until more longer term data is collected.) Then there are patient variations - a doc may make the same size sleeve (with or without the same sized bougie) but a patient may have a larger stomach to start with that will end up being a longer sleeved stomach overall, so therefore larger capacity - same diameter tube but longer. The pictures that are often shown can be deceiving as they are usually only intended to represent what the procedure does rather than be accurate in their scale.

I think that what he is saying, is in agreement with the OP and probably you as well, is that if one can lose the weight that they need to lose, and keep it off, then you don't really need his services. What is the point of putting the patient through yet another little temporary diet/weight loss effort, just to prove that they can do it for a couple of months? It has already been proven, in the prospective patient's case, that they can't over the long term and need the added help of the surgery. Some docs need the extra help of the quickie "liver shrinking" diet while others do not, so you do see some variations in surgical plans for that reason. From what I have seen over the years, those docs who have been in the DS business for a long time (and by default, VSGs,) tend not to be overly reliant upon pre-op diets.

I recognize that now - the pre-op thing that some docs do usually is a low carb program so this is often unavoidable. Once you get through that and past surgery, then you get a bit more flexibility to tailor things for your needs rather than the surgeon's (depending upon how much of a low carb enthusiast your surgeon is in his post op program.)

That makes some sense then. Double check with the insurance documents or your surgeon's insurance coordinator to verify exactly what the insurance company requires and do what they say. I didn't lose any weight on the 6 month insurance roadblock and it was fine; I just had everything documented - food tracking and exercise logs and doctor's visits notes and it went on through. My philosophy on these longer term pre-op diets (like the 6 month insurance diets,) is to emphasize establishing or reinforcing good eating habits for the long term over temporary weight loss thru fad diets. Good luck in your journey....

Here is a good explanation of what's going on with these stalls - http://www.dsfacts.com/weight-loss-stall-or-plateau.html You are probably doing OK on calories, though the most popular plan is for 600-800 calories, and being a relative lightweight, you can probably afford a few more calories if they come your way (but it's probably not worth getting too worried about it at this point - more calories will come your way as you progress up the food chain. Hydration (water - sip,sip,sip) and Protein are your biggest concerns at this point.

As the token counterpoint to the discussion, you can avoid most of those nasty side effects by keeping your carbs up some - the extreme ketosis state is not essential to burning fat or losing weight (though by the Atkins hypothesis, it might increase the rate of loss to some degree.) I'm glad I never had to put up with it.

Is this diet an insurance company or surgeon's requirement? Insurance company diets are primarily a hoop to jump through intended to delay approval while surgeons have a variety of reasons and requirements. Some surgeons want to test patients' compliance with instructions (can you stay on the doc's liquid post-op diet while others at the same stage are having steak?) while others need added confidence when operating around fatty livers (though these so-called "liver shrinking" diets are usually only a couple of weeks or so of low carb dieting.) Some require a specific amount of weight loss while others don't. My doc is in agreement with the OP in that if the patients could lose it on their own, what is he needed for?

As with most questions of this sort, it really gets down to your doctor's plan and how he defines things. I had oatmeal the day after I got out of the hospital, but my doc's plan calls for purees/mushes and soft proteins, as tolerated, at that point (and everything else the following month) while other docs have more discrete stages - clear liquids, all liquids, purees, soft proteins, everything else, phased in over longer times. It basically gets down to your doc's experience with the sleeve and his comfort level with his patients' progression. Myself, I would say that you could try it and see how things go, but I am not your doc and don't know where he places oatmeal within his progression stages - it's really his call, and that's what you are paying him for.

Is there something in your history, other than your recent sleeve, that contraindicates the use of NSAIDs? Some surgeons like to avoid NSAIDs early on during the immediate healing phase, but long term there is no reason that NSAIDs can't be taken with the sleeve - indeed, thats one of the major benefits of the sleeve over the RNY, and NSAIDs requirements are often used to overturn insurance company decisions denying the VSG or DS in favor of the RNY (though many RNY focused surgeons who are relatively new to the sleeve are slow to understand or accept this.) If your NSAID restriction is from your sleeve surgeon, then certainly you should go to him for approval, as he may have some specific reasons for you not using them. If there is not something specific to you, politely ask him to do a bit more research on the subject, as most of the long experienced sleeve and DS (which uses the sleeve as its basis) surgeons have no problem with NSAID use post op - it's even in my patient binder for use once the prescribed narcotic pain relievers are exhausted (they have about twenty years of sleeve experience behind them, so I tend to trust their word on the care and feeding of a sleeve.) If there is some other issue with your history that precludes the use of NSAIDs, then your orthopedic or primary docs would be the place to go. While there is nothing about the sleeve that specifically addresses or improves joint conditions, as others have noted, things can improve markedly just by getting the weight off, so that just takes a little patience. So, good luck with it, and things should be improving as you progress,

There are a lot of the surgeons out there who do not require an extensive pre-op diet. Some will require one only for some patients, usually those with a higher starting BMI. My doc doesn't require any pre-op diet other than the usual day before thing.

The general consensus from docs and nurses that I have seen seems to be whenever you feel like it (though most hospital nurses prefer that you wait until you get home!)

I had mine done at St. Mary's by Dr. John Rabkin last May; all went very smooothly. My wife had her DS done there a few years ago by his older brother.

6-7 hours for LA to SF, though they do have a semi-local office and support group about an hour away.

It is very difficult early on to get a significant amount of fruits and veg into our diets, even for those of us who ignore the low carb diet fad and seek to get as balanced a diet as possible. I used the semi-slider property of a lot of veg by having small salads with some leftover meat, a few berries with my greek yogurt, meat/veg stir fries and stews, etc. I found that combinations of meats and veg allowed for a fair extra volume of veg to be added to a meal with a small sacrifice in meat quantity. For example, my capacity for firm meats like steak or chicken is about three ounces, but if I cut that back to two ounces, I could fit in 3-4 ounces of misc. salad veg - chopped spinach, tomato, avo,green onion, bell pepper, snow peas, etc. Similar math applies to stews and stir frys (at least to my sleeve!) I somewhat lucked out in that Protein was never a big problem for me (doc was adding veg to my diet at day 10,) so I had some flexibility in my diet and not stuck with a protein only diet. Even at that, it was difficult for me to get in more than 2-3 fruit/veg servings per day during the loss phase, though now I'm happier being able to get in 5-6 per day in maintenance. V8 is a good help in getting in some veg content. One suggestion on that would be to try their low sodium original variety as that has about a large a dose of potassium as anything that I have found (about 1100mg or 25% of RDA in a 11.5oz can) and potassium is very difficult to supplement to any usable degree without prescription - most everything else we can supplement and get by for the time when our diets are fairly restricted during out loss phase. In time, you will be able to consume more and add more fruit and veg to your diet, but early on, it's best to concentrate on losing as much as you can while your restriction is maximized. Many programs want to limit fruits early on due to their natural sugar content and many docs discourage juices as they are too close to drinking calories, so those are things to be cautious about. But kudos for wanting to expand into the healty fare and not just cheat on chips and twinkies! Good luck with your journey - a healthy balanced diet is very workable with the sleeve, even if somewhat modified for a while with our protein emphasis.

It's a variable depending upon the doc's program and how one tolerates different things. I was playing around with small salads after 3-4 weeks, using chopped spinach instead of lettuce for its' little better nutritional profile, along with tomato, avo, bell pepper, green onion, etc. along with a couple ounces of meat for protein.

Not drinking Protein is not a big deal, however not getting in the requisite amount is a big deal. Some docs encourage their patients to move from Protein drinks to real food as soon as practical while others don't care so much. I was able to move off of the drinks as a necessity fairly quickly, around three weeks or so, but still used them as a convenience and exercise recovery drink. What issues are you having with the drinks - taste/texture, keeping them down, etc.? My wife had a hard time using them when she went thru this several years ago, but was able to make do with other foods, though it was more of a struggle for her for a while than it was for me (just those variations between us all....) The protein powders can be mixed into other things to enhance their protein, so you aren't restricted to the Protein shake form - add it into SF puddings, yogurt, mashed potatoes, Soups, etc. Try different brands if taste/texture is the issue, as there is a wide variation between brands. Good luck with it, but do get in the protein that you need, one way or another.

Did your gastro have any ideas/guesses as to why you are getting the test results that you are seeing? I'm not familiar with that test, or what it is really testing to produce its results, but since we sleevers don't have the mechanical malabsorption that is inherent in the RNY and DS, I am guessing that there is some other imbalance somewhere. Many of the diets that are used for weight loss and that often carry over into maintenance are inherently imbalanced - the popular low carb diets are often short of fiber, and the soluable fiber binds with fats to aid in their digestion. Maybe a fiber shortage (or shortage of the right kind of fiber,) is causing a high reading of undigested fats in the stool (just guessing here, but throwing out possibilities)? I know my nut wanted me to increase my fat consumption as I moved into maintenance to help ensure proper absorption of the fat soluable vitamins (A,E,D & K) so if there is an imbalance in fat digestion, that could ripple through to some vitamin absorption (this is a common concern with the DSers who malabsorb fats and have to watch that balance.) Good luck, and I hope that you find an answer - PS - while you are working on finding a solution to the fat problem, there are "dry", or water soluable, forms of the fat soluable vitamins available - Bariatric Advantage (and I'm sure the other bariatric specialty houses) sells a dry "ADEKs" tablet for the DS crowd, and places like Vitamin Shoppe also sell dry A,D,E, and K in various forms.

The body comp scales are measuring your body's impedance (electrical resistance) to derive the fat and lean mass percentages, and as a result, are very sensitive to hydration, which is going whacko these first couple of weeks (first they pump you full of fluids in the hospital, then that dissapates, then your body gets starved of its glycogen reserves from the initial caloric deficit, so then it needs to hold on to Water as it replenishes the reserves.... Right now, your body is confused, and so is your scale. http://www.dsfacts.com/weight-loss-stall-or-plateau.html This article gives a good explanation of what's happening these inital couple of weeks of weight loss and why we typically see a stall in these first 2-3 weeks. Once your body settles down into something more routine after the first month or so, the body comp readings start to make more sense. Your body fat readings will also vary during the day as your hydration changes during the day - you tend to be dehydrated first thing in the morning, which will read a somewhat higher body fat %, while the optimum time of day to read the body fat is usually late afternoon/early evening before dinner when you are typically as hydrated as you will be (you may see a 5% difference in your body fat % from early morning to late afternoon, and you may see a point or two difference from one day to the next depending upon day to day hydration differences; you may also see a change if medications change, particularly diuretics.) Of course, exercise routines and scheduling can impact your hydration and scale readings, so take that into accout as well (don't expect the best readings right after a workout!) The best way that I have found to use the scales is to follow a moving average of the body fat % and not get too wrapped up in day-to-day fluctuations. Your late afternoon readings may be measuring between say, 36 and 38 % at the extremes, so 36.7% one day and 37.1% the next (and 36.6 the next...) isn't particularly significant, but when you start seeing readings in the 35's and aren't seeing 37's anymore, that is a good sign of progress. The scales are a good tool for following longer term trends but are limited in value for snapshots - you may get whipsawed between despair and elation if you are looking for instant gratification from these scales! Used in this way, they seem to correlate fairly well with the "more accurate" body comp tools like hydrostatic testing or the bodpod. Good luck and have fun with this crazy journey!

As others have noted, this is a fairly common occurance, so I would read the OP's docs response as indicating that he may not be very comfortable with the sleeve procedure yet, so it would be worth getting a second opinion on this issue. This may not be very convenient at this late stage before your scheduled surgery, but the cost of the alternative - living with an RNY and all that goes with it for the rest of your life - is just too high to rush into it. Or, to keep the schedule, and if you really like your surgeon, perhaps he can have a more experienced sleeve doc assist so that he can better learn to handle this relatively common problem. Hopefully, if the sleeve doesn't work for you, then you would go ahead and have the DS completed rather than changing it to an RNY which would not likely work any better than the sleeve. Also, more than likely, once the sleeve is done, any future revisions would involve another round of insurance approvals unless the doc specifically had a two-stage DS approved.

Sliders are neither good nor bad - they just are. Most people focus on the bad sliders such as chips and twinkies (generally because the realization of their existence happens when we're early post-op) but there are many good foods that are also sliders - many essential veg, fruits, grains and nuts have a slider quality to them. I would never be able to get in anywhere near enough nutrition or calories to maintain a stable long term weight. The firm, dense meat type Proteins are still restricted to around 3 oz for me after 15-16 months, but I could never get in the 2000 calories per day that I need to be stable if I didn't use the slider quality of many foods - but those are good, high nutrition sliders rather than crap sliders. Learning to use sliders for good rather than evil is one of the things that most of us need to wrap our brains around when it comes time to stop the loss and maintain a healthy long term diet over the long term.

A couple of things that can shrink the list of candidates some - http://www.dsfacts.com/duodenal-switch-surgeons.html is a list of well regarded DS surgeons who are worth of consideration - as the DS uses the VSG as its basis, those who are well skilled in the DS will also have good experience with the sleeve, an important point with the growing popularity of the sleeve and the number of surgeons who are relatively new to the sleeve. If you find a surgeon who has been changing jobs or practices frequently - stay away. In the business climate of the past few years, a change of practice, practices splitting up or being absorbed by larger organizations is not uncommon so a job change or change of practice is not a big deal, but a doc who goes thru that every year or so is a big red flag. Also consider that raw complication rates, were they readily available and in comparable formats, may not tell you what you really want to know. Some of the best docs may have higher complication rates than their less skilled peers simply because they may take on more difficult cases. The old adage of the man who has never made a mistake has never done anything applies here.

It can get a bit mushy if you let it thaw too long (not bad if you are making guac or other kind of dip), and can turn brown like fresh avo if left out for very long. I usually pull out whatever slices I need while I'm preparing the rest of the salad or meal and by the time I'm ready to add the avo it has thawed enough to cut up and is just about right by the time it is served.