RickM

It is certainly something to discuss with your surgeon (and maybe the psych, too,) and get their views on the pros and cons of it. Sleeves are not made the same size- there is some controversy amongst the surgeons as to how big to make the sleeves - too big and weight loss may be insufficient and regain may be more problematic, while too small and reflux can be a bigger issue. They're waiting for more 5 year data to provide more guidance. As is often the case in this world, this may not be a simple case of more (restriction) is better. You may not actually need the smallest sleeve, which may be more appropriate for someone in the 50-60 or more BMI range; a somewhat larger sleeve will probably allow you to lose all that you need to lose if you eat reasonably well with it, and a smaller sleeve may not help you if you don't. Also, the sleeve may not be the right procedure for you. The duodenal switch, for instance, often provides better loss (which you don't really need at your moderate condition) and also better resistance to regain. It tends to allow one to eat more normally and somewhat larger quantities (it uses a larger version of the sleeve as its basis) while still keeping the weight off. As always, there are tradeoffs to consider carefully. Of course your surgeon may not make such a suggestion if he doesn't do them. I chose the sleeve because I have not had major regain or yo-yo issues and had already made substantial lifestyle changes which helped keep my weight fairly stable, but volume was still an issue keeping me from losing more than I was able to "the old fashioned way". YMMV The major "cure" that comes from any of these surgeries comes from the lifestyle changes that you make, which the surgery helps you make. At your moderate size, most any size sleeve will likely provide enough restriction for you to be successful - even the smallest sleeves can be defeated if you drink your calories. The RNY typically leaves a smaller stomach and more nominal restriction, but regain is still a problem with many RNYers. It can be a tough decision deciding which procedure is right for you, as none of them are a silver bullet that will cure all. They all take commitment and a willingness to make changes, though these are somewhat different for each procedure.

You are likely to be losing some of your lean body mass simply because some of your musculature will no longer be needed to support your weight. Ideally, we can redistribute that muscle mass, but I suspect that would be a tall order. Someone in one of these forums mentioned that their nut said that the rule of thumb that they use is that we will lose 1 lb of muscle mass per 9 lb of fat. I don't know the validity of that figure, but it seems like a reasonable starting point, and is consistent with my experience. My goal has been to get down to the 15% body fat level - starting at about 42% at 292lb. My first estimate was that I should get to 200 even to meet that goal, making the gross assumption that only fat mass was lost and I would readjust the weight goal as I got closer. Re-evaluating things as I got into the 2/3 loss region indicated that 190 would be a better weight goal - so I have lost about 10 lb of lean body mass despite swimming or strength training for about an hour a day five days a week - not an unexpected readjustment. For myself, as I have been working out these past few years as part of my attempt at getting down to semi-normal weight the "old fashioned way" I never really wanted to get muscular enough to be lean and still in the mid 200's - I figure that ultimately that "excess" muscle mass will turn to fat as I age further and/or get injured - it takes a lot of work to maintain that level of musculature. At 5'10", my goal of 190 would still be "overweight" on a BMI basis, albeit a healthy overweight, but it would probably still ultimately be "fat in escrow", but I can live with that amount. The body comp is not something I agonize over, but is more of a reference point - if I get into that 15% region, I will be happy with the result. The body comp readings aren't all that accurate for us "losers" no matter how it is done (impedance, calipers, dunking, etc.) since they're based upon population averages and their norms don't quite know how to deal with the excess skin that we typically have after substantial rapid weight loss - it seems to treat it more as fat than lean mass - but it's as good of a indication of our overall condition as we have.

5'10, was 292 at surgery, (highest was 335 several years ago,) down 32 after one month, down 72 now at four months and about 30 more to go to meet my body comp goals (15% fat mass).

Medicare approval of a procedure is a major milestone toward general acceptance - when Medicare started covering the DS a few years ago, that created a cascade of policy revisions on the part of the insurance companies, as they could no longer claim that a procedure covered by Medicare was "investigational" or "experimental". Currently with the VSG, more insurance companies seem to be covering it so that should be a tweak toward Medicare covering it - eventually. How long that could be is anybody's guess, given the pace of government action on such things.

The other aspect, beyond the basic sleeve healing and caloric intake issues, is liver health. Being obese, our livers usually aren't in the best of shape to begin with, and the rapid weight loss further taxes it by it's role in metabolizing all the fat that we're losing, so it doesn't need any more work by having to metabolize the alcohol. My doc is a liver specialist outside of his bariatrics practice, so you better believe that we are on the no alcohol program for the 12-18 months of rapid weight loss - he doesn't like seeing his WLS patients coming back as transplant patients!

I'm in SoCal (in the Valley,) but went with Dr. Rabkin in San Francisco. While not based down here, he does have a presence in Ventura where there are support group meetings (tomorrow evening, for that matter) and an office where they do some pre-op and follow-up appointments, so most of the work beyond the actual surgery itself can be done locally. His CV over on ObesityHelp lists that he has done about 90 VSGs and 1500 DSs (which include a VSG as part of the procedure,) so he's one of the more experienced VSG guys out there.

The RNY was never on the table for me (or vice versa, I guess!) since it really doesn't offer any upside to the VSG to go with all of its limitations. The DS was the only alternative considered as it does at least offer some performance upsides in exchange for its trade offs. I will only know if that would have been a better choice for me in a few years time if I experience any marked regain - an area where the DS offers a clear statistical advantage over the other WLS procedures.

My doc doesn't focus on a specific number (just on protein and water,) but wants us to avoid the simple carbs and otherwise empty calories.

My doc doesn't charge a program or admin fee, but he also doesn't supply any hardware - scales, protein powders, etc. His initial consult was $300, covered by insurance. The cost of his support group program is buried in his surgeon's fee and as a result, he doesn't generally participate in insurance networks (though he does do DS's for Kaiser, so he probably does have some kind of deal with them) so we pay somewhat more than a network doc. There are some docs that charge a "program" fee of some $5k or more, covering the support groups and follow-up appointments - not the most financially patient friendly practice as the follow-up is generally covered by insurance if it were billed separately. I guess it does inspire patient compliance though - incentive to get your money's worth.

I am a week behind you, on May 9. I noticed when walking this morning (which I don't do routinely at home - too boring and hot at home in socal, but much more pleasant when I visit the central cal coast with beach and forests available) that I could barely get my pulse above 100 when walking as fast as one can walk without breaking into a jog/run (which my knees do not like.) Only a couple of months ago I could easily get my pulse up into the 120-130 range (my nominal 80% level) with a similar pace of walking. So, you may be seeing a lower level of exertion in your swimming and Zumba without realizing it. I swim routinely also, but haven't really been checking my heartrate lately while doing it - will try to remember to do that when I swim this afternoon. Changing exercise routine is another common suggestion for breaking stalls; you may have already gotten too comfortable with your current regimen.

I weigh everything, so I can get some consistency in what I prepare and find it easier to log the ingredients. For my salads, I typically have a couple ounces of leftover meat, usually marinated in 10-15g of BBQ sauce, 15g of chopped spinach (I could never figure out what a half cup of spinach or lettuce was...), 25g of grape tomatoes, 10-15g each of pepper, green onion, avo, shredded carrot, chopped snow peas, shredded cheese and dressing. That's a comfortable amount for me, though about 3oz of meat will stuff me.

It doesn't seem to be particularly harmful - your body will tell you if it objects. My doc has us on mushies from the hospital, moving into more real foods as tolerated, but avoiding the simple carbs and empty calories (and his practice has been doing sleeves for around 20 years, so I figure they know about the care and feeding of this type of altered stomach - I still can't quite understand the extensive liquids that some docs impose upon their patients - maybe it's a holdover from RNY practice?) I tried some restaurant chicken parmesan and soft tacos from Chipotle (less the tortilla) at around the two week mark and they did fine. I was told to start adding veg at my 10 day follow up since I was getting in more than the requisite Protein at the time. I was making small southwest style salads with a couple ounces of leftover meat in them in the 3-4 week range and was adding some raspberry and almonds to my greek yogurt Snacks at around the same time. I haven't tossed anything back up yet, though a couple things didn't quite feel right at the time. Your doc seems to have a fairly sane program. I can't quite fathom the ultra low carb mania that some docs are on - it's a useful thing temporarily for some conditions, but long term seems to be substituting whatever bad nutritional habits we may have had pre-op with another one post -op. Still, it works for some, (and some have a lot more weight to lose than we do, so need to lose at a faster rate to lose enough during the prime losing phase) though long term they're likely to have problems from nutritional deficiencies if they continue to be obsessive about it.. I'm not having as much fruit and veg as I was having pre-op, but am usually getting in a couple of servings of them a day. That will increase in time as I get into maintenance mode. I try to keep a lid of 1200 calories on my daily intake, and am usually in the 1000-1100 range (though I will probably break thru that today - we're going to Outback for dinner tonight and I'm sitting at about 750 this afternoon. I was 2/3 to goal weight at around the 3 month mark, so that seems to be working for me.

I never really discussed it with my surgeon, but I've had my own goals in mind and have known him for so long that it was probably a moot point. Most surgeons like to see a BMI of about 24 as a goal because that is where they set their point of normalcy for their "excess weight loss" calculations that they report on; that's good for them when reporting on a population, but of less value to individuals with all of our variations. I set my goal at getting down to a 15% fat mass, which is on the lean side of normal (or the "fitness" category on the Healthcheck site) for men, which would equate to about 22% for women. Initially that equated to about 200 lbs assuming that only fat was lost through all of this (a gross assumption, but a good starting point and one that could be adjusted as I get closer to goal.) As I got down around 2/3 to goal it looked like 190ish was more appropriate to meet my body composition goal - still quite doable as I'm only 3 1/2 months out. I may have to adjust it again as I get closer, but probably not my much, though I may try to drop somewhat below that goal if I can since there is often some snapback once one stops losing. That would still leave me "overweight" on a BMI basis (around 27-28) or on the"ideal" weight charts but to get down to those levels would mean either being unhealthily lean or losing excessive amounts of lean muscle - neither of which are acceptable to me irrespective what the insurance companies may "think"

Drinking seems to be one of those variables where there can be wide differences between people. I have had no problem drinking, and like you, was a bit concerned that I could put down a 6oz or so bowl of soup and half cup of juice in the hospital if fairly short order, while my wife, when she had her DS, couldn't drink more than her nominal stomach size (which was a real PITA for her since it meant that her protein shakes had to be so concentrated in order to get the requisite protein in that they were ghastly - big difference between a scoop of protein powder in a cup of milk or water and a scoop in a quarter cup!). So you, like me, should be able to be more flexible in what you drink but longer term means that you will probably have to be more careful in what you drink so that you don't drink excess calories.

It partly depends upon how your doctor's program is structured - some are very slow to move patients off of liquids and into real foods while others (like my doc's) start with soft foods in the hospital and progress into more solid foods as tolerated. I was lucky (I guess!) that I had little problem tolerating new foods as introduced, so in that second month I was eating fairly normally, though in small amounts, particularly the solid Proteins like meats. But I was having restaurant meals when they happened and ate chicken parmesan, chicken marsala, soft tacos from Chipotle (less the tortilla), steaks, mexican restaurant carnitas; all are good for 2-4 meals with a doggy bag. Chinese (not my forte, though) would be good, particularly if it's the type where you share a lot of dishes, so you can have some soup and sample small amounts of other things, too. For birthday celebrations, it is well to stay away from most cakes and other sugary things - I tried a small piece of cake that my wife made for a club meeting and it didn't settle well with me, as seems to be the case for most sugary things. We all tend to have our differences with what works and what doesn't for us. However, I have found that some of the cake recipes on theworldaccordingtoeggface lady's site make a good treat that's WLS friendly - you might have one of them made for celebretory purposes: http://theworldaccor...takes-cake.html

The other factor on the RNY/NSAID issue is the suture line between the pouch and the intestine - since the part of the intestine that is joined to the pouch is not used to being exposed to stomach acid like the duodenum (which gets bypassed along with the stomach) that joint is very susceptible to being irritated. It also tends to never fully heal as a result and continually weeps a bit of blood, compounding the Iron absorption issues of the RNY

A good part of the high book rates for these medical bills are courtesy of you favorite federal government. Nobody pays those rates (though they do try to charge them to uninsured emergency patients...) but Uncle does have some reimbursements worked into their system that will pay a small fraction of the "written off" discount back to the hospitals - the higher the "discount" (book rate) the higher the gov kickback they get. Aetna is real slow about paying the surgeons for some reason - I'm over three months out and they still haven't paid the surgeon's fee, though they have paid everyone else.

Aetna approved my sleeve fairly quickly - they seem to treat the sleeve the same as the other WLS and dont seem to put any special conditions on it like some companies do. I'm in SoCal too but went to San Francisco for my sleeve for a variety of reasons, primarily that we already had a working relationship with Dr Rabkin up there thru my wife's DS. He is certainly one to recommend, though you may not want to travel to have the job done. Good luck with your future sleeve,

I did, at the start of the second week. Seemed to be a result over my body's confusion over whether it should be constipated from the holdover effect of the pain meds or having diarrhea from the soft diet (every fart that got past came with a surprise, just enough to have to clean up and further irritate things. Wasn't a gallbladder effect as I still have mine.

Stringbender, You are more of a pioneer than even us VSGers - good luck with it. All of these procedures start that way with little history and a good concept, with some enduring and becoming mainstream and others never being adopted widely and ultimately being dropped. My wife had a duodenal switch a few years ago, when it was reasonably accepted within the WLS community but still generally considered to be "investigational" by the insurance industry so we self paid for that one. Mexico didn't have the WLS factories that they have now, so the primary budget option at the time was Spain, but the delta cost wasn't worth the hassle over going to San Francisco. I was not overly concerned with leaks as my docs have been doing these VSGs for around 20 years as part of the DS and they are very anal (so to speak) about leakage and testing for them; I would be more concerned about leaks with some of the practices that do the VSGs outpatient where any leaks happen at home rather than in the hospital. Further, there is a small percentage of us out there whose bodies are particularly ornery and will react negatively to any procedure - that's just life. After being around the WLS community for a number of years now, I take a somewhat jaded view of "reversible" claims considering, as your surgeon notes, the body's propensity to adapt - things can often be reversed if there is some sort of adverse reaction early on, but less successfully as time proceeds. The bands are widely promoted as being "reversible", but more accurately they are "removable" while the damage that they can cause, sometimes in a matter of months, is far from reversible.

Unfortunately this turns out to be a false impression for most people - that the RNY allows them to eat as they did before, and is not much different than those who get the idea that the bands will be better because the procedure is simpler and quicker with no GI tract cutting, until they find out the problems that can be caused by that band longer term.. The net longer term result is that the RNY will malabsorb minerals but an insignificant amount of calories. This is why we see so many bypass patients totally failing and regaining all of their lost weight. The DS will usually maintain significant caloric malabsorption for the long term (10+ years) and is not as bad at mineral malabsorption as the RNY (due to the only partial bypass of the duodenum, where the bulk of the mineral absorption occurs), though the DS does malabsorb the fat soluble Vitamins (A,E,D & K) so those usually need to be supplemented with a Water soluble form. Overall, the RNY is no better at tolarating us drinking our calories thru sodas and milkshakes as the VSG. RNY dietary requirements for weight maintenance are pretty much the same as for the VSG, though the RNY has more restrictions on medications and greater need to supplement those minerals.

That is pretty much my fallback position if I need it - a revision to a DS, even if it means an open procedure for the second go-around. One word of caution on this plan, however, is that in my surgeon's experience, such revisions work best before any substantial weight regain has been realized - you typically don't get the same level of loss if one waits to return to their old weight than if they do it promptly after they start to regain and realize that they don't have control over it. Not the easiest decision to make at that point, and generally not covered by insurance until the first WLS is a total failure and one gets back to the35/40 BMI level again. For me, with my history, that was worth the risk of doing just the VSG.

I can't comment on the plication surgery, but I would expect that your goal is reachable with it - most of the common procedures offer enough restriction that 100 lb loss is quite reasonable during the 12-18 month prime loss period (the bands seem to be the least reliable in this area.) I am also looking to lose around 100 lb with the sleeve and am down about 65 lb after 3 months. The big differences between the different procedures for those of us in this "moderate" weight range is the durability of the loss along with the rate and severity of potential complications. The sleeve, with its relative simplicity seems to have a relatively low complication rate and its weight loss durabiliity seems to be similar to the other restrictive procedures like the RNY, while the bands seem to suffer from both poor loss durability and high longer term complication rates. I can't comment on the plication as it is even newer than the sleeve with less of a long term track record, but I would expect its basic near term loss to be similar but with a somewhat higher complication rate due to its band and folded type stomach restriction. As with the sleeve and RNY, I would expect that long term durability of the loss will be highly dependent upon your ability to stick to the lifestyle changes required to maintain a stable weight once the pounds come off. On the protein drinks, I find the EAS brand powders to be pretty good (or at least the least objectionable) with their chocolate having a fairly delicate flavor that can be enhanced with a little cocoa powder if desired. I use the Unjury unflavored powder as a mix in to other foods to enhance their protein component. Taste is such an individual thing that it's hard to give a solid recommendation other than just to experiment with the different brands. Good luck in your ventures,

Many docs feel the same way, in part because they are most familiar with the bypass, and in part because it is the most sophisticated procedure that they offer (unless they do the DS, in which case that is what they would usually recommend for their high BMI patients). Some docs feel that the threat of dumping from the bypass will help as a behavior modifier for their patients (yeah - fat people need to be punished for being fat...) There is not a lot of long term data yet on the VSG regarding weight regain, but what is there suggests that it is no worse than the bypass, which isn't all that impressive to start with, and some docs feel that there is reason to believe that it will be somewhat better due to its functional pyloris. There are quite a few on these boards (and on obesity help, too,) who started in the 60+ range and have good success so far. Probably the best procedure for the high BMI people is the DS which offers statistically better loss and better long term maintenance, however, it is a more technically challenging procedure so many of the docs don't do it, though to the patient the downsides are generally less than that of the bypass. Many prospective patients don't like the idea of the added intestinal rerouting that goes along with the DS and bypass and that is a fair perspective, though with many that is the price of long term success - only you can decide for yourself what is best for you. Bias disclaimer - my wife was a 60+ BMI when she had a DS a little over six years ago and is still maintaining a weight of around 135, while I opted for a VSG since I was a 40+ BMI and had already lost and maintained a reasonable amount of weight on my own through the requisite diet/exercise/lifestyle changes, but couldn't get the rest of the way due to volume issues. I never considered the bypass as, overall, it has all of the downsides of the DS (often more severe,) without the DS's better weight loss and maintenance performance, or looking at it from another angle, the bypass offers similar loss/maintenance performance to the VSG at a much greater cost in side effects and lifestyle restrictions.