RickM

Our program was for 18 months of follow up as part of the surgical fee, and then annually thereafter on our (or insurance's) ticket. In normal situations, follow up with the PCP is fine as they can order labs, etc. However, we find it useful to keep in touch with the surgeon for his annual follow up as a means of keeping him "on retainer" in the event something odd happens. We all have things happen as we get older, and one of the common questions that would come up in our support group (mostly veterans of 10-20 years) is that they are having some health issue, and is that related to their WLS? Usually it is not and just part of the aging process, but if there is something questionable, our PCP can call up the surgeon and ask about it, MD to MD. It is less common for something odd in our health balance to happen with a sleeve as it would be with one of the malabsorbing procedures like the DS or RNY, but that's where some odd long term nutritional balance issue is most likely, and that's where the surgeon's experience can help out.

Our surgeon does a lot of work with traveling patients, and his normal protocol for them is to stay in town for ten days until their first follow up appointment. But, he isn't in the business of doing things on the cheap, but doing procedures that others don't offer.

I can't help from any specific experience, but on the East coast, I would suggest talking to Dr. Mitchell Roslin in NYC. He is one of the big promoter/developers of the SADI (modified DS) but is also long experienced with the traditional Hess DS along with the RNY and VSG. Having all of the major procedures in his toolbox, he can give you better advice as to which procedure best fits your specific needs; certainly better than your corner "WLS R Us" practice that just does the RNY and VSG. While he may not be a big fan of the RNY (common amongst DS capable surgeons who find that procedure better in most circumstances,) I have seen him actively refusing to do a DS to a lapband revision patient because the RNY was the more appropriate procedure in his case. Unfortunately, many surgeons will recommend whatever procedure they do as the best one, as it is the best for them even if it may not be the best for the patient. Finding someone skilled with all of the major procedures if very helpful when one has special needs.

The thing to watch out for when doing a minimally malabsorptive RNY is the prospect of bile reflux instead of the acid reflux that you had with the sleeve. When I was looking into this for a non WLS reason (it's has long been used for maladies such as gastroparesis and gastric cancer,) was that one of the most common problems reported on the patient sites such as Facebook was bile reflux. Talking to the surgeon about it, he said that as long as he keeps that roux limb at (IIRC) 80cm or more, it's not a problem; it seems that many surgeons going for minimal weight loss for such patients go overboard on shortening things. The extreme of this would be the "mini bypass" that attaches the pouch directly into the intestine without the roux limb, and that is well known for bile reflux (and why it was never adopted here in the US as a mainstream approved WLS. However, there are also definitions and standards of care wrapped into the CPT codes that the docs use for billing, that define these things depending upon usage. I know this came up in one of the support groups with my wife's surgeon, and he noted that when he did the RNY, which he rarely did preferring the DS, he liked to make it as malabsorptive as the codes permitted. So there are standards that the surgeons are obliged to follow if it is to be a WLS procedure, and it doesn't seem to be a problem with most RNYs that we see as WLS, but could have been for what I was contemplating (but never proceeded with.) There's always an up side as well as a down side with anything we do.

Yes, the cause is often, if not usually, a mystery. I ran into an Afib problem a couple of years ago about this time of year, though it didn't get picked up until a month or so later when I went in for a pre-op exam for cataract surgery, and we were discussing the moderate shortness of breath I was experiencing while swimming, considered different things it could be until she took a listen and "Oh, that's it... you're not doing surgery tomorrow. Let's do an EKG as see what's going on." She had me in to the cardiologist that afternoon (it usually takes weeks or months to get an appointment). He had me go to the ER that evening to get the medication dosing down right (we can do this the fast way in the ER or the slow way back and forth to my office over the next several weeks to get this down...) Once the basic heart rate was under control, it was a visit with the cardiac electrician (electrophysiologist) to look at resetting things more permanently. The good news is that while he was in there burning out the short circuits he noted that my arteries are nice and clear, and while things are not back to a normal sinus rhythm, it's not Afibbing consistently so I don't need to be on the expensive anticoagulants. Here's to them getting a better understanding of what's going on inside you so that you can get back to your planned life!

You probably don't need to be taking all of that yet, unless your labs indicate a deficiency, but they want to make sure that you have everything ready for post op. However, some programs may want you to start taking all of that ahead of time to get in the habit. Either way, have them with you for your next appointment and if they had wanted you to be already taking them, then you can start then.

Possibly a hiatal hernia has developed, as GERD is a common symptom of that irrespective prior WLS history. An EGD (endoscopy) would establish that as well as anything else that is going on in there; possibly an imaging procedure like a barium swallow to look at shaping of the sleeve and associated connections can help to establish how things are flowing and why backups are happening. Your primary may order those things or refer you to a gastroenterologist to track down that problem, then they can start considering solutions - fix the hernia, resleeve to correct shaping problems or revise to an RNY.

First, a bit of confusion - have you hit your goal weight from surgery, as in 190 or so, or just some pre-op weight target and surgery is still in front of you? If you're still pre-op, then that is a fairly typical starting regimen, and yes, you should take extra calcium and iron above whatever the multi has in it - you won't be getting much nutrition from food for a while so you need the extra. If you are months post op and at your ultimate goal weight, then by now your labs will be guiding you and your doc as to what is needed - with a sleeve, a lot on that list will probably not be needed long term and will go away.

Check with your surgeon but typically/frequently the follow up appointments for the first year or so are included as part of the surgical fee. If so, they you are covered for the first year or two.

They will in time, but these drugs are only now becoming approved for weight loss use; they formerly were strictly diabetic drugs used off label for weight loss, and a darling of the Hollywood set, and followers of them, so that didn't give them a great image on an official basis. They are basically a lifetime use drug, so the cost is a big issue with those covering them, but that will decline as more competition comes on the market and they go off patent, and as they gain respectability in the "legitimate" medical world and not just the fly by night weight loss "spas".

Here is another take on this that just came through my email, aimed more at MDs but still very much at our level https://www.medscape.com/viewarticle/996189?ecd=mkm_ret_231030_mscpmrk_endo_top_content_etid5999473&uac=37787FY&impID=5999473#vp_1

Amongst all the paperwork that you sign with the surgeon is probably a form where you approve him to make a decision on the fly as to which procedure is best once he gets inside you - sometimes they find some obstacle to doing a bypass and will do a sleeve instead (or vice versa, though that is more rare.) Of course, one can not sign that authorization if one really wants a bypass and absolutely not a sleeve (or vice versa,) but then you wind up being sedated and going into surgery and having nothing done. So, a change in procedure once bariatrics are approved is not a big deal.

You likely will be OK, however, plastics have a higher chance of mild to moderate complications (incisions that don't fully heal promptly or reopen, saromas (fluid pockets) can form that need sometimes serial draining, etc. Best would be to talk to the surgeon about your concerns and get his take on the chances of any problems you might experience.

I have not (being over here on the "left coast" but he would be high on my list of docs to talk to if I were on the East Coast - his reputation extends this far. His name comes up positively on occasion in our support group of largely DS folks, as he has frequently given talks at the ASMBS conferences on related topics, and I've seen other positive responses online over the years. I like the way he thinks, from what I have seen that he has written. He is also one of the few capable of tackling the complex RNY to DS revision when that is necessary, so he knows his way around a sleeve.

Basically, no. We do hear this from time to time but I have no idea where it came from (as far as legitimate scientific sources.} I can buy into the idea that protein absorption would decrease some with increasing amounts in a meal, that wouldn't be unusual biologically (as in the first 30g is fully absorbed, the next 30 only 90%, etc.) But looking at it from an evolutionary perspective, our ancestors would gorge themselves on an antelope when they killed one, and then have relatively little protein for several days until they had another successful hunt. They got along just fine. That said, I generally do break it up during the day, but that's more of a balance thing, in order to also get in the appropriate amount of fruits, veg, grains, legumes, etc., though it can take a while before one gets to the point of doing that other than in token amounts (though good for helping to establish good long term habits!)