RickM

That is totally insane - I am really sorry that you have to put up with that. Note to lurkers and researchers - you don't have to put up with this type of treatment. Ask questions early in the process, like during the informational seminars, and decide then whether you want to go through with having surgery with that practice (they tend to spring these things on their patients late in the game, when it is too late to change surgeons.) Even the two week liquid thing is not standard, with most who do a pre-op diet doing some kind of hybrid low calorie or carb meals along with a couple of shakes a day; many don't do anything at all until the day before surgery. Most surgeons know how to do their job without putting this all on the patient. Good luck in getting through this!

Be skeptical of the BMR/TDEE, etc. calculators that you find online, particularly if they use scale or current weight in their calculation. Those work OK, for normal weight range people, but not for us fatties and former fatties since the critical weight factor for BMR is lean body or muscle mass; that extra fat that we carry or carried around does little to our actual BMR other than skew the results. For a better reading, use your goal or ideal weight for those calculators that don't use lean mass. The other problem that they have is that they tell you what your BMR should be rather than what it is. Our journey through obesity can compromise out metabolism such that we don't burn calories as well as we should - that's part of what keeps us fat - and that can carry over even after weight loss. A normal weight person who used to be morbidly obese will usually burn fewer calories on a treadmill doing the same work as a never-fat person of the same size, weight, sex, age, body composition, etc. So, take the calculators as a (very) rough guideline. From general observation of these forums over the years says that 12-1500 calories is high, even with guy metabolism. While 6-800 calories is often sited as being a good level to shoot for, that is probably overkill for you, and would be hard to attain once used to what you are currently doing. To the extent that we can compare individual experiences, as a comparison to my experience, I started out about 100lb lower than you (292) and at 4 months was down 72lb on an average of 1100 calories. I would expect to be losing a little slower simply by my lower starting weight and bit lower height (5'10). Prior to surgery, my total metabolism (BMR + activity) was 26-2800 calories based upon actual intake logging (weight was long term stable at that point - that's about as real world metabolism measurement as we can get.), So, call it around a 1500 calorie deficit. Total metabolism tends to decline as we lose (there's less weight that we are carrying around 24/7) so by the time I goaled out at 190, I was stable at around 21-2200 calories. My inclination for you would be to try to keep it around 1200 calories or below Another couple of factors to consider - 1 -stalls happen 2 - starting or radically changing up your exercise routine can cause a stall. Most stalls are water weight related (at least those not associated with eating too much!) and starting or changing up your routine can increase demands on hydration. As you do more lifting or strength training, those sore muscles you may be experiencing are associated with.....inflammation, which is more water weight. So, you are likely continuing to burn your stored fat, but aren't seeing that result on the scale because of the water weight changes, which will subside as the inflammation subsides, and you get better hydrated so your body doesn't have to hold on to every bit of water that it sees. Good luck, and have fun - you still have a ways to go, but are getting there!

I only had a day before diet along with a bowel prep (like for a colonoscopy) which is a bit of overkill for a VSG, but quite appropriate for a DS like my wife had with the same practice. Much rather have that than the multi-week liquid things that some practices impose.

The RNY and DS can have issues with extended release meds, depending upon the mechanism used, though crushing is rarely suggested to counter that problem (it can lead to too much of that med hitting too quickly) - rather doing as you are doing and going to smaller doses of the normal med taken more frequently. ER meds are not usually a problem with the sleeve, as the OP has. It's more likely that particular practice is a bit behind the times.

I never crushed them, either. Classically, that has been something of a bypass thing as they feared that pills could get stuck in the stoma, but as you can see from catwoman, that is far from a universal thing. Some practices really go overboard on their instructions on how long things need to be done or avoided, maybe to inspire their patients to go along with it rather than see it as just a short time thing that they can skip. Sometimes it may be a matter of ignorance, in that they say that something needs to be done for a year, and that works well, but they really don't really know from experience how long it needs to be done as they never experimented with it. For instance, I have seen a couple come through these forums that were surprised when their doc advanced them to the next eating stage earlier than their published guideline; when asked about it, the doc simply said that they had found patients cheating on the progression and not suffering from it, so they advanced it (they'll change it next time they print up more guidebooks.) You will find a lot of things like that in the bariatric world - some crush pills or use chewables while others never do; some are on a liquid diet at the same point that others are having steak, some have liquid pre op diets and some have none.... There is a lot more experience and habit than science in this game.

No, haven't had any ulcers from it (and neither has my wife who is pushing 16 years out on her DS - sleeve plus intestinal rerouting - and she is an occasional NSAID user.) I believe that ulcers can heal themselves given time and gentle diet, but they are usually helped along with medication, usually a PPI such as omeprazole and a coating med such as Carafate or Sucralfate, which are sorta industrial strength Pepto Bismol that coats the inside of the stomach between meals to protect it.

A couple of comments to fill things in here. It's not really a matter of steroids vs. non-steroids, but rather what a drug or class of drugs does to the stomach as a side effect, NSAIDs are merely the most common that are sited as being problematic for bypass patients. The issue is that the part of the intestine where where the stomach pouch is connected is not resistant to the stomach acid, so that anastomosis there is quite vulnerable to ulcers, so any med that can cause some stomach distress is generally to be avoided. Some of the osteoporosis drugs are avoided for this reason, too. This presumably applies to the MGB as well, as it uses a similar connection. The duodenum, the part of intestine immediately downstream of the stomach and is resistant to the acid, is bypassed along with the remnant stomach. These various meds can sometimes be used in limited times under certain circumstances under medical supervision, but it's a risk/reward trade off between doctor and patient. The sleeve based procedures are generally more tolerant as they don't have that marginal ulcer issue, but many docs still restrict them owing to their bypass experience, (and the sleeve is probably less tolerant than a normal person, while being more tolerant than a bypasser.) Your bypass can be reversed, (that is sometimes one of its "selling points" but it's not commonly done as it's a pretty complex job; not all surgeons will do it. It is usually reserved for times when there is no other option in treating some problem, rather than just buyers remorse. I have seen it done a couple of times in cases of intransigent ulcers, where no other treatment worked. It can also be revised to a duodenal switch, but that's even more complex than a reversal (they have to reverse it first, then sleeve it, and redo the intestinal rerouting. It is usually done when weight loss was inadequate or with excessive regain, or for other RNY complications such as the intransigent ulcers or bile reflux. You weren't offered the MGB as it doesn't fit the "standard of care" for WLS in the US - insurance doesn't normally cover it and the ASMBS hasn't approved it, though it has been further developed and used more commonly elsewhere. The next procedure that's likely to gain approval here is the SIPS/SADI/Loop DS

It varies - some walk out of the hospital free of insulin and meds, even with the VSG, while others it may take a few weeks or months. and occasionally not completely. Remission rates for the VSG and RNY are typically in the 80-85% range. Often the longer one has been in treatment for it correlates with a longer time after surgery for remission, but not always. For my wife, who had been on diabetes meds for around twenty years and just short of needing insulin, it took the batter part of a year to be free of all the meds, and that is with the more powerful DS that she had (which has remission rates in the 98-99% range.) So, it's a big YMMV thing. Best to continue monitoring things and stay a little ahead of the curve; much the same with blood pressure meds - it's often better to be a bit high for a while than be too low.

First - you should avoid setting weight/time goals because you have little influence over them; lose 15 lb, that's great, but it might take a week, a month or two. Don't knock yourself out about it. OAGB has the right idea that you can only generate a certain level of caloric deficit to drive your loss, That said, there are variations, primarily based upon manipulating your body's water weight. When we first start a major loss effort, we often experience the "easy 10" which represents the typical amount of water weight that we lose early on by burning up our glycogen stores (some who start bigger with more muscle mass and fat may lose a bit more from this - maybe 15 or so). Take this freebie and run with it, but don't agonize over how much this "bonus" might be - it is what it is. Concentrate more on setting yourself up for long term success by learning how to eat a healthy, sustainable diet consistent with long term weight control vs. quickie loss. When I was doing the 6 month insurance program, I ignored weight loss and concentrated on establishing the healthy eating habits that would need five or ten years in the future. That turned out to be worth about fifty lb, or about a third of my excess weight without agonizing over the scale. Learn to eat healthy and let the surgery do its job for you. Good luck,

One common suggestion is to fill a 1 oz shot glass or medicine cup and sip one every five minutes; if you can do more than that, that's great. Yes, it does get better, quicker for some than for others. But you have to do it as dehydration will get you put back into the hospital quicker than just about anything else in this phase.

I wouldn't necessarily worry, but it is something that might happen; it is not associated with any particular procedure, but rather with the rapid weight loss that we get from it. It seems to happen to a small minority of patients - my guess based upon what I see on these various forums is maybe 10% - your surgeon can give a better guess as he is dealing with this every day. Some surgeons prescribe medication to help with this, though from what I have seen, most do not. My surgeon routinely removes the gallbladder when he does the DS as he doesn't want some other surgeon getting lost in that altered anatomy in that region - this isn't a problem with the VSG or RNY and he only removes the gallbladder in those procedures if he feels any stones in there while he is working. If you are concerned about it, ask your surgeon about whether it would be appropriate to medicate for it, and talk to your RD about things that you can do on the diet front to minimize the risk. I still have mine and never had any problem with it and didn't do anything special to avoid it. YMMV

I'm kinda with Greater Fool on this, in that almost anything will work at this point, and even for the next few months. 20-30 years ago, it was not uncommon for bariatric programs to tell their patients to "just eat like you always have, just less..." and they lost weight just fine eating the same way that got them fat in the first place. At least they did for the first few months to year and then they started gaining again because they never learned how to eat sustainably. It is not unusual to see people come into these forums after having failed at (insert favorite fad diet here - Keto, Paleo, IF, Atkins, Zone...) and they continue eating that way and gee, all of a sudden that's the only diet that will work with your WLS. I did much the same thing, too, adopting a basically balanced nutrition oriented diet that I could do forever - worked on evolving that for several years before surgery, then tailored that for the lower post op intake and continued with that as the intake naturally increased over time; still doing that ten years later. IF works like most of those diets - by forcing a reduction in caloric intake. Some cut out fats, some carbohydrates, IF cuts out time, but they all are a mechanism for reducing caloric intake, which you really don't need at this point as you can't eat much to begin with. As noted, stalls will come and go, and there are as many personal experiences and hypotheses as to how to "break a stall" as there are people. I really have no input on how to break a stall as I never really had much of one, even at the dreaded three week point. Chalk it up to better diet, stronger underlying metabolism, not worrying about them - who knows. As to your experience, consider that you have a data set of one - and it's real hard to establish a trend with a single data point. Just go with the flow! Good luck

I'm not a doctor or pharmacist, but generally, the sleeve doesn't promote any particular issues with medications. The malabsorbing procedures like the RNY or DS can have issues with extended release meds depending upon the XL mechanism used, and the RNY can have issues with some meds known to promote stomach upset. Check with your bariatric surgeon or a pharmacist to make sure. el

I don't think it's such a bad thing; the problem is more a matter of expectations - if you are expecting to log a loss every day with no gaps or minor gains (water weight is everywhere!) then you should stay off of it. However, if you can just look at it and say, "gee, I wonder why that is?" then it's fine. I weighed twice a day because I was using a body composition scale to monitor that progress in addition to scale weight, and those work best if you weigh twice - first thing in the morning when your scale weight is most "accurate" (assuming after first eliminations, if you're that regular and before any consumption) and then in late afternoon when you are usually fully hydrated and the body comp measures are most "accurate" (or at least repeatable). Those in particular worked best with daily readings applied through a moving average. The body comp was of greater interest to me than the scale weight. That said, I only "officially" recorded weight once a week to smooth out the day to day fluctuations.

You are probably doing fine, unless you have known kidney issues, in which case your nephrologist would give you overriding instructions.. Typically, bariatric programs have recommendations on the order of 60-80 g for women and 80-100 g for men, sometimes somewhat higher or lower depending.... The 40-55 type numbers I think originate from WHO and represent something of an RDA type of level - sufficient to prevent deficiency disease but not necessarily what is needed for optimum health under varied circumstances. It's great if you are having to figure out how much of what type of food to send to some remote area after a disaster; not so great on figuring what you need for your lifestyle. The other end of the spectrum would be the recommendations for 150,200,300 g that you may see in the men's health or body builder magazines that are intended to sell protein supplements. Generally what you need is proportional to your muscle or lean body mass (similar, but not quite the same), so ignore any calculators that deal strictly with overall body weight - the excess fat that you are carrying now doesn't need protein to maintain it. The best indicator that I have found is from a Dr. Michael Colgan who is a sports nutritionist that does (or did, may be retired by now) a lot of work trying to figure out just what the body needs for different circumstances, as opposed to basic RDAs. The basic formula he came up with takes the premise that the body is replacing all of the muscle mass every six months, and that works back to the amount of protein that is needed daily. So, for my 150 or so lb of muscle mass, it needs about 105 g daily. A short woman with half that muscle mass would need half that, or about 50g. So his figures are in the same ballpark as most of the rest that were derived from other means, so it passes my "smell test" - it's plausible. Being a guy of similar size, I would expect you to be similar. Further, this method tells me that if I wanted to add muscle mass, then I would have to add around 40g per day to add around 10 lb over six months - a reasonable goal with suitable work and training and without funny drugs (but it does take the work - it doesn't just get there by eating more!) Overall, it seems like you are on the right track for your size and previously stated fitness inclinations.

I don't do much fast food these days, or even before, but what I preferred when I needed to during my early days - loss phase and early maintenance - was a Chipotle order of soft tacos, whatever fillings you like but I biased it toward the basic meat, cheese and veg. Early on just ate the filling out of the tortilla, but later included that, too (I never was big on the low carb game - just give me nutrition.) One taco was enough, and I would save the other two for future meals. Generally when we ate out we went to regular restaurants, more often independents rather than chains, and just ordered the healthiest things that looked good on their menu - nothing really special as ?bariatric food" - and split things up to take home the leftovers. Even today, ten years out (call it 16 for my wife) it is disappointing not to get two or three meals out of a typical restaurant meal.

Some struggle for a while with a lot of inflammation and resultant high restriction, getting in only in the low hundreds per day for a while, and others have a more nominal recovery and can consume somewhat more (not that one shoule necessarily be eating as much as one can!) I was around 900 within a week or two and settled at 1100 for the rest of the loss phase - but that's with a decent guy's metabolism and it still provided a large caloric deficit to drive the loss to its conclusion. Others, particularly women but some heavier guys too, need to stay a little lower - 6-800 it often sited - to ensure adequate caloric deficit through to goal (loss rate tends to decline over time as our total metabolism declines some with declining weight, so it's good to leave some margin.) My general philosophy on it is that if you have a decent idea of what your metabolism was prior to surgery (ideally from tracking your intake over time, rather than those weight based calculators which tell you what it should be rather than what it actually is,) that can be a good guide as to how far you can permit yourself to go calorically over time My weight was stable in the 26-2800 calorie range prior to surgery, and dropped with my weight to where I am now, stable around 2000-2200, so I still had a healthy margin to play with keeping at 1100 to lose. Some whose metabolism started around 16-1800 has a lot less margin to work with and needs to stay somewhat lower, and would seriously struggle at 12-1400 as some programs advise. It's not a one-size-fits-all world.

Usually, such things are not a problem and are simply repaired as part of your WLS; sometimes people don't even know that they had a hernia until the surgeon told them about fixing it while he was doing the surgery. Give your surgeon a heads up on it so that he can allocate a bit more time for your surgery if it makes a difference to his scheduling (some surgeons really pack their schedules, assembly line style, while others don't.

The best that we can do at our knowledge level is to consult with as many doctors as you can to get different, or hopefully, concurring opinions and then decide. In my situation, which was a very early stage cancer thing, I consulted at least four different doctors with relevant experience, and got four different approaches to the problem and then weighed all of the options. Ultimately in my case the most sensible was the simplest that also left the most options for future treatment if it ever became necessary (which was basically to do nothing except continue monitoring things.) In your case, it looks like there are more questions that need to be answered, so likely more tests will be needed to see what's going on inside you.

The fundoplication is used in the case of a hiatal hernia (where part of the stomach is pulled up through the opening in the abdominal wall, through which the esophagus passes) which can be the cause of acid reflux, and you are right in that in may or may not be appropriate depending upon whether there is enough fundus left to plicate. If your problem is more with the LES than with a hernia, there are other things that are sometimes done for that - there are implantable devices that replicate the function of the LES (LINX is one of them, there are probably others as well) and likely some purely surgical approaches to it (I am far from any expert on this!). Bile reflux is rarely a problem these days with the RNY, mostly because the surgeons have learned how to set up the limb lengths to avoid it in the most part; it is not uncommon in non-WLS versions of the procedure, such as the total or partial gastrectomies for cancer and the like, where they shorten the limbs to minimize malabsorption and weight loss in patients who can't afford to lose more weight. What can be done if bile is your problem is to move the pouch farther downstream on the intestine to move it farther away from the bile ducts. Revision to the Duodenal Switch WLS is the best response to it as it is virtually impossible for the bile to work its way back to the stomach and esophagus, but thats a very complex procedure that few surgeons in the world can do. The distal (or long limb) RNY is next best, but has similar nutritional consequences as the DS and by your figures, it doesn't look like you need to lose more weight. But there can be in between compromises on limb lengths that can do the job, if that indeed is your problem.

It can be done - it is called a total gastrectomy and is usually done for cancer, gastroparesis or other severe gastric problems - but it is something of a big deal to do. The long term functional difference to your RNY is small, but healing time is the big issue - the esophagus (eating tube) is only a two layer structure compared to your stomach pouch which is four or five layers (depending upon how you count things) so the direct attachment to the intestine is trickier than the stomach to intestine. This was an option I looked into some years ago on a cancer issue, and the partial gastrectomy (basically an RNY) had a normal RNY post op healing and eating progression. The total gastrectomy would have required several months on a feeding tube to let things heal before any food could be introduced. So, this is not something to go into lightly. (And, no, I never had either procedure done - second and third opinions indicated that they weren't necessary, at least for the time being.) Something else to look into - have they determined if the GERD is acid, or bile? That's a big difference in treatment, as if it is bile reflux, the basic RNY structure is already somewhat predisposed to that, and taking out the pouch will no help, and likely make it worse. A possible clue here is that the anti-acid meds aren't working, and they wouldn't if it was a bile problem. It sounds like your problem, or a good part of it, is a weak Lower Esophageal Sphincter (LES) which is the muscular valve between the stomach and the esophagus. That can be weakened by your obesity history (though that was a long time ago), by over eating - over stuffing your pouch can put pressure on it and weaken it, or by some other disease mechanism. There are procedures available specific to this problem that may solve things without having to go through the gastrectomy. Do some research on surgical treatment for GERD. You need to research and find a surgeon who is very experienced with bariatric problems and revisions to figure out what exactly is going on, and then what the proper solution would be. The RNY (or any procedure, for that matter,) does occasionally cause significant problems so you need someone experienced with that. Good luck in working this out! Note - there are some Facebook groups that cater specifically to people with total or partial gastrectomies, so that would be a good place to look to get a better idea of what living with that procedure is like.

I doubt that it was much more than a month or so for me, certainly no more than two months out (though we were on quicker progression than many, it was still based upon personal tolerances.) As others noted, people can have different tolerances for different things - steak, eggs and lettuce seem to be fairly common ones for some reason (but no problem at all for others.) My wife's surgeon, when she was complaining about tolerating ground beef, suggested that she try filet as that is often better tolerated than ground beef. He was right, and we still often fill that Rx! (it's on the menu tonight, for that matter.)

Certainly mention it to him so that he is prepared for it, but it is typically something that they do automatically as pare of the WLS (they probably can't do the WLS without correcting the hernia.) Many don't know that they had one when they went in for surgery and the surgeon just mentions that he fixed it while he did the sleeve.

That is curious, and beyond my limited experience! I suppose that is can be strictly an esophageal problem, though as I noted, I have only seen such things as they related to other root causes. No, I haven't had such a revision, though it was suggested at one time for another issue, but I have avoided having to go that route (with the help of some second opinions that basically said to leave well enough alone for now.) I do have minor GERD, which is readily treated with low level OTC meds, so there is nothing worth fixing at this point on that account. The sleeve is predisposed to GERD by virtue that the stomach volume is reduced a lot more than its acid producing potential, but the body usually adapts to that over a few months, and most surgeons prescribe a PPI for the initial few months and then wean off of them. (Similarlly, the RNY is predisposed to dumping, reactive hypoglycemia and marginal ulcers, so there is no free lunch in that regard, no matter what procedure one goes with - there is always some risk there.) I would prefer to keep the sleeve as long as it cooperates, as the RNY is a little bit fussier to live with, but it's not the end of the world, either, and certainly preferable to what you are going through; my wife has a DS which is a bit fussier still, so I'm familiar with all that entails if I need to go there. The surgeon who has adopted our local support group does quite a few oddball and esoteric revisions (like the complex RNY to DS), people come from across the country to see him, and he sometimes pulls up scans on his laptop of one of the wonky sleeves that has come his way, so we get some feel of what can be done, that other surgeons pass on. That's why I brought up the stricture idea (beyond your regurgitation sounding like that might be it,) because that is something that many surgeons prefer to revise away rather than correct. I does seem like you are heavily restricted, much more so than normal for a normal sleeve, or RNY. 500 calories isn't so bad - it's not that unusual for people with any of these WLS to still be down there, though more commonly somewhat higher in the 6-800 calorie range; it's the water intake that I would be concerned with as dehydration will get one thrown into the hospital a lot faster than low protein or other nutrients in the short to intermediate term. The vast majority of people go through this, an RNY, or VSG, or a DS, with little or no complications, but sometimes they crop up; hopefully, you have had your share of them now and that's it. In some respects, the RNY is a more familiar procedure for the surgeons,, even if they don't do as many of them as sleeves, as it has been around in bariatrics for 40-50 years, so most started out with them; the basic procedure upon which it is based has been around for some 140 years in treating gastric cancer and other GI maladies, so it is familiar territory for most; the VSG on the other hand, had more limited application until it was created/adopted for WLS as part of the original BPD/DS, so it was not as widely used until the DS guys started using it some by itself (usually as part of a two stage DS) and saw that it offered good weight loss all on its own, so I wouldn't worry too much about your surgeon's experience with it, as that was the default WLS in Canada until fairly recently.

It sounds like you may have a stricture in your sleeve (makes it hour glass shaped) - did he mention anything like that, as that would show in the barium swallow test? The drugs that you are taking wouldn't help that as they are just to treat the acid overproduction (the pantoprazole and Dexilant) and the resulting insult to the tissue (the sucrafate). From what I have seen over the years (not an MD, just an interested bystander) the problems with the esophagus are likely a result of the stomach problem (assuming that it is a stricture - I have seen such things sited as a result of lap band damage resulting in such symptoms) Strictures of such severity (if indeed that is what it is) were more common several years ago when the sleeve was new and most US bariatric surgeons were just learning how to do them. The stomach, when sleeved, tends to like to bend or twist in the middle if you don't do it just right - it takes practice. These days, I see it discussed more commonly in countries, like Canada and Australia, that were slower to adopt the sleeve, so as a result, their surgeons, as a group, are at about the same place in the learning curve as the US surgeons were 6-10 years ago. Usually, it is treated by a bypass revision as the surgeon won't know how to repair it (if it can be done.) Often, it can be repaired, or resleeved, to correct the problem, But that needs a surgeon who is much more experienced with the sleeve, so if it is possible in your system to get a second opinion on it (particularly from someone more sleeve savvy) that would be the way to go, if for no other reason than to get concurrence with your surgeon's solution (or hopefully, an alternative approach.) Ideally, you would like to find someone who is experienced with the duodenal switch WLS, as that uses the sleeve as its' basis and those surgeons tend to be much more experienced with them than the average bariatric surgeon, but they tend to be few and far between. The only one that I know of in CA is Michel Gagner, who IIRC works out of Montreal. Likely, the RNY revision is the standard of care within the Canadian system (and much of the US as well,) for this type of problem/ Good luck,