RickM

800 kcal per day is a very typical number and consistent with good weight loss. Our loss tends to be heavily forward loaded with a lot of water weight loss early on - your loss rate should be slowing right about now (do a search for the "three week stall") as your body pauses to catch up. As a reference, I lost 32lb the first month, and then 15 each of the next two months, so things do slow down. (What is happening is that your body, when it goes into a big caloric deficit as it does immediately after your WLS, starts drawing of your body's glycogen reserves - basically stored carbohydrate - which takes a lot of water to stay in solution. So your body is throwing off a lot of water as it burns the glycogen. Then, when that runs out (after 2-3 weeks typically) the body has to start drawing on its stored fat (which is what we want!) but it can take a few days (or weeks for some) for the body to shift gears to do that, so don't panic if your loss suddenly stops for a while. Also, your loss rate will be lower once you start burning your fat reserves, as the fat burns more slowly than the glycogen. The glycogen burn may also be why you are feeling a bit weak and tired, as that is your quick response energy store, and you are running low. Try working in a little more carbohydrate - oat meal, cream of wheat, unsweetened apple sauce are common - to help keep those levels up a bit more. In theory, our body is supposed to burn our excess fat to make glycogen, but that doesn't always happen as quickly as we need it (this is why marathoners will "carb load" with a lot of bread and pasta the day before an event - to make sure their glycogen levels are as high as possible before they go burning it all off the next day - we don't need to go that far, but the same principle applies.) Overall, it looks like your are doing great, and I wouldn't worry about losing too fast until you are within maybe five kilos of your goal weight - if you get there withing six months, then you may need to slow things down so that you don't overshoot the mark too far; otherwise, I wouldn't worry about it. (And yes, my doc's RN also told me to cut back the exercise because I was losing too fast - but that was at six months, and about 10 lb from goal weight, and while I wasn't inclined to cut back on what is my normal maintenance level of exercise, I did start ramping up the calories to start slowing things down.)

It can happen early on, and yes, it does seem as if we are eating and drinking all the time. Running out of gas and/or having to take a nap midday is not unusual for a while. Hydration, or lack thereof, can do it (how is your urine - clear and pale is good and a sign of adequate hydration, more deeply colored is not?) Does your program have you taking iron and/or B12 - those are the typical micronutrient causes early on (B12 not so much with the sleeve, but some people run short anyway.) Protein might be part of the problem particularly if you are depending upon genepro for it - that's a questionable product that doesn't provide as much protein as they imply (what exactly does "equates to 30g" mean?). Try changing product or doubling up on it. Our diets early on are heavily biased toward protein (and water!) with everything else being secondary, which means that we often aren't getting the carbohydrates needed to maintain our energy balance (and some go overboard on that under the belief that it will improve their weight loss.) Some programs specifically have their patients doing a bit of mild "carb loading" to help avoid this problem. Try having some oatmeal or cream of wheat for breakfast, or unsweetened apple sauce as a snack and see if that improves things.

We (my wife and I) usually see him (talk on the phone lately) every year, though there were a few years a while go when we skipped it after they closed their local office (they moved up to SF around 20 years ago, but maintained a local office for many years to serve all of their legacy patients and any new recruits from the area). He mostly go over the same things that our PCP does looking at the labs (much more extensive for my wife with her DS than for me with a VSG) so there normally isn't much added, though he often has preferred or recommended levels that he likes to see that may differ from the basic :normal" ranges called out on the lab sheets. We haven't had any show stopping problems with our WLS over the years, but I look at the annual check with the surgeon as something of a retainer fee so that he keeps us on his radar and current in his files in case something odd shows up, the PCP can give him a call and ask about it (or we can zap him an email.) Generally, the PCP is just fine for routine monitoring; it's when something questionable shows up that's beyond her experience where it's handy to still have a relationship with the surgeon.

I never had any nausea or vomiting as a result of the VSG; other causes on occasion, as happens in normal life, sure, but not from the surgery. I never even used the anti nausea meds that they prescribed post op. As with most things, it is one of those YMMV things, and some will have more problems than others, but it is nothing inherent in the procedure.

You have been through the wringer on this, so sorry you have had to go through it. I don't have any experience specific to this, but some maybe distantly related. I have seen that when they have an intransigent ulcer problem, classically it's around the anastomosis between the pouch and intestine, they usually just reverse the bypass, though that isn't really an option for you as that would put you back to your sleeve, which implicitly may not have been that well done in the first place. By reputation, I would try to seek a second opinion with Dr. Michel Gagner, who I believe has a presence in Toronto. He was one of the early adopters of the duodenal switch back in New York and has done some fairly complex revisions (such as RNY to DS) so is familiar with more complex problems. As to "done as much as we can" there is more that can be done. The most extreme thing would be a total gastrectomy, which isn't all that far from where you are now with an RNY, and is done in some cases of gastric cancer or gastroparesis. Basically they remove the remainder of the stomach and hook up the esophagus directly to the intestine, where your pouch is now. or close to it. Between surgery and adaptation, they form a new pouch in the intestine. Surgically, it is a bigger deal than it sounds as they don't like attaching the esophagus to anything other than itself (you would likely be on a feeding tube while it heals, but you've already been through that,) but it is a not uncommon configuration that people live well with (similar to your typical RNY lifestyle once everything heals.) Your average bariatric practice may or may not have the experience to do this, and you might have to go to a hospital that has a specialized gastric surgery department and/or cancer center. Simpler than the above, I have seen reference to a few people who were having significant RNY ulcer problems, again in the typical anastomosis region, where they went in and moved the anastomosis down the intestine a bit farther to a fresh spot, so that might be an option depending upon circumstances. Those are a couple of ideas that you can look into and question your docs about, and maybe seek out ones with a somewhat different specialty that may be able to help. Good luck in working through this,

For a regain problem I would not generally go from a sleeve to a bypass, as metabolically the two are too similar and one usually winds up in the same place after a couple of years. Indeed, most revisions don't yield a lot of additional weight loss; those that do mostly seem to be those who really crack the whip and get their dietary and psych acts together for the second try. One will usually lose a few pounds, typically twenty, give or take - mostly what one would expect from having to go through all the diet restrictions associated with going through the surgery again. The simple minded way I like to think of the reasoning for the general poor results is that our stomachs started out being able to hold 32-64 oz before our original WLS, and now, a few years post op, our stomachs, even after some adaptation and stretching, hold 4-6 oz (maybe 8 in some cases), we have gotten used to living with that, so there isn't nearly as much of a difference going through the surgery again. The DS will usually provide better results, particularly in being more regain resistant. As with the others, it is hard to expect as good results as with virgin DS, but it should still work better than the others. When I discussed this matter with our surgeon when I had my VSG - the prospect of using a DS revision as a "plan B" backup to the VSG, he cautioned about the problem of losing that regain; he said that the revision works best if you catch it early, before substantial regain has occurred, as the biggest strength of the DS is its ability to resist regain. You are fortunate in starting with the sleeve, as that has maintained more options for you - revising an RNY to anything else that may work better (like the DS) is a very complex undertaking that few surgeons can do; as the sleeve is the basis of the DS, changing to the DS is more of a "completion" of the DS rather than an outright revision and is a pretty straightforward procedure for any DS qualified surgeon. You seem to be doing the right things, in working out the problems that led to your regain, as that will be a key to your future success. Good luck!

It's very common - often patients don't even know that they had a hernia, whether it be a hiatal, umbilical, or whatever, before surgery and the doc just fixes it as part of the WLS. As to what you can eat for the rest of your life, most likely it can be whatever you are eating now. The problem is that whatever you are eating now is what got you to 400 lb and you will likely be back there again if you don't learn how to eat to maintain your weight in a healthy range. Think of WLS as more of a "do over" rather than a total fix - it helps get you back to where you should be so that you can start over again, but if you don't correct what got you morbidly obese (whether it be strictly diet, or psych issues, or likely a combination,) you will likely work your way back to where you are now. The good news is that you can start that now, working with a dietician and/or therapist to start correcting things and learning how to eat and live for the rest of your life, and that all carries forward making the WLS and post op processes that much easier. Good luck

I don't know what size bougie my surgeon used, never discussed it with him, nor do I care. It is just a guide for the surgeon to use, and as noted above, some may sew things tighter or looser around it. The important thing is the end result, so I would concentrate there. Overall, I have seen on these forums people mentioning having bougies typically between 32 and 40, and based upon the reported weight loss from them all, it is really hard to correlate results from stated bougie size. Further, based upon personal experience, my wife has a huge sleeve, likely a size 56-60 which is common for the DS that she has, and yet her meal size is very similar to my own with a typical mid 30s bougie. Go figure.. In short, there are a lot more important things to worry about than bougie size (like, how many sleeves has your prospective surgeon performed - how he uses that tool, and how well practiced he is with it is a lot more important than what specific tool he is using.)

The general industry practice is, assuming that there isn't any "1 WLS per lifetime" restrictions, is that for regain or inadequate weightloss problems, the same basic BMI rules apply (40 or above, or 35 with comorbidities). With a complication such as your GERD, however, it is no longer considered a "revision" as a surgery addressing the complication. The policy bulleting on WLS for your policy may or may not be that specific in this case, and you need to get a reading from the insurance company for you specific circumstance. Your surgeon's office should have an insurance coordinator on staff who handles all of this, as they know the language and the in's and out's of the system. Since it is how they (the doctor's office) get paid, it really is their job to do so. Perhaps there is another surgeon in your area who has a better business office? Assuming that the original surgery was covered by insurance, a complication such as this is usually covered as well.

As Tek indicated, do you really want to go down the dieting road again, and then learn how to maintain a healthy weight? keto will work as well as any other diet out there - about a 95% failure rate beyond a year. The usual problem with these diets is that people get tired of them and quit, or they reach their goal and go back to their old habits because they never established the healthy dietary habits that help maintain their weight. There is such a thing as "bariatric keto" which tailors it to WLS needs - basically higher protein and lower fat. It is essentially old school Atkins, but people can tell everyone that they're "doin' keto". The problem of all the other diets still remains which is what do you do once the fad fades - keep on with a "so yesterday" diet or jump onto the new latest thing? If you do want to adopt keto as a lifestyle, I suggest that you do just that - take is as a serious iifestyle and learn how to live with it and minimize the nutritional deficiencies that are inherent in it. Think of it as similar to those who chose to go vegetarian/vegan - if one looks at it simply as not eating meat, then trouble is lurking as one needs to learn how to get adequate protein, and the right kinds. Likewise, with keto, one needs to learn how to get all of the vitamins and minerals that we normally get from carbohydrate rich foods (all of our fruits, veg and grains.) At least, if one is really serious about it, our Covid19 days are a good time to try it, as with our normal social distancing protocols, one will be less likely to offend others with their keto bad breath and BO.

Probably not - that was on our early (first month) diet and I had some the first week, but surgeons know how they are doing these procedures best, and things can vary from surgeon to surgeon (one surgeon may make things more tolerable for such things early on than others). So it is still best to follow your surgeon's guidelines rather than someone else's (and you will get the blame for any complications that arise for being a noncompliant patient, even if the complication has nothing to do with your action.)

Boy, you have been through the wringer (and a run of not-so-great surgeons)! That makes some sense, as bile reflux is reputedly one of the problems of the MGB -(sadly, I guess you have helped confirm that...). I haven't seen much reference to it being a big problem with WLS oriented RNY procedures (it seems to crop up more with non-WLS RNY where the surgeons seem to keep the limbs short to minimize weight loss. I hope this one corrects everything and all works as it should once you're done; and you can be done with surgery for this lifetime. Good luck on it

We didn't have any pre-op diet, and many surgeons don't need to impose them on their patients. The big question here is what your surgery for? Talking about bile reflux problems, implies that it is to resolve that complication as opposed to weight loss, If you haven't regained substantial weight, there is probably little need to go through with any extensive pre-op diet. A few years ago I was looking at the prospect of a surgery with a bariatric center, though it was for reasons other than weight loss, The RD went through the usual nutritional spiel and outlined their pre-op diet. When I asked her if I really needed to do that as I didn't need to lose weight and didn't have fatty liver, she simply said, "let me ask the doctor..." since she didn't have the authority to make that decision. (The answer was no, I didn't need to do it.) So, if your weight is normal-ish and you don't have any liver issues, there is little value to the diet (other than the usual day before thing to ensure a clear GI tract. Curiosity here - what are they doing to resolve the bile issue? The DS will knock it out for sure, but few surgeons can do that. Moving the roux limb further down? Just curious.

Does your surgeon specifically limit their use, or are you drawing from online forums? As noted above, doctors give varying advice; the RNY has some specific problems that limit the use of such medications which doesn't apply to the sleeve, but some doctors or programs give blanket advice to all of their patients regardless of which procedure they had, while others will vary it depending upon the procedure. Since NSAIDs came off of prescription some twenty or so years ago, there has been a building opinion in the medical community that that was a bad idea and that they should have remained a prescription med owing to some longer term side effects that they can have with consistent use (this applies to all people, not just WLS or RNY patients) so some docs may publish in their guidelines that all of their patients should avoid them, despite the differing tolerances between procedures, but if consulted privately (as in patient to doctor, rather than in a group setting), they will usually give more specific guidance for that patient's needs.

First, whenever we see some reference to "WLS patients" in either the general media or even the general medical media. it is (unless specificallyl stated to the contrary) invariably referring to the RNY gastric bypass, as that has been the most common, and most commonly studied, WLS procedure over the past 30-40 years. Even most doctors (non-bariatric) whom we may consult over time will often confuse the procedures, or lump them all together as "the bypass". Something to keep in mind in later years if some doc suggests that "I can't prescribe that for you because of your WLS..." Ask questions and verify if that really applies to you. The RNY imposes a number of limitations that don't apply to other procedures. Aa few years ago we did discuss in our support group (in full HIPAA compliance) a patient of theirs who, after consults with many different types of doctors, had been diagnosed with ALS. As it turned out, after going back and consulting with the bariatric practice (as he had not done in years) it was found to be one of those nutritional problems that you mentioned. This patient, in his 70's if not 80's by then, had a Duodenal Switch, which is more malabsorbing than an RNY, and also somewhat fussier when it comes to supplementing, nutrition and lab follow up. This guy had not done his labs in several years, so things had skewed out on him. Once they got his supplements and nutrition in order, he was fine. The lesson here was that it was (is) imperative, particularly with these malabsorbing procedures, to stay on top of lab follow ups, as weird things can happen. Given that the RNY is also malabsorbing to a somewhat lesser degree, but much more common, I would expect that the medical field would see some of these problems in a population that may be fairly casual about following up on their health. I could certainly buy that there is some association over time with some increase in some of these symptoms owing to odd nutritional problems As to your brother with his sleeve, one of the reasons that many prefer the VSG is that there is no malabsorption, and is much more forgiving - less supplementing need, and hence less intensive follow up requirements -than the malabsorbing procedures. Further, the problem that the above patient had manifested itself over years of neglect, rather than a few months of normal WLS recovery, so I don't see that this is a likely situation for your brother; as above, it is likely simple coincidence. As with taking your car in for service and it breaks down a few days later - there is always a suspicion that they did something there - yet sometimes it is indeed simple coincidence. It looks like you are doing all the right things as far as second (and third, fourth, etc.) opinions, and this is vital when we get into situations that are beyond the normal. Another possible consult may be Dr. Ara Keshishian, also in the LA area, who is long experienced with sleeves and the DS; he may have run across something like this if there is any real connection to find. He does a lot of distance consults for revisions, so if distance is a problem, an initial consult can usually be done by phone/email/skype. All the hope in finding a good outcome,

I had one a few years ago and didn't have any issues with the prep - no real difference that I could remember from when I had one before surgery - but then I do seem to have a sleeve of steel that gives no particular problem with any food or medication. My wife has a bit more difficulty, though that is more due to her having a DS where the intestinal rerouting makes the cleanout somewhat more fussy (she needs to do the liquid diet for a couple of days to lighten the load, so to speak, rather than the more normal day before thing.) The last time she had one, the doc did give her a special cleanout mix that uses less volume than others (some of which have you drinking a gallon of that crap in a fairly short time). Hope yours goes easily - none of this is much fun.

I couldn't say specifically, but as the VSG is within the US standard of care for bariatric surgery, (along with the RNY, DS and lapbands) as generally defined by what is covered by Medicare, it should be covered by your insurance also. If Medicare covers something like this, a company has a hard time explaining to their customers and, particularly their regulators, why they don't cover it.

It's not that your stomach is holding more than you expect, rather as you are only having liquids and very soft mushy things, it is not holding it much at all, and letting move on through. Once you get onto more solid things, it should be much more restricted. Some will be very restricted on liquids if they have a lot of inflammation in the stomach from the surgery, but it's no problem if you don't (I didn't, either, and could down fairly large amounts of liquidy things even in the hospital, to no concern of the doc.)

It is inevitable that you will lose some during the process - when you are 100 lb lighter, your legs have that much less to carry around all day long and things adapt - you don't need as much leg musculature as you did before. Trying to reallocate the muscle mass and limit the loss is the best we usually can do - I lost about 10 lb of lean mass going through a similar loss to what you will be doing. I had been doing regular gym workouts (weight circuit and swimming on alternate weekdays) for several years before surgery and worked back into that over time after. I used to be able to leg press close to 500lb, but its more like 300 these days (it's also ten years later, and my goals have shifted some; Covid doesn't help either.) I have never been overly intent on numbers but rather strength endurance that allows me to do the things I like to do, along with the occasional aberrant chores like tree trimming or ditch digging, without significant muscle pain - exercise most everything so they are all used to getting some regular work. There are others here who are more into it who may chime in with more specific advice. During these Covid days and limited gym availability, look into TRX as a possible home alternative that can work a lot of different things in a limited space and budget. Good luck

It can also be influenced by hormone dumping, where the hormones that are stored in the fat gets dumped into your bloodstream as it burns off. It can also sometimes lead to what would normally be considered "ladies problems" of mood swings, etc. associated with that time of the month (wait - I'm not normally bitchy...!)

I just used a repeat meal or recipe on my software and edited as needed for the day. As noted, the basic salad veg are negligible on calories, but I was more interested in micronutrient counts so that I could adjust supplements as things progressed (do I need one dose of calcium per day or two, or three to meet my targets? How close to RDAs am I getting without supplementing - can I ultimately cut some out?) It also helped as time progressed, and our meal size naturally increases, to control portion creep and keep on top of what I was actually eating - I continued to base my lunch salads around 2 oz of meat but allowed the veg side of things grow over time. My software also keeps track of standard servings (or diet exchanges, in that system) so while one of my maintenance goals is to get ten fruit and veg servings a day, (I usually settle for 7-8), my lunch salad accounts for about half of that intake.

Yes, try different types of iron, as some are better than others. I have been using Iron bisglycinate chelate - the one I use is a Solgar product under the name of Gentle Iron. I only use it every other day for maintenance, but a few years ago when my iron was in the tank after a bleed I used it twice a day without any ill effect and that brought my levels back up to normal in a few months, and then I backed off.

https://www.dssurgery.com/ That's the site for Dr. Keshisian. He has a fairly extensive archive of his blog posts which cover all sorts of things, most at least tangentially related to the DS and WLS. A recent article that he wrote over on OH https://www.obesityhelp.com/articles/duodenal-switch-post-op-one-year/ This is one of the best resources that I have found recently (and a nice guy, too.) Another site, that isn't what it once was, but still good is https://www.dsfacts.com/ You can also look into different DS practices to see if they have accessible online support meetings which can also give you some additional insights.

The Isopure clear drinks are fine - I don't really like them (they have the consistence of anti-freeze) but use them when I am on a clear diet, such as before a colonoscopy. Usually, I mix them in with Jello and that makes them more tolerable.. Calories are fine - 160 cal for 40g protein means that all the calories are from protein - what you want at this stage of things. Sodium doesn't look terrible, and is rarely a problem while we are in a losing phase as we are eating so little overall; some people will actually run overly low on sodium at this stage. If you like them, go for it.

If it is too early to get labs done for your surgeon (it's often not until six months,) talk to your surgeon or PCP about your problem and maybe get your iron and B12 levels checked to see if either of those are your problem - a sleeve does not markedly change your B12 absorption (that's more of a bypass thing) but some people do run intrinsically low in it. Our program doesn't call for any B12 supplements for VSG or DS patients, and I never needed any. Electrolytes were mentioned, and that is something to look into. Another area where this is a common problem is simple dietary balance. Our early diets are usually by default low in carbohydrates, and some go overboard even further in limiting them, but they are also our primary energy source - lethargy and brain fade are not uncommon side effects of low carb dieting, so there may be something that can be tried there to restore balance a bit. While I never had any real lethargy problems after the first month or so, I was running out of gas after swimming for an hour, Working with my RD, we added some complex carbohydrate to my lunch before I went to the gym, and a simple piece of toast did wonders, and broke that wall I was having at an hour. That is a simple thing one can try (I didn't add any calories, just reallocated what I was already consuming. A bit of carbohydrate for breakfast - oatmeal perhaps - can help set the stage for more energy through the day (as opposed to late in the day.) I have seen references to some programs that specifically want their early post op patients to do a bit of carb loading (bit of fruit juice, apple sauce, oatmeal, etc.) specifically to help maintain energy levels (nothing big, we're mostly talking about minor adjustments here.) Something else to think about.