RickM

"Gold standard" is a marketing term used in selling a procedure (cynically, it has been said that it applies to the surgeons themselves, as that is where they make the most "gold") and as such is basically meaningless. Here in the States, there are four mainstream procedures that are routinely performed, and approved by the ASMBS and the US insurance industry - lap bands, RNY, VSG and DS. The bands are falling out of favor owing to their high longterm complication rate and low effectiveness, but there is still a lot of marketing push for them by their manufacturers. The RNY has been around for forty years or so, based upon procedures that had been first developed 100 years before to treat gastric cancer and other gastric maladies (Billroth II). It was an improvement over the existing malabsorptive procedures such as the JIB (jejuno ileal bypass) but it still had the longstanding tradeoffs of its basic configuration - bile reflux, marginal ulcers (aka, the "NSAID problem"), dumping syndrome and moderate nutritional deficiencies. Bile reflux has largely been eliminated in the RNY WLS procedure via tailored limb lengths, but the others remain as common side effects and are largely controlled by diet or medication restrictions and supplements. It is overall a very good and mature procedure that works well with tolerable side effects, but it is far from perfect, which is why there is been an ongoing effort in the industry to find a replacement (this is how progress is made.) The duodenal switch (DS) was developed in the mid to late 1980's, which combined a moderate level of malabsorption with a moderate level of restriction (compared to the RNY which is more highly restrictive and minimally malabsorptive) that takes care of the RNY's problems with bile reflux, dumping/reactive hypoglycemia and marginal ulcers. In exchange, it is more technically challenging for the surgeon (which is why most don't offer it) and is a little more fussy on its' supplement regimen. On the plus side, it is more effective in treating diabetes, somewhat more effective on overall average weight loss, and much better at resisting regain. It should certainly be on the radar for anyone in the high BMI ranges and/or with a history of yoyo dieting. The main thing that has held the DS back from being more popular is its complexity, which often doesn't fit in with either surgeon's skill sets or business models (can't do as many procedures in a day.) The VSG came out of the DS as it is the first phase when the DS is done in two steps. Typically the VSG stomach is made smaller, about half the size, than the DS sleeve. It overall yields similar weight loss and regain characteristics to the RNY but without the dumping/reactive hypoglycemia or marginal ulcer predispositions and is also quicker and easier for the surgeon to perform, which is why it has been gaining popularity. The primary downside is the predisposition toward acid reflux owing to the stomach volume being reduced much more than the acid producing potential, to which the body doesn't always adapt. Nothing is perfect, and they all have a place for different circumstances. Getting beyond marketing fluff, hey are all the "gold standard" when used appropriately. The next new thing that is working its way through the industry is the SIPS/SADI (sometimes called the "loop" or simplified DS) that shows some good promise of having effectiveness somewhere between the RNY and the DS, with surgical complexity on the order of the RNY (it is being promoted as being "almost as good as the DS" while being more "accessible" - simpler so more surgeons can do it. It is still usually considered by most insurance to be investigational, and has yet to gain approval by the ASMBS, but there's a good chance that it may become that RNY replacement that the industry has been looking for.

I think that, as with most practices that I have seen that offer the DS, they have little need to do the RNY anymore - they find that, overall, the DS works better and for those patients who don't need as strong a tool, the VSG (which is the stomach half of the DS) works just as well. However, there are situations where the RNY is the appropriate procedure for some patients, so most still offer it when needed. Most practices don't offer the DS because it's more technically challenging than the RNY or VSG and most surgeons have to take time out from their practices to go back to school (usually a residency with another practice) to learn how to do it, get some guided practice on it and get up to speed on the differences in after care. Most who are currently doing them got into it 15-20 years or more ago when they were dissatisfied with the results of the existing bariatric procedures, which at the time was primarily the RNY and lap bands.

Tolerances after surgery can vary widely, and for various lengths of time. Our program's general rule of thumb was to try new foods one at a time to test for tolerance - if it goes OK, great, if not, try again in a couple weeks. Meats can also vary in tolerability depending upon the cut. Dark meat poultry is often better tolerated than white meat - the extra fat helps it go down easier, while white meat is often dry. Likewise different cuts of beef will vary - our surgeon suggested filet to my wife when she was having problems with ground beef (which are usually really cheap cuts ground up) and he was right. Also, gravies and sauces (aka meat lube) can help.

We had puree and soft stuff (yogurt, scrambled eggs) in the hospital and could move between the typical liquid, puree/mushy and soft phases as we could tolerate. Of course, protein was mostly shakes at first, but that left margin for trying other things that might only be tolerated in very small quantities.

The main advice that I have seen, and my wife and I were given when going through this, is that things are a lot more difficult on the recovery side if you have both your upper body and lower body worked on at the same time. Think of trying to get out of a chair, or out of bed, with both your arms and legs (along with your abs) impaired. Usually, it is best to have one or the other fairly healthy and strong to help compensate for the other. They can all be done at once, and I know of people who have done that, but that really puts you down and makes you seriously dependent upon someone else to help during that recovery period. That, and you have that many more JP drains to fiddle with! As with most things in life, there are compromises and trade offs. Getting it all done at once is appealing, but it does tend to put you that much farther down for a while, rather than being semi-functional for a longer overall recovery time.

Of the mainstream procedures, the sleeve will be the most benign of them when it comes to supplement needs and the amount of trouble one can get into by ignoring them and the labs. Supplementing with the sleeve is largely an individual thing - there is much more influence by individual variations and dietary habits than there is from the surgery. I've never heard of B1 being a particular problem, but given that the primary dietary source is from the grain complex, and many people are into low carb dieting (Atkins, Keto, etc.) that minimizes that food group, it isn't surprising that such deficiencies would be showing up - not from the procedure, but from the chosen diet. My wife is chronically low in Potassium, but that is just her, not her WLS (as DS in her case.) That is managed by checking levels periodically and adjusting supplements as needed - just as if she had never had WLS. I have heard it hypothesized that there might be some iron absorption issue with the sleeve owing to the somewhat more rapid transit times of food through the stomach, but I haven't seen any validation of that concern. The malabsorbing (RNY, DS) procedures specifically do malabsorb minerals such as iron to varying degrees as much of the mineral absorption happens in the duodenum which is bypassed entirely (in the RNY) or partially (in the DS) so iron levels can certainly be more of a challenge with those patients. I had a bleed a few years ago that sapped my iron/ferritan levels, but was able to restore them to normal in a few months by doubling my oral iron supplement; most with an RNY or DS would need iron infusions to recover from those levels. I tend to lose a bit of D normally so have been supplementing that since before my VSG and continue to do so at moderate levels (2-5k IU) both from that perspective, and also our surgeon prefers to see us in the higher end of the normal range on the blood levels; some in the malabsorbing camp will use 50k IU supplements to keep things in line (particularly the DS folks who specifically malabsorb fat soluble vitamins such as D) I know quite a few long time DS people (10-20+ years) and have seen very little problem as long as labs are regularly taken (annually usually) and responded to; however ignore those at your peril as weird things can happen if you don't. And that's with the DS, which is the fussiest of the procedures in that regard. With a sleeve, you are much more likely to get into trouble by something that you bring to the table - whether that be intrinsic or behavioral - but that is good reason to keep up with periodic lab checks just the same (my labs are a lot simpler than those of a typical DS or RNY person, as there is less that is needed to be monitored with the VSG.)

All of the above are part of the problem. Classically, "high protein" diets tend to be constipating, and while are diets aren't really all that high in protein (they're basically a maintenance level of protein), they are low in most everything else - like fiber. I don't think that the shakes specifically are any better or worse than any other protein source. I average in the 110-120 g per day range typically and have no problems at all with this, and haven't for years. But my diet is also quite high if fruits and veg, and I don't skimp on the whole grains, so there is normally lots of fiber going through along with it. So, during this weight loss phase when your diet is quite restricted, some fiber supplements are usually called for to help keep things moving (and sometimes for the long term, depending upon what kind of dietary habits one adopts after the weight loss phase.)

Doctors' philosophy on this vary from a few weeks to never again depending upon their experiences. The basic issues are: Healing - alcohol is somewhat corrosive to the stomach lining so one needs to give things a chance to heal first, Typically we see a few weeks to a few months sited for this. Alcohol tolerance - rapid stomach emptying means it tends to hit faster, and with less (i.e., a "cheap drunk") so care must be taken there, Transfer addiction - we can no longer satisfy whatever addictive tendencies we have with food, so it is easy to transfer that addiction to something else, like alcohol, drugs, shopping, gambling, etc. What was a casual habit of a glass of wine with dinner occasionally can easily turn into full blown alcoholism. Liver health - starting as morbidly obese, or worse, our livers are not usually in very good shape to begin with (hence the "liver shrinking" pre-op diets that are often prescribed) and the liver is further stressed from its role in metabolizing all that fat that we are rapidly losing. It doesn't need any more stress from ingesting a known liver toxin like alcohol (not a judgemental thing, just our physiology at work). My surgeon is also a biliopancreatic (livers and pancreas) transplant surgeon, so he is in the no alcohol as long as we are losing weight camp (and ideally forever) and indeed we sign a contract to that effect - he doesn't want any of his bariatric patients coming back onto his transplant table! Those are the issues in play, and some aspects bother different surgeons to different degrees, so they have different policies. Check with what your surgeon's policy is, and decide for yourself - we are all adults here.

Yep - I weighed daily, but only officially recorded it weekly, so a week without loss (or a bit of gain) I chalked up to being a "stall". I only had one week without loss until I started ramping up my calories to slow down the loss leading into goal (and my "three/third week stall was maybe a day - it's a big YMMV thing.) There are too many water weight effects to worry about daily fluctuations.

As far as long term weight maintenance, there is very little difference between the sleeve and the bypass as they are both metabolically similar after a couple of years. Early on, the bypass may allow for a bit faster weight loss owing to its' malabsorption, but that caloric malabsorption dissipates after a couple of years and you are left in the same basic position as those with a sleeve; sadly, the nutritional malabsorption persists with the bypass, so it will continue to be a bit fussier on the supplement needs. The basic choice really comes down to other individual factors rather than weight loss needed or maintained, Are you subject to GERD, ulcers, stomach polyps, arthritis or other medical conditions that need medication that may be influenced by the changes, etc. etc, etc. If one feels that maintenance will be a problem (from a history of yo-yo dieting, for example) or one knows that there are already significant metabolic problems then the duodenal switch (DS) should also be considered as that is a metabolically stronger procedure than the sleeve or bypass, but it does have its own trade offs as well (that's life!)

The general consensus that I have seen, and my doc's policy as well, is no immersion until all of the incisions have healed closed, typically about three weeks. I had one that was still weeping some so it wound up being four weeks for me until all was sealed up. Getting wet, as in a shower, is usually fine, but no immersion. So, until then, it's just dangling feet in the water time. Once you do get in, take it slow, stretch things out and explore your range of motion to make sure nothing is hanging up before going for Olympic training.

It sounds like you have a reasonable chance of succeeding at this, given your situation. Likely what will happen, is that they will apply for approval and be denied due to the six month thing, then they will appeal the decision, and probably have a peer-to-peer review with your surgeon talking to their doctor and then a decision will be made. Likely they will approve it at that point (with some grumbling...) as they would rather pay for just one surgery to do both jobs than pay for the hernia repair now (don't take your gastro's word on this, talk to the surgeon who has to do the job! Surgeons, too, vary widely on their ability to do such jobs,) and then the bypass in a few months.

You certainly have been through the wringer on this, and for that I, too, am sorry to see your struggles. It does seem that a revision of some sort is called for, and a second opinion (and even third...) is certainly called for in cases like yours (or really for any revision.) My suggestion is to find a surgeon from the DS (duodenal switch) world for another opinion, as the DS is a more complex bariatric procedure that most surgeons don't offer, DS docs tend to come from the top of the class, and as the DS uses the VSG as its basis, they tend to be the most experienced surgeons around when it comes to sleeve problems as they have been doing them a lot longer than most bariatric surgeons. My first choice for discussing a problem such as yours would be Dr. Ara Keshishian, who is down in the LA area. People come from all over the country to see him on complex revisions and other bariatric problems, so he is used to doing virtual consults (at least the initial one) so you don't have to travel to get an idea as to what solutions there may be for your problem. A bit close to you would be Drs. Rabkin, Jossert or Cirangle, all in different practices in the SF area, but all from the DS world and well experienced with sleeves. It is good to hear that your doc has tried a Nissen; while not particularly new, it is somewhat unusual with the sleeve as there isn't much fundus left to plicate, so many bariatric surgeons go straight to an RNY revision as they don't know how to do the Nissen on a sleeve. I have a small hiatel hernia and talked to Dr. K about it, but it isn't appropriate for my situation, but since my symptoms are mild, it is a wait and see situation - I'm not eager to go to the RNY as it's something of a surgical dead end that removes a lot of options once you go there (but it generally works well once you do.) Good luck in working this through....

I would generally go with the advice of your surgeon's patient coordinator, as they have been through these hoops before, particularly if it is with a common insurance carrier in your area. If your surgeon has a dedicated insurance coordinator, who handles all of the insurance issues, that would be a better person to get an opinion from, but that might also be the patient coordinator that you have talked to - it's worth checking out to make sure you are getting the best information. You can verify this by calling the insurance company's customer service line, thought those reps don't always give the correct information (sad, but true.) The best thing is to look up the company's policy bulletin for bariatric surgery on their website which will spell out all of the specific requirements - that is their legal document that they must follow, irrespective what a customer service rep may say (but the doc's insurance coordinator should know all of the in's and out's of the language in it.) For instance, with my company, they implied that they wanted six monthly appointments, but did not specifically state that. Between my schedule and my PCP (who was my "medical supervisor" for this) we were only able to work in four appointments over the six months, and that was fine. (The insurance coordinator was concerned about how the PCP wrote up the report for it relative to the insurance requirement, but that was a different issue.) If your insurance requires simply a "medically supervised" six month program like I had, then the first and last months being with your surgeon and the others with an RD should be fine. but if they specifically require six monthly meetings with an RD (nutritionist), then is won't. It's all in the wording. Good luck on getting through all of these hoops - this is often the hardest part!

There is no "the" pre-op diet, as different surgeons and programs have different requirements for different reasons. Programs will vary from nothing at all, other than the usual day before surgery thing, to a couple weeks or more of only liquids, and everything in between. I have seen some that go for six months on only prescribed liquid products (go figure....) This is a good thing to establish early on (ask questions at the information seminar!) as it can be a factor in deciding one program from another - one may have a particularly tortuous program (or require one to buy expensive products from the doctor) while another may be very simple and short. It can also have implications on the surgery and post op recovery times.

If you are going to cheat, you are going about it the right way - green veg, eggs or lean meats. The main issue for the "liver shrinking" thing that some docs need is low carbohydrate; I have never seen any real rationale for the liquids only diets (other than the day before to clear out the system) but some docs go overboard on it. Many docs don't bother with these diets at all as they know how to work around the fatty liver (if it is there at all) and find that their patients recover faster on the other side by simply eating healthy ahead of surgery (one doc I know specifically does not want his patients doing any of these fasting diets as he wants them as strong and healthy going into the procedure, and fasting for weeks ahead of time doesn't do it. The best thing is to follow your programs recommendations as close as you can. There are also some surgeons out there who threaten to close you up and send you home if the liver is in good enough condition (and I have seen a couple actually follow through on that - definitely guys to avoid). so you want to make your surgeon as comfortable as possible when he is rootin' around on your insides.

Only the day before surgery, clear liquids only. Didn't have one post op, either, though things were mostly liquid at first, other soft and mushy things were acceptable, too.

There is very little, if any, difference in weight loss performance between the sleeve and bypass; the bypass may get one to goal weight a bit faster owing to the added boost of its caloric malabsorption, but that disspates after a year or two and one tends to wind up in the same place with either procedure, and likewise, regain performance is similar between the two. The choice usually comes down to compatibility with any pre-existing conditions (GERD, at least without an obvious cause such as a hiatal hernia that can be corrected along with the surgery is usually bad news with a sleeve; being prone to ulcers or stomach polyps is bad news for a prospective bypass patient, as is need for regular use of NSAIDs.) Metabolically, if one needs something stronger than a sleeve, the DS is the way to go as it goes much farther in normalizing one's metabolism; it is unlikely that the OP, being a young(ish), tall(ish) guy of "moderate" BMI (46ish) needs to go that far, unless he has had a long history of yo-yo dieting.

As you noticed, diet plans, both pre- and post-op, vary all over the map, and it isn't a bad idea to shop them ahead of time and consider them in choosing your program. Some programs will have their patients on steak while others are still on liquids., while pre-op, some impose liquids only for weeks ahead of time while others do nothing special until the day before surgery. One can draw implications from both on the surgeon and program, but on should follow your surgeon's instructions on both as we can't tell why they are telling us to do these things - are those with lengthy liquid diets simply behind the curve of other programs ("that's the way we've always done it...") or is there some reason for it - is there something about the way that they do the surgery that requires it, but other surgeons do things differently so they can use a different diet? The safest thing is to follow your programs instructions, and for peace of mind, do as much research ahead of time, and take each programs' features and protocols into consideration in making your choice. Personally, I would avoid those programs with extensive liquid pre-op diets and favor those with more rapid post-op progressions, as from what I have seen over the years, those tend to provide more rapid recovery and better overall results.

HI, welcome to the club! I am familiar with the Cedars bariatric department, having met and talked to them several times over a few months on a prospective non-bariatric procedure (that I ultimately never had) but came out with an overall positive opinion of them. I am not personally familiar with UCLA's program, but have seen a couple of questionable things from them over the years. Here in the LA area, one doc that I would certainly have on my list to consider for sleeve type procedures is Dr. Ara Keshisian in the Pasadena area.. I would probably have gone to him for my sleeve if he had been practicing here at the time; instead I went to the Rabkins up in SF as no one in LA had much experience doing sleeves then and they had been doing them for around twenty years at that time. Dr. K will probably push you to do a duodenal switch (a sleeve plus malabsorptive intestinal rerouting) over the sleeve as it tends to have better long term results with better regain resistance than the VSG or RNY. For me, I felt that it was overkill for my needs (though was just the right thing for my wife,) so a good, honest look at what your needs really are would be in order in working out that decision. Good luck, and PM me with any other questions that you have,

As noted, diets, pre- and post-op vary significantly. We were on purees and soft foods in the hospital, while others will have to wait some weeks for that. The prospect of the pureed lettuce that they served there kinda turned me off to the thought of pureed anything (lol) so, with the flexibility of our program, I never did, but just danced around the issue between the various liquids, mushies and soft things that we could eat. Yogurts, oatmeal, cream of wheat, puddings (made with protein powder) eggs and soft cheeses should do the trick. For specifics on what exactly is allowed for you, that's specific to your doctor's program and they should provide you with guidance as to what exactly they consider "pureed" and what they expect at this time.

As soon as I got home from the hospital. Unless one has substantial inflammation in the stomach narrowing the passage, there is no reason to avoid normal sized pills with a sleeve (some bigger pills like some calcium tablets may take a few weeks.) Some practices follow old RNY protocols to avoid getting pills stuck in the stoma (which we don't have with a sleeve) but that is far from universal.

Pre-op diets are all over the board from several weeks (even months!) of nothing but liquids to nothing special at all depending upon surgeons' or program preferences. Our program only the day before.

Fecal transplants have been used for a while in treating recurrent Cdiff, and there is now a Cdiff drug in trials (if not more than one) that is effectively a micro-targeted probiotic, or fecal transplant in a pill.

Be watchful on this, as the caloric malabsorption of the RNY that helps in the weight loss dissipates after the first year or two and this can lead to regain for those who establish habits early on in maintenance that they can't break later. So, continue to pay attention to your weight and intake an make adjustments as needed over time.