RickM

There is no universal RNY or WLS or VSG diet, as doctors and diets vary all over the map. If the surgeon who did your bypass is the same as the one who did your sleeve, then most likely the diets will be the same as most doctors do the same thing for all of their patients. Some might be more restrictive than others for their bypass patients, fearing something getting stuck in the stoma (but again, they usually apply the same instructions to their VSG patients as well, even though they don't have a stoma.) You may find diet guidelines from another practice online, but no guarantees as to whether is fits with your doctor's instructions (some surgeons would have an absolute fit if their patients used our surgeon's diet progression!) If you keep things on the liquidy side this first week or two, that will be consistent with most surgeons' instructions

Yeah, 6-800 is a common range that seems to work well for most from what I have seen over the years. But, if one is already used to eating more, it can be hard getting down that low as opposed to starting lower and maybe working up to that level.

You may have to drop it some from there to speed things up. It is not unusual for some to maintain in the 1000-1200 calorie range, particularly women of average to below average height - it's just a metabolism thing. I would (and did) lose like crazy at that level, but that's a guy thing - I maintain well in the 2000-2200 range. To lose, try getting down into the 800 calorie range consistently and see what happens.

Strictly on a weight loss basis, from what I have seen over the years, I would not revise from a VSG to an RNY, simply because the two are so close metabolically that one doesn't really work any better than the other for weight loss. One may lose a bit more, maybe 10-20 lb, during the early post op stage when the diet is so limited during recovery, and the RNY malabsorption makes the loss a bit faster, but overall on winds up in the same place. In 2-3 years, you will likely be struggling to maintain your weight as you are now. If you need to keep yourself at, say, 1200 calories to maintain weight now, that will also be the case long term with the bypass. The RNY does tend to help with reflux problems (not guaranteed - some will still have it post RNY, or develop it later - but statistically better) but I wouldn't go through that unless it can't be controlled with medication. That is something to be medically evaluated, and if appropriate, that may be a good reason for such a revision. For weight struggles as the primary problem, I would look seriously at the DS as a better alternative as that is a metbolically stronger procedure than either the VSG or RNY. It is also a straightforward revision as it starts with your sleeve and adds the intestinal malabsorption to it. If appropriate, as resleeve can be done at the same time if there are any problems with your sleeve. The downside is that since the DS is more technically challenging for the surgeon, not as many surgeons offer it, so one sometimes has to look around to find one. Good luck!

Dumping, when it occurs, is primarily a function of rapid stomach emptying owing to loss of the pyloric valve, rather than the intestinal bypass portion of the procedure. The DS typically doesn't dump because it uses a VSG as its basis (so it preserves the pyloric valve) but it has a very aggressive malabsorption component. I don't know what the common practices are these days on RNY limb lengths, but it is specified to some degree by the insurance billing codes which define the standards of care for the procedure. When my wife was getting her WLS years ago, the surgeon mentioned at one point that when he did an RNY (usually because the patient's insurance wouldn't cover a DS) he liked to make them as malabsorptive as possible within the limits of the CPT codes. There is what is called a distal RNY which is much more malabsorptive than the standard proximal RNY that most get, but it is rarely done (at least in the US) as insurance rarely covers it. Within the normal proximal RNY world, there are some tradeoffs at play (when isn't there?) between amount of malabsorption within the legal limits on the long bypass side, and the threat of bile reflux is things are made too short. So, while it's a good topic to discuss with your surgeon if you are interested, I would go with their experience on this to get things right for your case.

Water is mostly absorbed in your colon, not your stomach, so the reduced size after WLS isn't a big factor. However, in the first few days or weeks, there can be varying amounts of inflammation in the stomach that can prevent fluids from flowing through normally, so we have to be doubly aware of our fluid consumption and sip, sip, sip water all day long to get enough during that time. But that usually only lasts a few weeks unless there is something wrong with the surgery (such as a stricture) that impedes flow longer term and I would expect your surgeon to find or eliminate that problem fairly quickly. At six months out, hydration shouldn't be a problem, at least not physically. How much fluid are you getting in per day?

My wife and I still see (well, talk to him - he's 3-400 miles away) every year (almost nine years for me, fifteen for her.) They include the first 18 months in the surgical fee. They are used to doing remote follow ups as they have patients all over the country, so have been doing that for years - other docs are rapidly learning how to do that now! Unless there is something seriously wrong where they need some hands on examination, there is rarely anything that can't be done over the phone/fax/email.

The DS folks are old hands at this, as that specifically malabsorbs fats; while the bypass isn't specifically known for it, there no doubt is some fat malabsorption going on there as there is some commonality in the sections of intestine that are bypassed. There are some D supplements that are water soluble (strangely referred to as "dry" form) that are commonly available from the usual Vitamin Shoppe/GNC type places, or online. You may also need to adjust the dosage; within the DS crowd, some, like my wife, only need one of those 50k pills every week or two (she varies depending on her labs) while others need one or two per day. Go figure - but that kind of individual variation is not uncommon.

If she is lethargic before she ever gets to the gym, that is a sign of a possible anemia problem (iron and/or B12) or a possible dietary problem - low carb dieting can do that to some people (we all do it to some extent just by virtue of the low calorie levels we are maintaining to lose weight, but some take it to extremes in the belief that it helps weight loss.) As AZhiker mentions, six month labs may point to something (she has had them done, right? if not, do so,) and if nothing shows there, than maybe a talk with an RD (dietician) can point the way. After around four months, I added some complex carbohydrate ahead of a workout to improve my endurance (a snack of high complex carb, moderate protein and low to moderate fat was recommended.) I was running into a wall after about an hour in the pool and that helped it quite a bit, but I had no problem getting to the gym in the first place. Most of us have lots of energy, usually from a couple of months post op, from losing all that weight, so something is abnormal here. Get some things checked out with the professionals before looking for some miracle product.

Yes - this is a transition, rather than a step change (liquids only, then next week no liquids and just mushies). Try new things one at a time to check for your tolerance to it - if it goes well, then great, add that item to your menu and continue trying new things. If it doesn't, try something else and try that item again in a couple of weeks. Our program gave us the option to transition between the liquids, mushes and soft things as we could tolerate them, and go back and forth as needed (scrambled eggs, yogurt and pureed thing in the hospital). You usually wind up with a blend of things on the menu for a while as most protein will still come from shakes as that is where you can get the volume needed, but the stomach usually appreciates the "physical therapy" of working on small amounts of the more solid things.

I can't quite remember how long my wife's was, but I think that it is usually in the 2-3 hour range but can be much longer (6-8 hours) if a patient presents complications (extremely obese, lots of prior surgeries leaving adhesions, etc.) Also, some docs do other associated procedures along with the DS, like gall bladder and/or appendix removal.

Have you had any medical evaluation of your GERD other than just what you are feeling - an upper GI or endoscopy to see whats going on in there to cause it? Self diagnosis is not a good start toward a revision. The VSG has a predisposition toward GERD owing to the stomach volume being cut down much more than the acid production potential along with its high pressure character (much like the RNY is predisposed toward marginal ulcers, dumping and reactive hypoglycemia owing to its specific quirks.) If your GERD is a simple result of the above VSG factors, then revising to a DS won't help the situation; an RNY is the more typical solution. However, if your GERD is caused by a hiatal hernia or a malformed sleeve (strictures and the like) then it is not unreasonable for surgery to correct that particular problem will do the trick; a DS in itself will not do anything for GERD as it will use your existing VSG as a starting point - a re-sleeve may be done at the same time depending upon need. Revising to the DS will help some with losing some regain but mostly will help avoid future regain, but revisions in general are typically only marginally successful in treating regain. I can't speak for your specific insurance, but generally insurance will cover any medically necessary revisions for treating complications.

That does give you an indication of their priorities! The practice my wife and I used was proud of the extensive collection of bariatric furniture they had, and also the fat suit that they used in training new staff so that they have some feel for what their patients were going through living as a fattie. Maybe your guys are trying to "shrink" their world around their customers to encourage them to shrink along with it. Probably not the best approach, but it does give you some idea of what you will be putting up with over the next few months. Maybe consider a change in practice to one who is more patient focused? Even our local hospital has a decent selection of fat chairs in their various outpatient clinics (just for the general population, not just in the bariatric clinic.)

One of the characteristics of the gastric bypass is that the caloric malabsorption that you have initially which helps with your weight loss that first year, dissipates after a year or two (unfortunately, the nutritional malabsorption persists, so you still need to take your supplements!). So, if you lost all your excess weight within the first year and were stable at, say, 2000 calories per day, after 2-3 years your stability point may only be 16-1800 calories and you have to cut back a bit to compensate. With the VSG, I didn't have that extra bit of malabsorptive help in the losing phase so my loss was maybe a bit slower, but then I didn't have to compensate for its loss as I worked into the maintenance phase. Beyond that, we all have (with any WLS) the tendency to experience portion creep as get more comfortable with our new life, our diets become more varied and we get more casual on tracking things.

Dr. Roslin is one of the good guys - he is on the short list of guys I would be talking to if I lived on the East coast. Most of the guys that don't do the pre-op thing also tend to have more rapid progressions post op, which usually helps in healing and recovery (we were on mushy and soft foods in the hospital, along with liquids as needed.) Sitting on liquid diets for weeks on end pre- and post-op, the stomach forgets how to do its job and has a harder time re-learning what it is supposed to do. So, it's best to avoid those liquid pre-op diets when we can.

Mine was similar to yours - just the day before surgery, with a bowel prep the afternoon before; congratulations - you have found one of the better programs out there. One of the prominent DS docs that I know quite specifically wants his patients as strong and healthy as possible going into surgery, and fasting on one of these diets for weeks ahead of time doesn't do it. It is not unusual for programs to specify a couple weeks of pre-op diet to help "shrink" the liver, as some surgeons may have problems in that area (while others, such as yours, seem to know how to work in that area without that imposition on the patient.) Some go so far as specifying a liquid only diet for a couple of weeks (or more) and I have never found a good explanation of what that is supposed to do (compared to a more conventional low carb diet). I would avoid programs that go that far.

It sounds like someone in the surgeons office coded things wrong, and they are evaluating it as a weight loss revision rather than as complication revision

It will vary from person to person within your surgical population, but your program will put out a recommended starting point and maybe specific products. But, after a few months or a year or so, your labs will dictate what is needed. For instance, those with the traditional BPD/DS will usually start out with a dry ADEKs tablet (water soluble version of the fat soluble vitamins A,E,D and K) in addition to iron and calcium (and probably a multivitamin). But after a lab test or two, most will drop the ADEKs and go with individual vitamins as they will find that, for instance, they need more D and K and less A and E. So, it's not worth worrying too much about what product to take initially, as at best it is an educated guess. But any of them will be a good starting point from which you can make later adjustments.

Likewise, check with your doc or pharmacist on specific instructions, but think of sucrafate (and the currently much more expensive liquid version, carafate) as industrial strength Pepto Mismol (at least the description in their commercials) in that it coats the stomach to protect it and relieve irritation, allowing it to heal. Eating or drinking after taking it washes it away. My gastro put me on it for a while, and when talking to him about this - that since I ate 5-6 meals a day and drank water in between, it didn't make sense to follow the typical directions. He said, 'you're right, just take it overnight.' Now, that was fine for my needs, but may not be appropriate for you, so talk to your doc.

I don't think that you will find much in specific threads on this, as it can be quite individual. First off - do you have a "traditional" BPD/DS, or the newer SIPS/SADI/"Loop DS"? I know Dr. Roslin does both, but that certainly plays into this. If you have a BPD/DS, that specifically malabsorbs fats, more than the RNY or SIPS, so will have a somewhat different character. Some DS folks go on about how they "need" to have lots of butter, bacon and cream, but that's mostly an individual interpretation on their part rather than medical direction, though medically one doesn't have to worry much about low fat eating. My wife (DS class of '05) eats a lot less fat than many claim is "essential" yet gets along just fine. The main compromise is that too little fat can leave you constipated, while too much can leave oil slicks in the toilet (kind of a hardwired Xenical effect) and one needs to find the right compromise between the two, and that comes with experimenting. How the DS was done plays into it as well, as there can be substantial variations in how surgeons perform it - common channel length and how the rest of the intestines are split up. Your best bet would be to check with Dr. Roslin's staff and see what they recommend and go from there, still keeping in mind that you may vary some from their "average" experience.

I never did - I put too much effort into developing decent dietary habits centered around a balance of high nutrition foods to toss that away in favor of the "flavor of the day" diet. People used to obsess over fat counts, and that did just as good as obsessing over carb counts. At the end of the day, you have to figure out what works best for you and go with it; otherwise, you just wind up chasing the diet of the day, What's next after keto? Does anybody still do Zone, or South Beach?

The key here on a surgery decision is how well can you maintain the loss that you attain? It is not unusual to lose 10-15 lb fairly quickly when one starts a serious weight loss program (the so-called "easy ten") as your body tends to use up its quick energy reserves of glycogen (basically stored carbohydrate) which burns off fairly quickly. On average, we have 2 lb of glycogen kept in solution by about 8 lb of water - the "easy 10". YMMV, but I suspect that guys tend to store a bit more as we are more muscular, and glycogen is stored in the muscle tissues. Once your body runs out of glycogen and it gets the idea that you are serious about this caloric deficit thing, it changes gears and starts to tap your stored fat to live on and to partially restore functional glycogen levels, but there may be a bit of a lag or stall before that happens (look up the three, or third, week stall) It is very common for people to go through a pre-op weight loss program of some months, either for insurance purposes or as a "one last try..." and lose a lot of weight and think they have this nailed, and decide against the surgery. And then the weight comes back on, just as usually happens after major diet efforts (which is why most are here looking for WLS.) I did the insurance diet in concert with my wife, who was #1 on the runway - much higher BMI and comorbidities - and lost about 50lb or a third of my excess in that time. Philosophically, it was less of a weight loss oriented diet as it was a weight control or maintenance diet - what habits do I need to develop for 5-10 years out to maintain health and weight, rather that maximizing short term loss. As we were still trying to get my wife on the table (the DS she needed was still considered "investigational" by many insurers at the time) so I went into sustain mode - kept up tweaking the diet to keep it sustainable but made little progress on additional loss, but also maintained the loss that I had accomplished. Even after she finally had her WLS I maintained the loss and didn't feel overly inclined to go for the WLS (the VSG was not routinely performed or approved by insurance yet at that time, and I deemed the DS and RNY to be overkill for my needs.) Once the VSG was being approved by our insurance, several years later, it was apparent that I still needed that help to get the remaining weight off, though I was still maintaining that initial loss; had I regained what I had lost as is often the case, I would have gone for the DS instead, as that has much better regain resistance than the other procedures. So, by all means, think, rethink and reconsider the process and be comfortable with it. But do take a long term look at it, not just what weight can you lost over the next 6-12 months. Good luck on it!

Anytime that I see someone contemplating a revision, I would advise getting a second (and even third) opinion, both from the perspective that revisions are typically more complicated than a virgin surgery, and also the reasons for the revisions are more varied, and this is where the perspectives of different surgeons with different experiences is most valuable. Strictures and twists like you are describing are an indicator of technique problems (which isn't to say that there is something particularly quirky with your individual anatomy that would have caused problems with any surgeon, just that they are frequently associated) so it is quite possible that another surgeon who is more experienced specifically with the sleeve and sleeve related surgeries may have some other ideas of how to tackle your problem. There are some surgeons out there who routinely perform some very complex revisions (such as converting a problematic RNY to a DS) and this is the type of doc that you would like to consult with, as they would be best able to straighten out your sleeve (and if they concur that an RNY is the best approach for your particular problem, that provides a lot of confidence in deciding to go that route.) I tend to like DS surgeons for sleeve problems as they typically have a lot more experience with the sleeve and correcting sleeve problems (as the sleeve is a part of the DS, most of them have been doing sleeves for over twenty years, while most bariatric surgeons have been doing them part time for 5-10 years, and some less. https://www.dsfacts.com/duodenal-switch-surgeons.php gives a very incomplete listing of DS surgeons, and unfortunately, there aren't any very close to you - NY/NJ/PA area is the closest, but probably worth the effort; most can do initial consults over phone and email. Dr. Roslin in NYC and Dr. Greenbaum in NJ both have good reputations in the DS world for complex revisions. As a side note, the mini bypass isn't often done in the States as US insurance rarely approves it, and it has never been accepted by the ASMBS.

Doctors' programs and, as AJ noted, patients as well, vary widely on this based upon surgeons' experiences and philosophies and patients individual quirks. Some docs may have had a difficult patient once, so they treat all of their patients as if they, too, will be difficult while others tailor things more specifically to patients' needs. Generally, a week in each phase works well for most, with some needing more time while others could progress more rapidly. Our program had us on mushies and soft things in the hospital - if we could tolerate them (some could, some couldn't) but liquids were always an option and we could experiment within their basic limits as we could tolerate. Their general finding was that patients do better as they moved into more real foods, as the GI tract needs to be stimulated to remember what it was doing before surgery. This may also help explain why some who were on extensive liquid diets (including pre-op) often struggle to transition to more solid foods. As noted by others, follow your doc's particular plan (you hired him for his expertise, after all...) as it is what they have found works best for them. (and if anything goes wrong, you will get the blame for not being compliant, even if your action has nothing to do with the problem.)

My doc will take a feel and remove the gallbladder if he feels stones in there, otherwise he leaves it alone. That's with the VSG; with the DS he removes it as a matter of course as he doesn't want another surgeon getting lost in the altered anatomy should it cause problems later.