RickM

With a sleeve, you don't have an anastomotic stricture, as you ask about on your other thread, as you don't have an anastomosis - this is more of an RNY thing. Strictures with the sleeve are usually due to surgical defects, and as catwoman relates, usually show up early. I suppose that it is possible that you have a twisting stricture in your sleeve that can be delayed (as things are always moving around some in there) but that is nothing that you just want to "just live with" as that can also lead to loss of the blood supply to the stomach leading to loss of the stomach via necrosis (the tissue dies). Not a good way to lose that regain. Not to be alarmist, but worst case scenario is that there is something growing in there that you really don't want growing in there - either in the GI tract or outside of it putting pressure on it. There is a whole laundry list of cancers that can do this, so it is best to get this checked out, as the sooner you find out what is going on, the better. It may be something entirely benign, but it is best to know just what is going on. And soon. Good luck,

My read of it is that they aren't specifically talking about weight loss diets, but general good health, so a 2000 calorie diet is the typical "standard" adult diet (that's what most of the RDA's are based upon - then you adjust those according to what calorie level is appropriate for your individual weight maintenance needs.) Their findings aren't really anything new, but merely a continuation of the evolution of nutrition science, which still holds that for optimum health we need a balance of various micro and macro nutrients, spread through the various food groups. One of the salient points they bring up, one that I have long followed, is that the quality of the food, whether they be carbs, fats or proteins, is a lot more important than the quantity. This is why these fad diets that hold to certain magical macro counts or ratios tend to be pretty silly - and we see that sometime in these forums. Some may hold to that magical 20, 30 or 40g carb count, and then skip the "carbs" in that apple or broccoli to save up for that Snickers bar in their carb budget. I never worried about carb or fat counts while I was losing (and still don't) as the restricted calories and protein minima in the early post op world took care of that; rather I just worked to maintain as healthy a balance of foods as I reasonably could within my calorie budget; on average I ran around 100g of carbohydrates per day, but I was still working to slow down the loss rate at the six month mark. I actually increased my average carb count selectively at around the 4 month mark to promote better exercise endurance, and my weight loss trends improved (they stayed steady rather than declined as is typical) as that probably helped promote a marginally better calorie burn rate. The other benefit of using a more "normal" diet during the weight loss phase is that the transition to maintenance was much easier, as my maintenance diet is fundamentally the same as the "loss" diet - just more calories from the non-protein side of the diet spectrum (as protein should already be at a maintenance level during the loss phase.) I didn't have to learn a new diet for maintenance, nor have to switch diets to lose again if needed - just adjust the calories as needed.

It didn't seem to bother me; I haven't seen much that the quickie week or two diets do to prepare one for the "afterlife", as those first few weeks one doesn't usually feel like eating much beyond what one can tolerate in the mushy regime. I can understand that some programs may hold patients on liquid diets long after what is therapeutically necessary, so those may feel the need to put them on an extensive liquid diet pre-op to "get used to it". But this can be something of a self-fulfilling prophesy, as the long liquid diet pre-op may well require a long post op liquid phase as the GI tract has "forgotten" how to process anything else and has to re-learn it. Our program's experience over the years has been that patients tend to do better the sooner they get back onto "real" foods, and generally accommodates that end, to the extent that patients' tolerances permit. Absolutely! The docs have developed, or adopted, practices that work best for them, and we want to cooperate with them for best results. Some may be very sensitive to the fatty liver issue and really need their patients to do all they can to minimize that potential problem for them to do their best work, while others may be entirely comfortable working in that environment and find that they get better results with quite different protocols.

I didn't have any pre-op diet from the surgeon, other than the usual day before surgery thing (though I was obliged to do a six month thing for insurance approval, though it was nothing that would fit the definitions of the typical "liver shrink" diet.) Docs vary all over the map on the need for such diets, and in what should be done for them if they require one, from those who impose weeks of liquids only and tell their patients that they will close them up and send them home of they don't comply (and occasionally one actually follow through with such threats - there's one to avoid!) to those who specifically don't want their patients fasting for weeks prior to surgery (they want them as strong as possible going into this.) Congratulations on finding one of the good ones!

The main thing that might cause a problem is overdoing the artificial sweeteners - some will experience different forms of GI distress from certain ones (which can differ between individuals.)

The RNY is fundamentally the same thing procedure that is done for gastropareses under the heading of "partial gastrectomy" (and in some cases a total gastrectomy may be done.) Limb lengths may be a bit different if weight loss is not an issue, though there may be other trade offs in doing so (for instance, bile reflux tends to be more common with shorter limbs for less malabsorption and weight loss.) There are some useful Facebook groups that cater to total and partial gastrectomy patients that are worth looking into, and will have more people in this situation.

This is one of the things that programs are often poor at - telling us how long we need to do some of these things such as sipping. Basically, as long as you need to (that helps, right?) as some may have a lot of inflammation and may need to for quite a while, while others may be able to drink fairly normally straight away. Just work yourself up slowly, trying a bit more each time. Avoid gulping as that may put too much down at once and it will come back up. Remember, your pouch is maybe an ounce, give or take, of capacity, (a sleeve, maybe two or so,) so use that as a guide as to how much at a time.

It sounds promising - at least they are talking the right line, lol. I like to think of WLS as a do-over - it won't fix everything (particularly the head games) but it helps get you back to where you should be, and then it is largely up to us to maintain things from there. We often hear of some who regain most, all or even more than they lost from their WLS, and the most common cause of that is not doing the head work and simply going back to the habits that got them into trouble in the first place. One thing to consider in your long term planning is that over time (years) your meal volume slowly increases - not as far as it is now, but maybe half that volume typically, and this is something that you should plan for (you won't be eating two tablespoons forever!) I don't get along with everything he says, but his volume progression is consistent with my experience, and whether or not one gets along with his suggestion as to how to counter it, it is something to consider as we progress through this adventure, What may work just fine after a year, may lead to some regain after four or five, if we aren't vigilant. His approach of filling in that added volume with bulky, low calorie veg is a good one, but may not be for everyone - but think of how you can handle this quirk of our WLS that suits you.

It's great that you have insurance that doesn't require that particular hoop to jump through - they are getting more rare every day. As to the surgeon's requirement for a six month diet, whether it is worthwhile depends upon what its intent is. If it is just to get you to lose X amount of weight before surgery and they are putting you through some kind of weight loss diet program, then it probably isn't worthwhile, and may even be detrimental, If you were starting at 500+ lb, then yes, you would need all the help that you can get, as the wLS only goes so far on its own. But at your weight, as a guy, you will likely be trying to slow things down by six months post-op (as I was, starting at about the same stats.) If, however, they are helping you to learn how to eat and maintain your weight in the long term via an overall healthy diet, then it can be quite valuable. When I started this, in parallel with my wife going through it, we had to do the six month thing for insurance. They didn't have much in the way of requirements other than "medically supervised" so we studied up on nutrition and worked to improve our diet - what should it be five or ten years out - any short term weight loss was incidental (but in my case turned out to be about 50 lb, getting down to your level.) As it turned out, I delayed surgery for several years (it took a couple to get my wife on the table, after serial insurance denials) but I maintained that loss all that time, using the WLS to finish the job and get down to normal weight, which has likewise been maintained fairly well since then. I have seen some good programs with some docs, that did a good job teaching and helping the patient transition to a better, more sustainable long term diet, and I have seen some pretty crummy ones that were little more than one short term fad diet or another, but did little other than promote yo-yo dieting long term. My inclination would be to ask more questions along with researching other programs to consider. Good luck on this venture!

In general, we should follow our program's instructions; however, if you are being held up by scheduling issues rather than their progression calendar or individual problems, then I agree with livdacovich and give them a call - 2 months on purees is insane (as a general rule - some rare individual circumstances may require it.) We were on a puree diet, including eggs, in the hospital, so there is a huge YMMV thing going on between programs - some will allow steak at the same time that others are still on liquids. This is one of the things about these different programs that is really interesting (and a bit concerning) to me - are the ones with slow progressions doing so from experience (they tried going faster, but their patients had problems) or inexperience ("that's the way we've always done it..." and they never bothered trying anything else)? Is there something about the techniques that a surgeon uses that requires a slower progression, or conversely allows for more rapid progression? As patients here, we don't really know. There are lots of stories and urban legends on the internet about someone's sister-in-law knew someone who died from something they ate ahead of time (and some doctors or staff may repeat them to encourage compliance.) I have noted that several of the legacy DS/VSG programs are similarly quick progressing to what I went through - is there a difference between a sleeved stomach and a pouch in that regard (I don't know if my program differs any in that regard with the RNY as they rarely do them anymore.)? Give your doc's office a call when you would normally be scheduled to advance and ask about it. Good luck

The body fat scales measure impedance (electrical resistance) between your feet (or in the better ones, between your hands, too.) As such, they are sensitive to your body's water content - hydration - so variations in your hydration will change the readings. On mine, there was a 4-5 point difference between first thing in the morning, when we tend to be dehydrated, and late afternoon, when we tend to be more fully hydrated. So, being consistent with time of day is important. There can also be a point of two difference day to day from simple hydration variations due to diet, activity, weather, hormones, etc. Of course, there can always be differences between scales (or any other measuring instruments.) The most accurate way to measure body composition is via autopsy, but that has the undesirable side effect of having to be dead first. Next best is generally considered to be DEXAscan, which is pretty good, though there can still be differences between machines and even software loads (as it is dependent upon large population datasets.) Hydrostatic, or water dunking, (or the related BodPod, which uses air instead of water) is next best, but may be a bit quirky for us former fatties as the excess skin that we often have can create some errors in the results. The calipers are generally considered to be the least worst, as they are very dependent upon operator skill and experience to interpret the results, and given the problems of skin condition (excess) that we typically have, they are virtually worthless for us. I have found that the scales work fairly well if you have one at home and use it consistently, same time each day. Given the day to day hydration variations that we can have, it is only good within a point of two. I found that using a moving average of daily measurements worked well - as I was losing, I may have seen BF readings in the 32's and 33's, after some time I would start seeing 31's and the 33's dropped away, so I was consistently in the 31-32 range, and so on. It couldn't reliably show may anything closer, but that's a pretty good ballpark. How much variation would one see if you did a DEXA or dunking every day (I suspect similar, but maybe a bit narrower bandwidth on the variation.) Using this method, the scale was pretty consistent with the water dunkings that I had done. The way the scales are used in gyms and doctors' offices - read at month or more intervals - they are of limited value (even detrimental) as the variations from time of day and day to day hydration levels overwhelm whatever true changes have actually happened since the last reading. I played with the one in our surgeon's office when my wife was going through her surgery, and over the couple of weeks that we were in town for it, I had "gained" about 10 lb of muscle mass with no weight change. Right - from walking around the hospital and SF some every day! For the OP, if you can, try to use their scale each time you go to the gym, preferably before working out and dehydrating yourself, and keep track that way. Your readings may or may not be "accurate" on an absolute basis, but relative to where you are now and in the future, it should give some useful insight into your progress, Note, that mid teens BF% is quite lean for a woman (though about average, or "normal" for a man,) while mid 20's is "normal" for a woman. Mid teens was my target when I was in losing mode. Good luck in further progress!

Our program's basic standard was to shoot for an ounce (28 ml, for those so inclined) every five minutes; if you can do that, great, if not, do what you can do. Some have a fair amount of inflammation in their stomach post op which makes it like dribbling the water through a pinched soda straw, while others have little swelling in there and the water flows through fairly easily. Just sip a little at a time and see how it goes; if it goes easily, try sipping a bit faster, but if it threatens to come back up (or actually does) then slow down and do what you can - it will resolve in time. I had little problem and was able to go through a bowl of broth (6-8 oz?) and a 4 oz juice box in one sitting (half hour?) in the hospital; my wife on the other hand was much more restricted and it took a while to resolve.

I looked into this 3-4 years ago when it was one option in handling a cancer scare. There are several Facebook groups catering to the partial and total gastrectomy crowd which I found useful, particularly in bringing up topics to discuss with the surgeon. One of the concerns was that bile reflux seemed to be a relatively common problem (much more so than with its' close cousin, the RNY gastric bypass.) The surgeon's experience was that if he kept the limb lengths above a certain minimum (IIRC, 80 cm) there was no problem with it. This would make some sense, as most of those patients were starting at normal-ish weight rather than morbidly obese, so the temptation is to keep the limbs short to minimize malabsorption and weight loss - something that is not a problem with most of us! It is certainly something to discuss with the surgeon, however. Recovery time with a TG, seems to be a lot longer than even an extensive PG (partial gastrectomy - basically an RNY). The doc does use a J tube for feeding for some weeks or months with a TG, but basically a normal WLS post op diet progression for a PG. It seems the esophagus is only a double layer structure, contrasted with a five layer structure of the stomach, so surgically, and healing-wise, there is a substantial difference between connecting the esophagus directly to the intestine, compared to using a small piece of stomach as the connection. Longer term, there seemed to be little difference in living, as they form a small pouch from the intestine similar to what is done with the stomach in the RNY or PG; it's just that the recovery and transition was longer and harder with the TG than with the PG, though there may be a bit more potential for reflux with the TG, as the lower esophageal sphincter (the valve that keeps things from backing up from the stomach into the esophagus) is usually removed along with the remains of the stomach. Remember, it may not be a big deal for the surgeon to do these things - he isn't living with it! It does seem that, if at all possible, it is worth keeping even a small section of stomach as a transition, rather than going direct from esophagus to intestine; it may not be all that much different in the long term, but the healing and recovery do seem to typically seem to be a lot easier. Good luck with this all (you've already been through enough!)

I have never found a good explanation of what the liquid pre-op diet actually does. Yes, clean out the stomach and intestines before surgery, but that only takes a day, or a few hours. Shrink/improve the liver condition - yes, sorta, but that doesn't take a liquid diet to do, just one that is low in carbohydrates. Annoy and/or punish the patient for being obese - most certainly! Make the post-op recovery and diet transitions more difficult - quite possibly. Most aren't required to do a liquid diet pre-op, but rather some kind of hybrid with a light meat/veg meal or two and a protein drink or two per day, and many others aren't required to do anything special at all.

Yes, many need to do three to six months of dieting for insurance approval, and some have already lost substantial weight ahead of time, yet some programs still insist on these diets, cookie cutter style. I fully appreciate a surgeon who can look at a patient as an individual, and consider their unique circumstances rather than lumping everyone together.

I don't necessarily, either, though that would be the opinion of some surgeons relative to some of their peers - it is not unusual for surgeons to have a bit of a God complex, given the nature of their work. I don't mind a surgeon requiring some kind of "liver shrink" diet if they are sensitive to that issue ("a man's got to know his limitations" in my best Clint Eastwood voice...); however, from what I have seen over the years, the need for a liquid only diet, other than the day before surgery, is very questionable, and may indicate a bit of a disregard for the patient (maybe a bit of a "that's the way we've always done it" approach.) Whatever the reasoning, given that there are plenty of surgeons out there who don't do liquid pre-op diets (or any diets in many cases), and perform these procedures as well or better than those who do, I would stand by my opinion to avoid those who do impose them.

Foods like yogurt are pretty slippery and soft, so you usually don't feel the restriction or satiety with them that you do with something more solid like meat or cheese, so it is quite normal that you can eat more yogurt than the nominal 2-3 ounces that is often stated. I could likewise go through a normal 5-6 oz yogurt serving at that time, though I usually just kept it to 4 oz as that was adequately satisfying for me, and provided enough protein for that particular meal/snack (though by that time I was also throwing in a few berries for added nutrition and variety.)

From what I can tell, the liquid diet requirement isn't as common as it might appear- it only seems universal because those who have to do them complain a lot about it, while those who don't have to do it have nothing to complain about (it's called adverse selection and is fairly common in internet forums.) It seems that for those programs who do some kind of pre-op diet, it is more common (and more sensible) to do some kind of diet with a meal or two per day of meat and veg (or a low cal frozen dinner) and a protein drink or two.) I've never seen any viable explanation as to what the liquid diet does that a basic low carb, calorie controlled diet doesn't do (other than annoy the patient!) Our doc doesn't do any pre-op diet, other than the usual day before GI surgery thing, no matter what BMI the patient is, and the doc who runs out support group now quite specifically doesn't want his patients doing such diets - he wants his patients as strong as possible going into surgery, and fasting for weeks ahead of time doesn't do it. So. there are lots of docs with differing philosophies and practices out there. Personally, from what I have seen over the years, I would avoid the ones who do those liquid pre op diets as, at best. there are other ways to accomplish the same thing with less trauma on the patient, and at worst, it may be a crutch for a doc whose skills aren't quite up to scratch.

Yeah, the recommendations vary from doc to doc. Early on, most surgeons simply copied their RNY protocols for their sleeve patients - diet, supplements, drug interactions, etc. Those who had been doing sleeves for a long time - primarily the DS crowd - had lots of experience indicating that NSAID use was fairly benign (indeed, that was one of the selling points for the DS or VSG over the RNY.) As more got familiar with the sleeve, they often loosened up on their restrictions. At the same time, the medical world in general has become more cautious about NSAID use in general - for everyone - so we have two conflicting trends. The main point is that there is a physiological difference between the two procedures that influence their relative tolerances for these meds, and that is something that should be considered in these decisions. Ideally, none of us will need to take these meds, but the world isn't ideal, and that's where these compromises come into play.

I started playing with small salads after about a month - doc had added veg to my diet after ten days as my protein intake was already more than adequate at that time. I generally use chopped spinach rather than lettuce owing to its somewhat better nutritional profile; for some reason. lettuce seems to be one of those things that some have a hard time tolerating for quite a while, though I had no problem with it. I usually made them as part of a normal protein based meal rather than an add on. I cut back the meat of a normal meal from a nominal 3 oz to 2 oz, then added a few grams each of chopped spinach, grape tomato, avo, snap pea, scallion, cheese, bell pepper, etc. (whatever we had around...)

Any of these procedures may predispose you to some kind of problem as a result of the anatomical changes that the surgery makes; this doesn't mean that you will have such a problem, just that the problem shows up in more often than in the general population. With the sleeve, the main predisposition is for GERD, as a result of cutting back the stomach volume more than its' acid producing potential - usually the body adapts and adjust things over time, but sometimes it doesn't. I have mild GERD which is well controlled with mild OTC medication; a few get it so severe that no med controls it and they have to get their sleeve revised to correct it, while others - most people - have no problem with it at all. GERD problems may also result from poor surgical technique, and was more common when the sleeve was new to the WLS world 8-10 years ago and most surgeons were still figuring it out (this is why I traveled to a practice that had already been doing them for some twenty years, so avoid this kind of "learning curve" problem. Most surgeons in the US today are experienced enough with it that this isn't much of a problem anymore, but it does seem to show up more in countries that are farther down that learning curve, such as Canada and Australia. People with the bypass will also sometimes develop GERD, though usually more in line with general population numbers, and seems to often be associated with chronic over eating, volumetrically if not calorically.. This may also be why some with the sleeve also develop GERD after some years. The bypass is predisposed to dumping and its close cousin, reactive hypoglycemia, as a result of rapid stomach emptying from the lack of the pyloric valve in the active GI system metering the stomach contents into the intestines. Some people with the sleeve, or even no stomach surgery at all, may dump as well, but it is rare. It is generally controlled with additional dietary restrictions. The bypass is also predisposed to marginal ulcers, typically around the anastomosis between the stomach pouch and intestine. This is a result of the section of intestine being used not being resistant to stomach acid like the duodenum is (the part of intestine immediately downstream of the stomach in the natural anatomy, which is bypassed along with the remnant stomach in the RNY), leaving a very sensitive suture line that is easily irritated. This is why NSAID pain relievers and other similar medications are a big NO-NO with the RNY, but are better tolerated with the sleeve based procedures; one still needs to be cautious with them, but they are more usable with a sleeve than a bypass. For the benefit of the OP, with no prior GERD history, but a history of orthopedic problems, I would be inclined to go with the sleeve, owing to its better tolerance for the various pain relievers that you are inclined to need at different times. Good luck - none of this is easy, as it is often a matter of trade offs, and sometimes it's less a matter of good vs. bad as it is bad vs. less bad, or bad vs. not-great.

I can't speak for your specific case, but in general, the liver is stressed by metabolizing all of that fat that we are losing so quickly - this is why many surgeons advise against consuming any alcohol during that first year or so of rapid weight loss (the liver doesn't need any additional stress from a liver toxin like alcohol). So, liver numbers in blood tests are often abnormal for a while during this loss phase and for some time after; whether that extends to a physical fatty liver diagnosis from an ultrasound, I don't know. My surgeon is also a liver guy (does transplants in his "spare time") so these things get discussed in general in the support groups, though I never had occasion to talk any specifics with him. It is hard to say if your surgeon is just being casual about it because what he sees is fairly normal, or is something beyond his job description and experience. While they may not have anyone else within the bariatric department who is more knowledgeable, they certainly have a liver disease department there that will have a hepatoligist that you can talk to. The problem is that they may not be that familiar with bariatrics and rapid weight loss so may want to go farther in treatment than is necessary - they may need to get their heads together between the two departments to determine what is really going on. Good luck...

Your initial couple weeks or so of loss includes a lot of water weight, as you body gets used to the large caloric deficit and struggles to get used to operating on so little (that initial loss is primarily glycogen - stored carbohydrate - which comes off quickly and includes a lot of water that keeps it in solution. Once that has burned off and the body gets the idea that you are serious about this caloric deficit thing, it finally decides that it needs to get serious and start drawing on your fat stores, which comes off more slowly. So, yes, it is normal to lose a lot the first couple of weeks, and also to stall a bit and not lose anything for a week or so, and then start losing again, but more slowly. Long to intermediate term, figure on 1-2 lb per week (5-10 lb per month) as a good sustainable loss rate, with some weeks or months being above or below trend. For instance, my loss, starting from a bit under 300 lb, was 32 lb the first month, followed by 15, 15, 10, 10, 10, by which time I was within about 10 lb of goal weight and started ramping up my calories to slow things down. Also, figure on your loss rate declining over time - it simply takes fewer calories to move your body around 24/7 when you weigh 250 vs. 350. This trips up some people, particularly if they increase their intake after a few months - increasing intake meets declining calorie burn and you reach stability, whether you are at goal or not.. So try to maintain a fairly low intake at least until you are within sight of your goal weight. Good luck!

It is difficult to compare the two directly as few surgeons do both, (Mitchell Roslin in NYC is the main one I can think of that actively performs both) so there a lot of variables that get in the way. The DS is indeed the most powerful procedure commonly available, but it is also the most complicated to do, which is why few surgeons offer it. It has been around since the late '80's, it is one of the procedures endorsed by the ASMBS (along with the VSG, RNY and bands) and accepted by US insurance as a mainstream WLS procedure (they can't call it "investigational" any more since Medicare started paying for it.,) The SIPS (SADI, Loop DS, and other names that it goes by,) is newer and not as well established, nor quite as standardized, as everyone is still figuring out the optimum configuration. It is being promoted as being "almost as good as" the traditional DS, but "more accessible" - simpler so more surgeons can offer it. The hope is that it will fall somewhere between the RNY and DS in performance, with fewer side effects and limitations than either. If that holds true, then it will earn a spot in the WLS world, and if not, it will be another procedure that doesn't quite make it, like the "mini" bypass. Most of the BPD/DS surgeons don't offer the SIPS as they don't need a simpler procedure, and already have the VSG for the less challenging patients. Here is one very biased opinion on it from one of those surgeons: https://www.dssurgery.com/weight-loss-surgery/sadi-sips/ The position of the ASMBS on the matter: https://asmbs.org/resources/position-statement-single-anastomosis-duodenal-switch and, here is Dr. Roslin's take on it: https://www.nycbariatrics.com/weight-loss-surgery-options/sips-procedure Dr. Roslin is well quaiified on the BPD/DS (and is one of the few with the skills to do the very complex RNY/DS revision) but it seems that he is actively working on the SIPS for the greater good of the WLS community as a whole - that "almost as good as, but more accessible" concept that can hopefully benefit more patients over the long run. At this point, only time will tell. As an individual decision for right now, that's a tough one. With your regain history, I would be inclined to go the the well established BPD?DS, as that has proven to have the best regain resistance, but that would likely involve travelling for you (I don't know of any DS docs in MA, but there are several in the NY/NJ/PA area.) It is good to see that you are doing the "head work" as that is an essential part of any of these procedures - one can "eat around" any of them, though it is harder to do with the DS. One of the things that I have found to be helpful is what this doc covered here - One of the things that doesn't get covered much by other surgeons is that our eating capacity does increase slowly over time, and this is something we have to compensate for. One may or may not get along with this doc's prescription for a veg first diet, but it does make sense from the perspective of filling in that added capacity with bulky, low calorie veg. Think about it, discuss it with your therapist, and maybe you find a different approach to handling this problem. Good luck!

Things to try - take the omeprazole in the evening instead of morning since your problem just seems to be overnight - timing shift may be all you need, but if not... try 2x per day, or another drug in the PPI class - Protonix, Nexium, Prevacor their generic OTC analogs try adding an H2 inhibitor such as Zantac, Pepcid, or their generic OTC equivalents in the evening - this class of drug, while less effective overall than PPI's, is reputed to be particularly effective for overnight reflux, and has less worrisome potential side effects than PPI's.