RickM

Actually, with the DS (at least the "traditional" bileopancreatic diversion (BPD) DS. bile reflux is near impossibility, as the duodenum is split between the bile ducts and stomach, forcing the bile and pancreatic enzymes to flow downstream some ten feet or so (depending on individual variations) until it hits the common channel where it meets the food flow and actual digestion can occur; for it to reflux into the stomach, it would then have to flow back upstream some 4-5 feet or more (again, depending upon individual variations) before it could get to the pyloric valve and reflux into the stomach. The newer "simplified" SIPS/SADI/Loop DS is more of a classic Billroth II configuration (cousin to the RNY) where bile reflux may be possible, depending upon how the surgeon sets up the limb lengths. With the RNY, like any Billroth II based procedures, bile flows downstream from the bile ducts and can reflux into the stomach pouch. The main counters to this is neutralizing the bile with stomach acid from the remnant stomach, and limb length between the bile ducts and pouch. Bile reflux is not uncommon amongst cancer patients who have had a gastrectomy, where the basic layout is an RNY without the remnant stomach, The surgeon that I worked with when I was considering this told me that he has never had any bile reflux problems if he keeps that limb length at 60cm or above; presumably, some of these cancer patients received a shorter limb in an effort to minimize malabsorption and weight loss. As with many things in life (and medicine in particular here,) there is a balance between the therapeutic and objectionable side effects - and people will vary as to where that balance may be in their particular case. Perhaps the OP experienced classic RNY marginal ulcers from the acid incompatibility with the intestine and anastomosis, and in the process of these serial revisions, wound up with an overly short jejunum? Hopefully she can get this sorted out, but the DS does provide something of a last ditch option of other avenues don't resolve the problem; unfortunately, such revisions are very complex, and there are only a half dozen or so surgeons in the country with the skills and experience to perform it. Perhaps a distal RNY, where they move the pouch waaaayyy down the intestines toward the colon may be a middle ground that might do the job.

Sometime in the first week after I got back home. Your weakness and lethargy is unlikely due to vitamins, but just a hangover from the surgery as you go through the initial healing, and quite possibly a result of your current diet being very low in carbohydrates (intentional or not) which is what helps keep our short term energy levels up.

Our plan was for liquids, mushes, purees and soft proteins like fish. eggs, beans, etc. from the hospital on out for the first month, and then everything else after that. The primary rule was to try new foods one at a time to test for tolerance and if a small amount went down OK, then great; if not, go back to known foods and try it again in a week or two. You likely won't be doing much solid food yet as protein still is a priority and you probably can't get enough protein with solid food yet, so there will still be a lot of protein shakes, yogurt, etc for a while as you experiment with more advanced foods. Some people will be able to progress more quickly than others - that would be normal so don't worry if you can't take some things yet.

This is something with a two part answer. The first is that, on average, we will be slowing down continually as we lose, simply because it takes fewer calories to move ourselves around all day at 300 lb as it did at 400 lb, and even fewer at 200 lb, etc. We will likely see stair steps, and some weeks or months will be lower or higher than others, but the overall trend is declining. The second part is that we will usually experience a big drop the first couple of weeks or so (and then typically get the dreaded "three week stall") and the proceed lower at a somewhat reduced rate. This is because our initial loss it mostly water weight associated with burning off our short term energy reserves of glycogen (basically stored carbohydrate) which gives us the "easy ten" lb that we typically lose when we start seriously dieting. After the glycogen is used up, we start to draw from our fat reserves, though there is often a pause or stall as the body changes gears.

I'm glad that you like their program - my nephew just finished his RD internship program at OSU (now he can be frocked as an RD!) Our program didn't have an RD at the time, but I used on associated with our PCP. I only saw her 2 or 3 times but she was very useful. I had already learned a lot about nutrition on my own (as opposed to "dieting") when my wife was going through her WLS journey and I was doing fairly well effectively living a WLS maintenance lifestyle prior to surgery, so she helped in translating the surgeon's nutrition program to my tastes and needs, and then later helped in transitioning to maintenance once all the weight was off and I needed to ramp things up to get stable again.

An endocrinologist, particularly one familiar with bypass patients, would not be a bad idea to get a handle on things; this far out, he has gotten used to things and there may have been a slow decline in levels, or some other physiological activity may be going on. A minor bleed is possible (presumably no obvious signs like bloody or dark, tar like stool) as that is something of a characteristic of the bypass - the anastomosis between the pouch and intestines is somewhat delicate and can be irritated by its acidic environment. Pain relievers can be a red flag as NSAIDs are a big no-no with the bypass, but sometimes they can sneak into some pain relief products without being aware of it, and that can cause a bleed.

It might be, but probably not. Presumably, the doc has prescribed omeprazole, or similar PPI medication for it. The sleeve is predisposed toward reflux problems as the stomach volume is reduced much more than the acid producing capacity, and it takes a while for the body to adjust (doesn't mean that one will have that problem, just that the odds are higher than the general population, in comparison, the bypass is predisposed toward marginal ulcers, dumping and reactive hypoglycemia, so there are potential problems with whatever procedure one chooses. ) Usually, the problem goes away as the body adjusts, but sometimes it doesn't completely and one needs to stay on some type of medication for it, or in extreme cases, revise the surgery.

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, 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 for 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.

Most discussions on the SIPS (aka SADI, Loop DS or Modified or Simplified DS) usually happen in the DS forums as it is being promoted as an alternative to the traditional DS (though the mini-bypass is a similar alternative to the traditional RNY gastric bypass and gets its own forum). Perhaps there isn't yet enough traffic to warrant its own forum (Alex?) so the DS forums are its closest home for now. It is being done more, as one of the big benefits that is being promoted for it is that it is almost as good as the traditional DS, but is more "accessible" (i.e, simpler so more surgeons can perform it). However, it is still considered to be experimental or investigational and is not yet accepted by the ASMBS or routinely covered by US health insurance. A couple of references: http://web.duke.edu/surgery/2017BariatricMasters/yurcisin_current_status_of_the_sips.pdf https://asmbs.org/resources/position-statement-single-anastomosis-duodenal-switch

Fortunately, there is no reason to do such a diet after surgery (unless there is some medical reason for it, in which case that is something to work out with your docs and dieticians.) Yes, you will be quite restricted calorically due to the low amount that you can physically eat for a while, but there is no reason to go overboard on restricting carbohydrates, fats or whatever you need to function. People have been successfully navigating WLS long before low carb/Atkin/keto diets were ever popular, and will be doing so long after they fade from popularity. I couldn't afford the common side effects (like fatigue and lethargy) of the popular low carb diets, so I never did that, but rather sought out the best nutritional bang for my caloric buck with the non-protein side of my diet. That also dovetailed in with what my long term maintenance diet/lifestyle would be, so there was little transition problem as is often seen when moving from "diet" to "maintenance". You can expect some fatigue for a couple of weeks to a month or so as you are recovering from major surgery, but as the weight comes off, your energy usually increases markedly. But your experience is consistent with many who do go a very low carbohydrate route and report months of post op fatigue.

So true; the surgeon that now runs our support group does a good business revising RNYs to the DS (as does the surgeon who did my VSG). They all have a place in the world, and different procedures work better for different patients. And, the surgeons tend to gravitate toward what they find works best for most of their patients. The VSG, while a straightforward procedure in concept, has lots of subtleties and nuances when you get into them in detail, and these take time and practice to master, so I can see some surgeons giving up on them if they are already well skilled with the RNY. OTH, several of the docs I have worked prefer the DS as they have developed those skills, and reserve the RNY for only specific cases where the DS or VSG isn't appropriate. It's all a big YMMV thing.

Some stretch, or growth or adaptation is to be expected - we don't stay at eating only 3 tablespoons forever. This doc gives a good idea of the progression of meal volume that can be expected, and is consistent with my experience - You may or may not get along with his prescription for countering this effect, but it is a viable one. In short, we need to learn to accommodate some increase in eating volume without allowing the calories to get out of hand - taking up that added volume with high bulk, low calorie veg is a good way to do it. As to which procedure to go for a revision, the first thing I would want to know is whether the stretch that your doc sees is unusual - sleeves done by docs early in the learning curve of doing sleeves (and 2012 is consistent with that for many surgeons) may have undue stretch if it wasn't formed well to begin with. Sometimes excess fundus (the stretchy part of the stomach that is largely removed with the VSG) is left behind at the top or bottom of the stomach, or other shaping issues may lead to the problem. If the sleeve is nominally well done, there is probably little to gain be resleeving it - you will lose some at the outset from low capacity due to surgical inflammation and the very restricted diet that we have early on, but overall you shouldn't expect great things from it. Likewise, a bypass is similar in its overall power to the sleeve, but does have some temporary caloric malabsorption that can help get a little extra weight off, but doesn't do any better when it comes to resisting regain; in some patients it is worse in that regard due to reactive hypoglycemia inducing more inter meal hunger. Overall, when I think in terms of revisions, I see a procedure that is more complicated than the original virgin WLS, and usually less effective overall (think in terms of your stomach originally having a capacity of 32-64 oz, and now a few years post op it may have a capacity around 6 oz, so there is less difference to play with. Being more complicated both in implementation and in the reason for doing it in the first place, I like to get a second, or even third, opinion on the matter - different surgeons have different experiences and perspectives on these things. There is also the aspect that while doing a virgin sleeve is a fairly straightforward procedure, and most surgeons are now fairly well up the learning curve in doing them, repairing or revising a faulty sleeve is another matter, so I would look to a surgeon who has done lots of them. In NJ, I would suggest Dr. David Greenbaum as a good guy to consult with. A final thought - what is the capacity of your sleeve now? How much chicken or steak (and nothing else) can you comfortably eat? We usually remain fairly restricted on firm meats for a long time, but can eat an almost unlimited amount of "sliders" - things that just slide on through with limited restriction, which are frequently also pretty junky.

I would "guess" so, as they apparently want things that are free of chunks. You really need to get clarification from you doctor's staff, as there is no real rhyme or reason to most of these pre-op diets; instructions are all over the map and many don't even need to do anything.

I certainly wouldn't count on it. The ketosis thing is just the latest fad in the diet business - if it actually worked, we would have been doing it all along (they like to say that this has been "known" for 70-100 years - if it really worked, why would they have stopped doing it and gone on to other diets?) All the ketosis means is that you are burning fat from somewhere - either from your stored fat or from you diet. One can be in ketosis and not lose any weight if one eats to much, so it is not an indicator that you are doing what you want to do - burn your fat stores. I was "in ketosis" as I was losing, as indicated by my lab tests, but I was no where near a "ketogenic" diet - typically more on the order of 100-120 g of carbohydrates per day, but I was still burning my stored fat because I was in a caloric deficit (eating less than I was burning) which is ultimately what it takes. Put this stuff on the same shelf (or bin) as the all of the miracle metabolism boosting potions.

I was down 100 in little over seven months, and that was with slowing things down after six months - but I have a guy metabolism that is relatively intact, so that helps a lot. The ability to drink is pretty much irrelevant as you will be heavily restricted as you move into more solid foods, so as long as you are not drinking a lot of calories, then all should be good in that regard, The ability to drink relatively unrestricted just means that you will be less likely to suffer from dehydration, which is one of the major early post op risks.

You are well within the range of normal expectations - some will have substantial post op inflammation in the stomach making drinking difficult (hence the typical advice to sip, sip, sip. all day long) while others will have little inflammation and be able to drink somewhat normally. I downed a bowl of broth and a box of juice within about a half hour(?) sitting the day after surgery, and the doc was not at all concerned; my wife, on the other hand, when she went through this, was much more restricted even though she had a nominally much larger sleeve.

I am not sure what is meant by "erosion" in this context, but the RNY anastomosis is something of a delicate structure owing to its environment. The part of intestine that the stomach pouch is joined to at that point is not resistant to stomach acid, as the duodenum is (that's the part of intestine immediately downstream of the stomach in the normal anatomy, and is resistant to stomach acid, but is bypassed along with the remnant stomach in the RNY). Consequently, the anastomosis is often under frequent or constant irritation from the acid, and sometimes never completely heals, and can in some cases be a continual source of minor blood loss or weeping. This is also the point where ulcers usually occur (the so-called "marginal ulcers" that are a predisposition of the RNY) and is the origin of the "no-NSAID" rule that permeates the bariatric world. I don't have any particular studies or sightings on this, but it was something we covered in our pre-op education seminars. Techniques do indeed improve over time; for instance, bile reflux used to be relatively common with the bypass, but careful adjustments to the limb lengths seems to have minimized that. And, when my wife and I were first looking into WLS some 15-16 years ago, we found references to the matter that endoscopic dilations of the stoma had become so common that they ceased being considered a "complication", but just SOP; that doesn't seem to be that common these days as I have seen very few references to that being needed, so they seemed to have figured out the "just right" sizing compromise for it. We tend not to get the whole story when we run into these occasional problem cases, either in person or online - were they doing everything "right" or were they getting lax on some of the rules (this is not helped by many practices that fail to distinguish between early post op rules for good weight loss and "forever" rules to ensure proper long term health and function,) - did the patients, for example, get tired of ineffective pain relief for their arthritis and start hitting on the Naproxen (an NSAID) for better results?

May, 2011 here. I should probably qualify my answers, as per usual, I tend to defy categorization. 1 - yes, at goal with some ups and downs. 2 - I usually go to they gym five days a week, alternating between swimming and a weight circuit, depending upon which is more available crowd-wise. And a hike with the dogs in the woods or up in the canyon every day, weather depending. 3 - I basically do what I did before surgery, which owing to my wife's WLS around six years prior, was/is effectively a WLS maintenance life. I started when she was working up toward her surgery with a strict no-fad-diet regimen - cleaning up the diet as much as possible while being sustainable long term rather than the quickie diet of the day. Best description of it now would be "a bit of everything, not too much of anything" - fundamentally what most any RD would set up for a normal person for good health and weight control. Protein is only what is needed for lean mass maintenance, or about 20% of total, so certainly not "high protein" (though typically in excess of 100g per day) along with lots of fruits and veg and some whole grains.

Most likely you will have to pinch your pennies, as the usual practice is that you need to meet the same BMI requirements (35 or 40 depending upon comorbidities) as the original WLS, unless there is some complication that needs to be corrected (in which case it is no longer considered weight loss surgery but corrective surgery) that can't be addressed by some cheaper means (such as medication). The other twist is that many policies have a lifetime restriction for a single WLS procedure.

If the main reason for seeking WLS is treatment of your T2 diabetes, then the duodenal switch procedure should at least be on your radar as while the RNY typically shows remission rates in the 80-85% range, the DS typically shows 98-99% remission rates. There is some legitimate sense to this as the DS started as a procedure to specifically treat diabetes, to which the VSG was added to make it a weight loss treatment. It is a more technically challenging procedure to perform, which is why most bariatric surgeons don't offer it - it takes resources to develop, and most particularly maintain, the appropriate skills, but ii is well worth the effort to research it and seek out a DS surgeon for a consult. It may or may not be the right thing for you, but it should be part of your "due diligence" in making a decision. Good luck in getting through all of this!

I would ask your surgeon how he wants to handle it, as it is difficult to effectively take early on when we are often eating and drinking very frequently. Drinking will wash it away as well as eating, so you have a conflict between taking the Carafate and staying hydrated (hydration is probably more important still at this point) I was prescribed it a couple of years ago and asked the doc (not my surgeon - this would be several years post op) if it really made any sense to take it an hour (or whatever) after a meal and then nothing for x hours as I eat 5-6 meals a day and drink all the time in between. We agreed it made the most sense to just take it over night. Collectively, you need to figure out the best compromise to get the desired results from conflicting requirements.

Check with your doctor's staff, as there is no universal "liver shrink diet" - programs vary all over the map on what they want your to do from months of only clear liquids to nothing special at all.

Talk to the gastroenterologist (or whomever it is that is doing the procedure) about the problem, as there are lower volume protocols available. While yes, fluids do pretty much flow on through, a gallon is still a lot in a fairly short time for one who is not far out from surgery. Even my wife, who is 14 years out, the doc set her up with a special low volume product, so there are alternatives.

In SoCal, I would look up Dr. Ara Keshishian in Pasadena/Glendale area. He is one of the legacy DS surgeons, (which starts with the sleeve and adds a malabsorption component) which means that he has been doing sleeves longer than most surgeons who only started doing them a few years ago when insurance started covering it. When I had my sleeve done eight years ago, I went to SF for it as there was no one in SoCal then with that type of experience; If Dr. K was in town then (he moved down from the Central Valley), I would have gone with him rather than travel.

As noted above, programs vary all over the place. Quite commonly, "full" liquids frequently include a lot of sloppy mushy foods that don't necessarily fit through a strainer - puddings, yogurt, jello, etc. Go by how your program defines things rather than someone else's (my program just put all the liquids, mushes, purees and other soft things into one phase and we could move around between all of them as our tolerances allowed, so I never got into distinguishing between "full liquids'', purees, soft proteins, etc.) Things like oatmeal, cream of wheat, apple sauce, etc. are classics in the bariatric world and have been a part of early diets for many years, so that is nothing that is going to adversely affect your overall weight loss results; they may not be something that one wants to continue later on, but they do serve a purpose early on when the menu is fairly limited and one is just working to find something that goes down easily, The carbohydrate aspect of some of these foods does have some benefit despite their being contrary to many of the currently popular diets in the mainstream dieting world. They do provide useful energy at a time when we are often sapped for energy in the early post-op days (indeed, I have seen references to some surgeons who specifically want their patients to do some "carb loading" early after surgery for the same reason that marathoners often "carb load" before an event - there's good energy in there. It is not unusual to hear of people reporting that they were dragging and fatigued for weeks after surgery and just chalked it up to it being major surgery - but they were usually the ones who were diligently avoiding "carbs" because that is what one is supposed to do to lose weight (right?) That's not to say that one should be loading up on chips and Twinkies, but have a bit of faith in your program - they have likely been doing this a while and know how things work. Of course, with your diabetic concerns, one needs to be careful, but your RD should be able to work through the appropriate compromises for you.