RickM

Your stomach is in charge, so follow its' lead. That's why our program had the 'test for tolerance' advice admonition. We all progress at somewhat different rates within a normally expected band of results, inflammation within the new stomach can be highly variable. Some programs will hold all patients back to the progression of the slowest expectations while others will try to hit an average progression. There will always be questions as some will be concerned that they aren't progressing as quickly as others or the program guidelines while others will wonder if something is wrong that they aren't having the problems of others. You can't win in producing these guidelines!

If the GERD is a result of a hiatal hernia, not uncommon amongst the morbidly obese, then there is a good likelihood that it will be resolved when the hernia is repaired as part of the surgery. Another option to consider is the DS, which typically uses a larger version of the sleeve, so GERD tends not to be as big of a problem as with the smaller VSG sleeve. It is a malabsorptive procedure, though of somewhat different character than the RNY so medication absorption is a consideration, but my wife is able to work through it with her DS and the various meds that she has to take. In general, I would like to get a good handle on what is causing the GERD before getting into WLS, so that can be considered in weighing the options, as each procedure has its strengths and weaknesses.

I don't know how many are "many" (there is something called "adverse selection" that is common in online forums, where negatives outnumber positives because everyone with a complaint will post about it, but those with nothing to complain about are largely silent, so things tend to seem worse than they are,) but it does happen for a few reasons. The sleeve is predisposed do reflux problems due to its geometry and physiology. The volume of the stomach is reduced much more than the acid producing potential, so it takes a while for the body to adapt, and sometimes it doesn't. Also, the sleeve is considered to be a "high pressure" system in that the stomach is often closed off by the pyloric valve at the bottom, so excess gas, fluids or solids have no place to go other than back up; the bypass is a "low pressure" system as there is no pyloric valve in the system, so excess gas can vent down into the intestines. In contrast, the RNY due to its geometry and physiology is predisposed to dumping, marginal ulcers, reactive hypoglycemia and bile reflux. With either procedure, this does not mean that everyone will experience these problems, just that this is the natural result of the anatomical changes that have been made. Another compounding factor with the sleeve is the relative experience level of the profession - in the US, the sleeve has been routinely approved by insurance for about the past 6-8 years, while the bypass has been routine for around 40 years. This means that there has been some revisions needed due to inexperience in some of those early sleeves - the surgeons may have been well experienced doing bypasses and bands, but a new procedure, even a straightforward one such as the sleeve, brings along its own subtleties and nuances that take practice to master. Resultant shaping issues can promote or exacerbate the reflux problem. In the US, most bariatric surgeons are now far enough up the learning curve that most are now making routinely making functionally competent sleeves (one should always seek out a surgeon who has several hundred of whatever procedure one is interested in under his belt.) However, now the problem is, as it has been since early on, is that many are not very experienced in correcting any problems that may crop up with a sleeve, so the natural inclination is to stick within their comfort zone and revise to a bypass when a problem occurs, rather than correct the sleeve. So yes, the OP is correct in some respects that there are some unnecessary revisions being done, though not necessarily just for the sake of charging for two procedures. As time marches on and the industry gets more experience with sleeves, I would expect that the revision rate will decline as both the sleeves will be made better overall, and the surgeons learn how to repair them when necessary rather than revise them, much as the bypass has matured over time and some of its predisposed problems are less common as they have learned how to mitigate them to the extent they can (bile reflux isn't too common anymore as they have worked out techniques to minimize its occurrence, for instance.) Another factor that may skew the impressions some is that the bypass is a difficult procedure to revise - it is something of a dead end surgically speaking. If poor weight loss performance or regain is experienced, there is little point in reversing it and revising it to a sleeve as they are both so similar in performance that there isn't much to be gained. There are minor tweaks that are offered - tightening of the stoma or intalling a band over the bypass - but overall results are generally pretty poor. Revising it to a DS, which can offer improved weight loss and regain resistance, as well as diabetes remission, is a very complex procedure that only a handful of surgeons are capable of performing. So, we don't see a lot of bypasses revised for that reason, though sometimes they are reversed if there are significant complications that can't otherwise be resolved, though that isn't a trivial option, either.

There are a couple of factors at play here. Yes, revisions typically show slower results than an original or virgin WLS. Think of it this way - when you had your first surgery, your stomach had a capacity of somewhere in the 32-64 oz neighborhood, depending upon how much you stretched it at a meal; after surgery and some months or years of adaptation and growth, your stomach would have a capacity of maybe 4-8 oz. that you had learned to live with, so there isn't nearly the difference in capacity with your revision surgery. There are also some metabolic and hormonal changes that come with the surgery that help you over your "normal" obese state, and that change is now less with a revision. Further, if you had a pre-op diet where you lost the initial 20ish lb, you have already lost most of that quick and easy water weight that we lose when we first start a major weight loss effort; those of us who never had a pre-op diet will experience that rapid water weight loss soon after surgery and will show those impressive numbers that you sometimes see in the forums.

Carbonation, like straws and other such bariatric urban legends fall into the category that they might cause some discomfort, particularly early on. If they do, skip it and maybe try it again in a few weeks. If it doesn't cause any discomfort, it isn't going to hurt anything. No, it isn't going to cause your stomach to stretch, particularly with an RNY which is an open system (no pyloric valve), but the gas pressure may cause some discomfort as it passes up or down on its way out. The main thing that it could possibly do, with either procedure, is to stress the lower esophageal sphincter which is supposed to keep everything down in the stomach and not flow back up into the esophagus (reflux) making GERD a greater possibility (even with a bypass.)

That's a great question for which I have no answer - low carbohydrates and some caloric restriction is what's needed for the "shrink the liver" thing that some docs seem to need. I'm beginning to think that the whole liquid only pre-op diet is one of those "that's the way we've always done it" things. Some say that it is supposed to be helpful in getting you used to all the liquids post-op, but I never found that to be a problem as you don't feel like anything else at first - it's pretty self policing unless the program specifies post op liquids for a lot longer than is necessary. No pre-op diet here, and I never had any problem adapting to the post-op world, and neither did my wife when she went through this. It's all a big YMMV thing, but a word to those lurkers/researchers who are just getting started in considering WLS - ask questions well ahead of time when looking at different programs and consider one which is more "patient friendly" in this respect.

Here is the perspective of one bariatric surgeon on how our meal volume progresses over time. In short, after a few years, we will typically be able to eat about half of what we could eat pre-op in a sitting or meal. This is consistent with my experience at seven years out, and my wife's at thirteen years out. There is still enough restriction to aid in effective long term weight control, but also plenty of capacity to go overboard on the wrong foods and see extensive regain. This doc is one of the few that I have seen that discusses this aspect of our surgery, and offers a prescription on how to mitigate the negatives of it. You may or may not get along with his prescription (I don't buy into everything he says....) but he does offer a model that we can use to develop our own approach to long term maintenance and weight control.

If 10 lb in a week isn't "really seeing their weight drop", I don't know what is. It is unlikely to be any better than that. Your first 2-3 weeks is usually the greatest loss rate as you are mostly dropping water weight. After that (and possibly the common "third week stall") you will start actually burning off your stored fat, though that burns off more slowly. Also, your loss rate will slowly decline over time, on average, as your weight drops - it takes fewer calories to move 150 lb around all day than 250 lb.

We had a combined liquid, puree, mushy and soft foods stage for the first month followed by everything else thereafter. The general rule was to try new foods one at a time to test for tolerance - if it settled, OK, great, and if not then back up to familiar things and try again in a week or two; That said, the safest thing to do is to follow your programs guidelines, and if in doubt, check with them - surgeons often advance patients ahead of their published guidelines if they feel that they are ready for it. We don't know if your program's progression is based upon specific experiences - your surgeon may make his sleeves differently from others such that it needs more time - or if it's just "that's the way we have always done it."

Basically, protein drinks until you can get enough from real food - which can be quite variable, a few weeks to a few months.

Typically, most seem to recommend that one can drive once one has been off of narcotic pain relievers for a day or two. I didn't drive much the first week or so as my wife was around and she liked to play "mother", but I drove the couple hours to the 10 day follow up appointment without any issue (she doesn't do mornings well!)

The issues regarding alcohol and WLS are the following: Healing - alcohol is corrosive to the raw stomach tissues that have been exposed during surgery, so we need to keep away from it while the stomach heals. Surgeons differ in their opinion as to how long that should be, from a few weeks to a few months. Liver health - starting out obese or worse, our livers are often in pretty poor shape (hence the "liver shrinking" pre-op diets that some surgeons impose). Further, our livers are further stressed by their role in metabolizing all that fat that we are losing, and doesn't need any further stress from ingesting a liver toxin like alcohol (that's not a moral judgement, just basic physiology.) Surgeons vary widely as to how much this bothers them depending upon their backgrounds and WLS philosophies (short term vs. long term.) In my doc's program, we are under contract to not drink as long as we are in a weight loss phase (call it a year, though ideally forever) - with his "sideline" as a liver transplant surgeon, he doesn't want any of his bariatric patients coming back onto his transplant table. Transfer addiction - to the extent that we are/have been addicted to food (a very individual thing) that we can no longer satisfy, courtesy of our WLS, we can be prone to transferring those addictive tendencies to something else - alcohol, drugs, gambling, shopping, etc. So, a casual drinking habit pre-op can (and often does) morph into full blown alcoholism.

The best advice on such things is to check with your surgeon's team and see what they say, and work under their guidance. The bariatric NSAID thing has its roots with the RNY, which is predisposed toward marginal ulcers, and has little tolerance for any kind or stomach irritants; bleeding ulcers are not uncommon with NSAID use for RNY patients. While a sleeve patient may be somewhat more sensitive to NSAID use than those in the general population, they have a much greater tolerance for them than an RNY patient. As most bariatric surgeons have been raised on the RNY and no doubt have had some "exciting" experiences with their RNY patients and NSAIDs. Overall, they tend to have less experience with the sleeve based procedures, so they remain gunshy about their use for all even when they know of the anatomical differences between procedures - they want to see it with their own eyes, but usually won't because they continue to advise all their patients to avoid them. Surgeons. Surgeons who were early adopters of the VSG - primarily those from the DS camp - tend to be more liberal in their allowance for NSAID use as that is what their experience promotes. Tylenol is generally the first line of treatment as it is considered to be the most benign, though often less effective. Caution should also be applied in its use as the toxicity levels for it are not much higher than the therapeutic levels, so acetaminophen poisoning is not unheard of - many feel that as it is an OTC drug that it is "safe" and a little extra won't hurt, or aren't aware of it being in multiple medications that they may take (pain remedies, cold remedies, etc.) As bariartric patients who often have the "no NSAID" thing drilled into us, we are more susceptible than others to overdoing the Tylenol since we don't have other convenient pain relievers available.

Unfortunately, you may be one of the 15% or so who do not resolve their diabetes with the sleeve or bypass (both have remission rates in the 85% range, give or take a bit) or you may be one of those who just takes a while longer for it to resolve. There is a generalization that the longer one has been on medication and/or insulin, the longer it can take to resolve (but, of course, not always - YMMV.) My wife had been on medication for it for around twenty years and just short of needing insulin when she had her DS (which is a stronger treatment for diabetes, with typical remission rates in the 98-99% range) and it still took her the better part of a year to be off all of her diabetes meds. So, there is still hope yet, as frustrating as it may be to see others walk out of the hospital free of those meds.

I'm in the valley, but I went with Dr. Rabkin in SF because at the time, Dr, K wasn't working in So Cal (he was up in the Central Valley) and no one else down here had that much experience with doing sleeves, and my wife had a DS performed by the Rabkins several years before so we were already familiar with them and their program. They also had a local-ish support group and office in Ventura where they used to work before moving north and there are several of Dr. K's patients in that group. Dr. K now sponsors that group and often shows up with his family when his schedule permits (it's a dinner group held at a restaurant.) IIRC, at the time, the Rabkins self pay rate for the sleeve as about $17k complete; I don't know what it is now, or what Dr. K's self pay rate is, but I would expect it to be in the same ballpark. Good luck in getting this done!

Lettuce is often a problem for some (and not others.) I never had a problem with it, though by preference I usually use chopped spinach over lettuce given its' somewhat better nutritional profile. Our general rule of thumb was to try new foods one at a time to test for tolerance - if it worked, great, if not then try it again in a couple of weeks. I think that the first meal out was at Chipotle, and had their soft tacos, left the tortilla behind and had the filling of chicken, cheese, bit of rice & beans, and a bit of their veg (all of which I had sampled in one form or another before this) and it all settled well

For the sleeve, I like to look for surgeons who also do the duodenal switch, both from the perspective that the DS is a fairly complex procedure in the bariatric world, so it tends to attract the better surgeons to it, and as it uses the sleeve as its basis (and adds a malabsorptive intestinal rerouting) most of the DS surgeons have been doing sleeves longer than most other bariatric surgeons (the sleeve has routinely been done for about the past 5-8 years, while the DS has been performed for around 25 years.) Here in CA, Dr Ara Keshishian in Glendale is well worth looking into if you are in So Cal, and in the Bay area there is Dr. John Rabkin (I traveled up to SF for my sleeve as Dr. K wasn't working in SoCal at the time) and there is also Drs. Greg Jossart and Paul Cirangle who are also well regarded. Certainly go to whatever support group or introductory meetings that they have to get a feel for the practice and personalities involved, Ask questions learn what you can ahead of time so you aren't surprised later. As a bonus for most of these DS oriented surgeons, they generally don't impose any significant pre-op diets that many struggle with - they know their way around in there well enough that they don't need whatever extra help those are supposed to provide (personally, I would avoid any of those guys the impose multi-week liquid only pre-op diets.) They also usually have fairly rapid post-op progressions (as tolerated) so you tend to get back to normal-ish sooner.

Protein drinks were the main protein source for a while, though we could mix protein powder into other things as we progressed. We could play with most any kind of soft, heavy liquid or pureed food that we could tolerate for the first month, so oatmeal, cream of wheat or mashed potatoes (of varying sloppiness) made with some protein powder were all good transition foods.

We were on purees along with soft foods like scrambled eggs or some fish as tolerated from the hospital on out for the first month.

The 30 minutes before rule that some impose doesn't make a lot of sense after the first few weeks, but the 30 minutes after does make sense long term. Drinking during or soon after a meal tends to wash the food through the stomach rather than allowing it to stay there and be digested more slowly, keeping you fuller longer - this is particularly the case with the bypass which removes the pyloric valve from the system, leaving basically a funnel (pouch) between the esophagus and intestine, but still works somewhat the same with a sleeve with the pyloric valve intact. Even years post-op it is not comfortable drinking much for a while after a meal (though I may sip a bit during if something is dry.) Before a meal with an empty stomach, it doesn't matter much whether you drink or not, as any fluids you drink flow right through fairly quickly. During the initial couple of weeks or so, you may or may not have significant inflammation in your stomach such that fluids only trickle through (if that) which is why we sip, sip, sip rather than drink normally. We want to leave some time to make sure that whatever we had been drinking has had a chance to move on through. So, once you get to the point of being able to drink fairly normally, there is little reason to stop drinking before a meal.

Most certainly you can eat more; some of that is natural growth and adaptation of your sleeve to the new world (it wants to counter the insult that happened to it, to the extent that it can), and some of it is the greater variation in your diet that typically occurs once you reach goal and have to increase your calories to maintain things (you aren't on a "diet" anymore.) If you go back to just having a piece of chicken or steak, your capacity will probably be similar to what it was at six months post op, but now you are probably eating a lot more different things, things that are to varying degrees "sliders" that move through your stomach faster, letting you eat more. There is nothing wrong with sliders as long as you understand what they are doing and they aren't junk food - lots of fruits and veg can be sliders, particularly if served with sauce or dressing like a salad. I can put away a lot of salad, but still not that much basic meat by itself. This doc describes the typical progression that he sees in his patients, and offers a prescription of how to mitigate its effects. In short, over time, as in 5+ years out, you will likely be able to eat about half of what you could pre-op; this is enough to provide substantial nutrition and control your weight if you eat wisely, but also enough to allow substantial regain if you do not. You may or may not like his prescription for dealing with this fact, but it is something to consider in working out your own weight control plan. I don't buy into everything he says, but much of it does make sense, as vegetables tend to be bulky and low calorie, so work well to fill that added capacity that we tend to pick up over time without a lot of calories. Good luck in exploring this phase of your post-op life!

Most of the popular fad diets over the years have some therapeutic basis - ketogenic diets are useful for epileptics, Atkins, etc. have long been used for diabetics and the insulin resistant (since long before Atkins, for that matter), gluten free is just the thing for those with Celiac disease (and some forms of non-Celiac gluten intolerance). It is when they cross the line to be promoted as all things to all people, and the latest "must diet" for weight loss that they enter the fad diet domain. So yes, keto is a fad for non-epileptics looking for the next weight loss miracle cure. The current low carb craze started with Atkins, and as the pendulum moved to greater extremes that not only are carbs bad, but fats are divine and one can't have enough of them. When the diet pendulum was last moving from low fat to low carb, courtesy of Atkins, the full fledged HFLC diets a la Paleo and keto were too extreme to be marketable at that time. From a long term weight loss perspective, these diets are no better than any other that has come and gone before (and will likely return again in time) - there is really nothing new in the weight loss business that hasn't been tried before and found wanting, often multiple times. In keeping with diet fashions, terminology becomes flexible, as those who need to be seen as doing the latest diet tend to adopt the term for whatever they are doing ("I have eliminated all fats/carbs from my diet - well, not those fats/carbs, those are the good ones....", " I'm doing XYZ diet except...") Your nutritionist's advice is sound - it is fine if you want to do that type of diet, as it isn't particularly harmful as long as one doesn't go overboard on the calories. That is the big benefit of your WLS - it doesn't care what kind of diet you use with it as it gives you this year of time, give or take, to get your dietary act together and learn what you need to do for the rest of your life. Most who go with the popular diet of the day run into diet fatigue and get lost when they never learned sustainable nutrition, or they jump to the next trendy diet when the current one becomes old. WLS gives one the chance to get off that merry-go-round if one is so inclined.

The first thing to do is to verify whether this loss requirement is that of the insurance company, or of the surgeon's program. Six month diets are fairly common for insurance companies to require, though the specific loss requirement is less common - that is more typical of some surgical programs, irrespective insurance requirements. Check with your insurance company - call them or find their policy bulletin on their website, which will spell out the specifics of their requirements. If indeed it is an insurance requirement, you might have to continue, or the requirement may be negotiated or appealed - your surgeon's insurance coordinator can help with that. If it is a requirement of your surgeon's practice, that can also be negotiated as this is not a standard requirement within the industry (you can go to another practice that doesn't have such requirements). In either event, talk to your surgeon's team - including whatever dieticians or therapists they may have on staff or referral to see if you can get to the root of the problem. Some programs may just reject you for "not trying" or being "non-compliant" while others will help craft a solution to your problem. You may have a greater than average metabolic problem that is inhibiting your weight loss, and this may point to the need for a stronger surgery than the bypass or sleeve - the DS is a stronger metabolic tool than the others and may be worth looking into, though your doc's practice may not offer it. It's better to investigate it now and understand it than get into a bypass that may not be strong enough and have to revise to it later - that's a real complicated revision that few can perform. Good luck in working this out....

The various bariatric vitamins formulated for specific procedures are generally OK, and my be worth the cost if the convenience is that important to you. The problem with them is that over time, as your lab results come in you will probably find that you need "more of this and less of that" than what the product provides, and you wind up going with separate supplements. Also, with a bypass, you probably need more calcium and iron than those products provide, and they need to be spaced out during the day, so you still wind up taking supplements 3, 4, 5, or 6 times a day because those multis don't provide those added minerals that you need at different times, Try them if you like - many do but ultimately most give them up as they usually don't make things all that more convenient to be worth their cost.

I would give it a couple of years before resorting, or going back to, any of these fad diets. One of the greatest strengths of your WLS is that it works well irrespective the diet that you use, so there is no need to jump into one of these diets to try to "improve" your weight loss. As long as you are getting adequate protein to maintain your muscle mass (which at 65 g for an average to shorter woman, you are), and your caloric intake is low enough to provide the caloric deficit needed for burn your stored fat, you will lose. Two of the things that have been shown time and again over the decades to torpedo WLS results is consuming empty calories (calories with little or no nutrition tied to it, i.e. junk food) and drinking your calories, both of which you would be doing by adding that junk to your protein drink. You don't want your calories at a "normal" level - you want them at a deficit (though not ridiculously low - where you are at with 5-600 at this stage is just fine as that is very common at this point for successful patients. Keeping your calories "normal" is how we all got here needing WLS. As noted above, search for "three week stall" as that is very common in these circles no matter what diet is used - it is part of the normal physiological response to the sudden caloric deficit that you now have. That you may not have lost much immediately after surgery is likely just part of the normal water weight fluctuations that occur around surgery time, and if you lost a fair amount of weight before surgery, then you already have lost that big slug of water weight that we all lose when we start one of these programs - particularly if you were playing keto games then, which only accentuates that water weight loss (only to gain it back when you stop.) In short, adding empty calories isn't going to "boost your metabolism", but is a good way to inhibit your long term progress. The best long term results that I have seen over the years is to take this opportunity to learn how to eat a normal, healthy human diet balancing meats, fruits, vegetables and whole grains that that are associated with good long term weight control rather than the diet of the day, which is a good way to help ensure regain once diet fatigue sets in, or it goes out of style and a new latest diet has to be found.