RickM

Basically, the DS is the same as the sleeve from a medication perspective - the bypass has specific structural problems that contraindicate some medications (NSAIDs being the biggie) that doesn't apply to sleeve based procedures. The DS has problems absorbing some time release medications depending upon the time release mechanism used. That's something to discuss with the surgeon and to research the specific medication. IIRC, those that are activated in the stomach work fine while those depending upon transit time through the active intestine don't work so well.

SIPS/SADI/"Loop DS" (three names for the same thing) is a simplified DS-like procedure using a VSG (like the DS) but a simpler intestinal rerouting that is hoped to provide results similar to (or "close enough") the DS but in a procedure that can be done by more surgeons (the DS is a technically challenging procedure, such that many surgeons can't, or don't want to, develop and, most particularly, maintain the skills to perform.) At this point it is still generally considered to be "investigational" meaning that insurance rarely covers it. As for the OP, I would expect that it would be similar to the bypass or DS, with 2-4 days in the hospital and 2-4 weeks at home depending upon how physical ones' work is.

As noted above, check with your surgeon's team to see what their specific requirements are. Some crackers, like saltines, are basically mush by the time they get to your stomach and should be ok. They were recommended by my team for settling any minor stomach queasiness early on, but then we didn't have discrete liquid, puree, and soft stages - they were all grouped together and we progressed as we could tolerate things, so check with your team to make sure.

The 500 in your multi isn't doing anything as you have little, if any, of the intrinsic factor in your pouch to absorb it. Beyond that, you need as much as you need to keep your levels up and you are doing more than well there (IIRC, 1000 is the top end of the "normal" range, depending on which test is done.) The papers provided by your surgeon will be an initial catch-all recommendation for all, which should then be tailored by your lab results, which certainly indicates that you can cut back. The once a week that your surgeon suggests is probably good advice until your next round of labs indicates otherwise, or you start feeling anemic/lethargic.

You may or may not be at your max loss, but you may well be in maintenance (how long is a "long while" in which you have not lost anything?) The only real way to continue losing is to increase your caloric deficit which usually means reducing your intake (since exercise doesn't seem to do much for our weight loss unless one is excessively serious about it - like marathon/tri training level of effort.)

When your insides start trying to get outside (shades of Alien!) through the incisions in your abdominal wall (aka an incisional hernia). The incisions in your skin may have closed and healed and your ab muscles may feel stronger, but connective tissues such as the fascia of the abdominal wall don't get nearly the blood supply that the muscles and skin get, so the heal much more slowly.

It seems to be done on a case-by-case basis depending upon what the patient brings to the table and the surgeon's preferences and experiences. With the sleeve, my doc only takes the gallbladder if he feels stones in there at the time of surgery, otherwise he leaves it alone. With the DS he takes it as a matter of course because the small to moderate risk of it giving problems during weight loss is offset by the risk of a general surgeon getting lost in the altered anatomy of the region with that procedure should the gallbladder give trouble. Mine was fine and left in when I had my VSG and hasn't caused any problem since. Going by the ultrasound results will give you a good heads-up towards any potential problems with it.

My wife got a little portable bidet that she used for a while. It has a folding wand on the end so it's semi-purse size so she could use it anywhere she was.

Some programs include all kinds of gloppy things like puddings and yogurts as a "full liquid" while others go by a more classic definition (such as you can drink it through a straw....but don't use a straw!) So, it's another area where one needs to defer to one's surgical team as to what they want. It's an area where things like that never came into question on my doc's program as it never had a liquid only stage.

I never had a limit, and still don't. If your calories are low enough to stimulate the weight loss that you need, and your Protein levels are high enough to maintain your lean mass, your diet will by default be "low carb" and "low fat". Indeed, this is one of the reasons that WLS has been the most successful means of weight control for decades - it works well with whatever diet is the fad of the day. As a reference, my carbs the first few months averaged in the 70-90 range and in the later months when I needed to increase the complex carbs for endurance purposes they averaged in the 100-120 range and my loss remained steady. This is a case where quality is much more important than quantity. Some may keep their carbs at some low number by having a lot of low carb junk - artificially sweetened crap and low carb frankenfoods - and will have more problems than those with higher carb numbers coming from real food with real nutrition - fruits, veg, whole grains and the like.

Everyone's preop is different (unless you know someone who has your surgeon). Even that isn't a reliable source as many of the surgeons who require such diets will vary the requirement for different patients. Yes, check with your surgeon's team as only they can tell you what they want. Such diets can vary from only Clear liquids to "full" liquids (whatever "full" is) to some compromise plan of liquids for some meals and some form of healthy real food for other meals to no particular requirement at all. My doc's plan, for instance, was for clear liquids (including Jello and the like) the day before surgery.

Yes - number one is to check with your own medical team, and not anybody else's. Philosophies and rationales vary all over the map with different surgical programs depending upon their own background and experiences. With my doc, it is no alcohol at all as long as we are losing weight - it's a liver health issue (our livers are usually in poor shape to start with from our obesity, and are further taxed with their job in metabolizing the fat that we are losing and they don't need the extra load of metabolizing the alcohol.) Overall, this is one of the many "when can I..." (drink, eat pizza, Cookies, cake, lattes, etc. etc. etc.) that we see where the first question should be "why is it that important to me?" and how does that desire relate to the condition that has got you into WLS? Can you enjoy a birthday without drinking or cake once? Do you need to have pizza with your kid's little league team after the game (instead of something more WLS friendly)? That's not to say the we can never drink or have cake or pizza, but it these things are no longer all that important to us, then we are much better able to tolerate them when they may be appropriate due to various social situations and not be as vulnerable to their addictive qualities.

If you don't mind travelling a little bit, give a look at Dr. Ara Keshisian in Glendale. He has been doing DS's (sleeve plus intestinal rerouting) for a good long time which means he has done more sleeves than most any other bariatric surgeons, and one of the handful capable of doing the very complex RNY to DS revision (not that you need one, but good to have an overqualified surgeon than an underqualified!) He is the guy I would go to if I were in the market for a sleeve (or other revsion) in So Cal.

While it is possible that he did nothing - there are quacks and frauds out there - but more likely is that he just did a poor sleeve. One of the problems that has come about with the rapidly increasing popularity of the sleeve is that there are lots of experienced bariatric surgeons who have jumped into the sleeve business due to market demand, who are consequently not very experienced with the sleeve (or were not at the time.) It takes practice and repetition to develop the new skills required for the new procedure (consensus is that they should have several hundred of a procedure under their belts to be considered adequately experienced.) Various shape issues can result from a poorly crafted sleeve, most particularly an excess amount of the stretchy fundus left over at the top or bottom of the sleeved stomach, which would result in a feeling (and fact) of minimal restriction. I don't know how well an EGD would allow the gastro to evaluate the shape of the resultant stomach (particularly if they were not overly experienced in dealing with sleeved patients - RNY's are of course the largest bariatric population out there and that configuration would be obvious in and EGD. When my wife had an EGD a couple months ago, the gastro had forgotten that she had had a DS (sleeve plus intestinal rerouting) ten years before, and commented that her stomach didn't inflate normally (of course not - most/all of the stretchy fundus had been removed...) so a normally functioning sleeve was obvious to him. Talk to your gastro or PCP about this - it may take a barium swallow imaging to see the actual shape of the stomach to determine if the procedure was done at all, or done incorrectly (there is a legal difference between not doing a job at all, and billing insurance, and doing a job poorly - one is criminal while the other merely negligent.) You may also want to consult with a bariatric surgeon who is experienced with sleeves - I like to use the DS as a filter for experience as the DS surgeons have been doing sleeves a lot longer than the "average" bariatric surgeon. They are few and far between usually, but worth seeking out. If you can make it up to LA for a consult, Dr. Ara Keshisian in Glendale it the go-to guy to see (and he usually does his own imaging tests so he can see what the problem is rather than depending on a gastro's written report!) Good luck in getting this resolved

By all means, make the lifestyle changes, as they will be essential to your long term weight stability and well being, even if they aren't likely to get your weight down to where you want it to be - once we get to the size where we are considering WLS. there are enough various factors stacked against us that we run into that 5% success rate noted above. The way I approached this problem, when my wife and I got serious about our respective weight problems and started toward WLS was to start doing those lifestyle changes that would help to ensure my long term success. We know what we have to do - be more active (it seems like you already have that inclination), cut the junk out of our diets, improve the overall nutrition while reducing the calories to a level that will maintain us (if not leading to total weight loss to normal.) Most have already found that the various fad and "book" diets (any book entitled "The _____ Diet", most particularly if it also mentions "miracle" and is authored by a "Dr.") don't work in the long term. They may get your weight down to something approaching normal, but they teach you nothing about how to maintain that loss over the years, and the weight builds up again when trying to go back to a "normalish" maintenance diet. I avoided those diets, but worked on moving my diet as close to the ideal as I could sustain in the long term. It was not "perfect" by any book or nutritionists' standards, but it was what I could do within my tastes and it was something that I could do forever, and it was much better than the normal American crap diet that got most of us where we are/were when considering WLS. I kept tweaking things to carve out a few more calories where I could, and improve the overall nutrition of what I ate. That was almost 13 years ago, and I dropped about 50 lb over six months (335 - 285) or so and came to a halt. I could make small moves down and then back again. But I did maintain that loss for several years. In the meantime, my wife had her WLS after the serial insurance denials and ultimately self paying for her DS, and we settled into a reasonable maintenance lifestyle, though I usually ate about twice what she did. Once our insurance started covering the sleeve, I went for it as it was clear that I was not going to lose the rest on my own in any sustainable manner. That was five years ago, and so far so good. I also used that interim period to test my maintenance ability and help choose which surgery, if needed, was most appropriate for me. Had I regained what I had lost over those few years, that was a sign that I should go for the DS, with its better regain resistance. With the stability that I had managed over that time, the sleeve seemed like a good bet that I could avoid any revisions due to regain problems.

They're OK- their specs are good, and they are one of the few choices around for a clear diet. I tried a couple of their "tea" flavors and found them sickeningly sweet. For my taste, the best use for them is to mix them into similarly flavored jello, but I only use them if I have reason to do a clear diet, otherwise there are better products for my taste. Since taste is such a YMMV thing, if you like them, then go for it - they are a good product.

It depends very heavily on how much inflammation you have in your stomach after surgery, and that's a big YMMV thing. I had no problem sipping down a bowl (6-8 oz maybe?) of broth and a half cup box of juice in a half hour or so in the hospital, whereas my wife, when she went through this, was much more restricted. Both results are within the normal window of expectations according to the doc. If you don't have a lot of inflammation, your stomach is like a soda straw and you can sip quite a bit through there in time, while if you do have more inflammation, it's like a pinched soda straw and it will open over time as the swelling goes down.

"There's no reason for it, it's just our policy...." You need to get back to the surgeon's office to get that coding changed, as that is where the problem apparently is. I can see that they don't cover it when coded as "obesity" as insurance often doesn't cover weight loss programs, though they will cover WLS. It needs to be coded as something acceptable (the surgeon's insurance coordinator should be up on this,) and still accurate, such as pre-op labs for covered surgery. It reminds me of the days when routine annual physicals weren't covered (and may still not be by some companies) and you (doctor and patient collectively) had to establish a complaint as the excuse for the office visit and tests. It's all part of the game, unfortunately, and it seems that your surgeon's office isn't very good at playing it.

My wife has been on it for quite a while (though she has evolved into other meds for the problem) and she is over ten years out on her sleeved stomach. And, yes, as Jamie suggests, it can be something of a fussy drug, so coordinate between your PCP (or whomever wants to prescribe it) and your surgeon to make sure all are on board with it. I think that the limitations that she had with it involved taking it early in the morning and not lying down for an hour or two after taking it (hints at its potential effects on the upper GI.)

What you need to do is check Aetna's policy bulletin on WLS, which should be on their website somewhere, and see what it says - exactly. That is your legal bible. The main concern that my surgeon's insurance coordinator had was that my PCP's (who "supervised" my six month program) documentation met all of their requirements. The main objective of these insurance diets is to slow down your approval in hopes that you will go away, self pay, or be on somebody else's policy by the time you are ready for surgery. The insurance company's published policy is the law on this and is what is used for any appeals you may need to do. Not what somebody on an internet forum tells you, or even what the company's phone rep tells you. Some companys will deny coverage as a first step since some people will give up at that point and not appeal, and then they will approve on the second submission when they find their "mistake". If you can't find Aetna's policy bulletin, or can't understand it, check with your surgeon's insurance coordinator as to what it says - it is their job to understand these things. I didn't lose or gain anything on my six month program and was approved by Aetna, but that was 5-6 years ago and policies can change.

I've never heard the wet lettuce expanding thing before, that's a new one on me. Bread, toast and rice are often thought by some to have that effect, and likewise readily ignored by others to little effect. But this early out you should be taking things slowly and following your doc's advice. Some people do have a problem with lettuce for some reason, even many months out (and, as usual, many others have no problem at all - a big YMMV thing.) I generally use chopped raw spinach rather than lettuce due to its somewhat better nutritional profile, but haven't had any particular problem with lettuce when I have had restaurant salads (I just don't eat much of it since they use it as filler instead of the more expensive and nutritious vegetables and Proteins.)

I have found salad to be something of a slider for me, too - which isn't really a bad thing considering the high nutritional density of most salads (if you do them right and don't load them up with a lot of high calorie junk!) I found when starting with salads a month or so out that if I cut back my normal serving capacity of meat from 3 oz to 2, that I had comfortable room for another 3ish oz of salad veg (typically chopped spinach, avo, tomato, green onion and bell pepper, and/or whatever else I had around. I found it a convenient way to get in at least a token amount of veg, and make my eating a bit more "normal" than typical post-op fare, which made for less of a "being on a diet" feeling and reinforced what good sustainable eating habits that I already had. Such salads are still a staple of my diet five years later.

Ditto on asking your surgeon's team - it should be in whatever instructions they provide but if not, when in doubt, ask. I never had a liquid diet so the question never came up, but some find chewables or gummies useful early on due to the amount of inflammation they may have in their stomach post op (particularly for things like calcium that usually come in horse pills.)

oops...deleted

Neither. My doc never jumped onto the carb counting bandwagon when that came into fashion a few years ago (sugars and other simple carbs are limited, however.) Net carbs came about when the Atkins people realized the need to make their diet plan relevant to the realities of human nutrition - there is a reason why low carb dieters tend to be constipated. The main driver for your long term weight loss is your caloric deficit; carb levels drive short term variations within the long term loss trend, primarily by way of changes to your body's glycogen levels and the Water needed to keep it in solution. Your doc's program seems quite reasonable, and it is only providing you with a max level per meal - you can go under it if you so desire. But generally, the carbs that need to be severely limited are the junk carbs that have little nutrition tied to them, while those that come as part of real food (that which comes out of the ground, as opposed to out of a box...) that has real nutrition behind it does little damage to your loss efforts. As a side note, my carbs averaged (I didn't control them, but did record everything,) 70-80g per day in the early months of my loss phase, and around 100-120 g per day in the later months, and I wouldn't have wanted the weight to come off any faster - but I had a fairly high caloric deficit driving my loss, so carbs didn't matter, but the nutrition derived from them certainly did.