RickM

Did your gastro have any ideas/guesses as to why you are getting the test results that you are seeing? I'm not familiar with that test, or what it is really testing to produce its results, but since we sleevers don't have the mechanical malabsorption that is inherent in the RNY and DS, I am guessing that there is some other imbalance somewhere. Many of the diets that are used for weight loss and that often carry over into maintenance are inherently imbalanced - the popular low carb diets are often short of fiber, and the soluable fiber binds with fats to aid in their digestion. Maybe a fiber shortage (or shortage of the right kind of fiber,) is causing a high reading of undigested fats in the stool (just guessing here, but throwing out possibilities)? I know my nut wanted me to increase my fat consumption as I moved into maintenance to help ensure proper absorption of the fat soluable vitamins (A,E,D & K) so if there is an imbalance in fat digestion, that could ripple through to some vitamin absorption (this is a common concern with the DSers who malabsorb fats and have to watch that balance.) Good luck, and I hope that you find an answer - PS - while you are working on finding a solution to the fat problem, there are "dry", or water soluable, forms of the fat soluable vitamins available - Bariatric Advantage (and I'm sure the other bariatric specialty houses) sells a dry "ADEKs" tablet for the DS crowd, and places like Vitamin Shoppe also sell dry A,D,E, and K in various forms.

The body comp scales are measuring your body's impedance (electrical resistance) to derive the fat and lean mass percentages, and as a result, are very sensitive to hydration, which is going whacko these first couple of weeks (first they pump you full of fluids in the hospital, then that dissapates, then your body gets starved of its glycogen reserves from the initial caloric deficit, so then it needs to hold on to Water as it replenishes the reserves.... Right now, your body is confused, and so is your scale. http://www.dsfacts.com/weight-loss-stall-or-plateau.html This article gives a good explanation of what's happening these inital couple of weeks of weight loss and why we typically see a stall in these first 2-3 weeks. Once your body settles down into something more routine after the first month or so, the body comp readings start to make more sense. Your body fat readings will also vary during the day as your hydration changes during the day - you tend to be dehydrated first thing in the morning, which will read a somewhat higher body fat %, while the optimum time of day to read the body fat is usually late afternoon/early evening before dinner when you are typically as hydrated as you will be (you may see a 5% difference in your body fat % from early morning to late afternoon, and you may see a point or two difference from one day to the next depending upon day to day hydration differences; you may also see a change if medications change, particularly diuretics.) Of course, exercise routines and scheduling can impact your hydration and scale readings, so take that into accout as well (don't expect the best readings right after a workout!) The best way that I have found to use the scales is to follow a moving average of the body fat % and not get too wrapped up in day-to-day fluctuations. Your late afternoon readings may be measuring between say, 36 and 38 % at the extremes, so 36.7% one day and 37.1% the next (and 36.6 the next...) isn't particularly significant, but when you start seeing readings in the 35's and aren't seeing 37's anymore, that is a good sign of progress. The scales are a good tool for following longer term trends but are limited in value for snapshots - you may get whipsawed between despair and elation if you are looking for instant gratification from these scales! Used in this way, they seem to correlate fairly well with the "more accurate" body comp tools like hydrostatic testing or the bodpod. Good luck and have fun with this crazy journey!

As others have noted, this is a fairly common occurance, so I would read the OP's docs response as indicating that he may not be very comfortable with the sleeve procedure yet, so it would be worth getting a second opinion on this issue. This may not be very convenient at this late stage before your scheduled surgery, but the cost of the alternative - living with an RNY and all that goes with it for the rest of your life - is just too high to rush into it. Or, to keep the schedule, and if you really like your surgeon, perhaps he can have a more experienced sleeve doc assist so that he can better learn to handle this relatively common problem. Hopefully, if the sleeve doesn't work for you, then you would go ahead and have the DS completed rather than changing it to an RNY which would not likely work any better than the sleeve. Also, more than likely, once the sleeve is done, any future revisions would involve another round of insurance approvals unless the doc specifically had a two-stage DS approved.

Sliders are neither good nor bad - they just are. Most people focus on the bad sliders such as chips and twinkies (generally because the realization of their existence happens when we're early post-op) but there are many good foods that are also sliders - many essential veg, fruits, grains and nuts have a slider quality to them. I would never be able to get in anywhere near enough nutrition or calories to maintain a stable long term weight. The firm, dense meat type Proteins are still restricted to around 3 oz for me after 15-16 months, but I could never get in the 2000 calories per day that I need to be stable if I didn't use the slider quality of many foods - but those are good, high nutrition sliders rather than crap sliders. Learning to use sliders for good rather than evil is one of the things that most of us need to wrap our brains around when it comes time to stop the loss and maintain a healthy long term diet over the long term.

A couple of things that can shrink the list of candidates some - http://www.dsfacts.com/duodenal-switch-surgeons.html is a list of well regarded DS surgeons who are worth of consideration - as the DS uses the VSG as its basis, those who are well skilled in the DS will also have good experience with the sleeve, an important point with the growing popularity of the sleeve and the number of surgeons who are relatively new to the sleeve. If you find a surgeon who has been changing jobs or practices frequently - stay away. In the business climate of the past few years, a change of practice, practices splitting up or being absorbed by larger organizations is not uncommon so a job change or change of practice is not a big deal, but a doc who goes thru that every year or so is a big red flag. Also consider that raw complication rates, were they readily available and in comparable formats, may not tell you what you really want to know. Some of the best docs may have higher complication rates than their less skilled peers simply because they may take on more difficult cases. The old adage of the man who has never made a mistake has never done anything applies here.

It can get a bit mushy if you let it thaw too long (not bad if you are making guac or other kind of dip), and can turn brown like fresh avo if left out for very long. I usually pull out whatever slices I need while I'm preparing the rest of the salad or meal and by the time I'm ready to add the avo it has thawed enough to cut up and is just about right by the time it is served.

Sounds good. It's probably the lime juice that helps it keep - that's often the advice one hears to keep an opened avo fresh. For general use as in salads, etc. I slice up the avo and freeze the slices, then thaw and use as needed. Grilled chicken breast with avo and jack cheese....

There is some ongoing discussion within the bariatric community as to what stomach size is optimum - too small and there seems to be more problems with reflux and too large is thought to lead to more regain longer term. This is an area where they are waiting for more 5+ year studies to provide guidance. Our bodies do adapt in time and we can consume more as time progresses and we move to a more varied diet Generally, they will talk in terms of the starting size of the sleeved stomach because the % removed is a large variable due to the variability of stomach starting sizes (so that 85% figure that we hear so often is an average or generalization.) My stomach started at about 2.5 oz at surgery (RNY pouches tend to be around 1 oz) while a larger stomach of maybe 4 oz is commonly used with the DS in concert with its malabsorption. At about 15 months out, I have little problem getting in 1800-2000 calories per day with a well balanced healthy diet and that is maintaining my weight well (I've been at goal for most of this year.) Many who are smaller at goal (and women, who typically have a somewhat lower % of lean body mass than men,) need less to be stable, while others who are more active than I need somewhat more and are able to accommodate those needs. DSers, with their malabsorption, often need around 3000 calories per day to be stable and get in the nutrition that they need - a level that would have the vast majority of us VSGers back at our original weight in short order. As to the reason they settled on the sizes that they use now, I suspect that since the stand alone VSG evolved from the DS and has no malabsorption component to help it along, they felt that a somewhat smaller sleeve than they typically use in the DS would work better for most getting the VSG by itself.

It is really one of these "it depends" type of things. The general rule is to have your Protein first and then some veg or whatever if you have room. I never had much problem getting in my protein allotments (doc was adding veg to my diet at the 10 day follow up checkup) so I have been able to fudge some on that rule. Also, my sleeve seems to be fairly predictable day to day while some people report large variations in their restriction levels from one day to the next. Since I know that I will be getting my protein in for the day, I can have small salads with leftover meat, meat and veg stews, chilis, stir-fries and the like and not have to pick the meat out first. One of the advantages to mixing your protein and veg is that much of the veg tends to be a slider (at least they are for me,) so while my comfortable capacity is about 3 oz of meat protein, if I cut that back a bit (or sometimes not, depending,) and add some veg in a combined dish, I can comfortably have 5 oz or so of the mix. That adds some useful nutrition with little calories. I am like you in that I'm not much for sweet potatoes. I never bothered adapting to them and just used regular potatoes when appropriate - often an ounce or so of roasted yukon golds - as they both are one of the most calorically efficient sources of potassium (which we need but don't supplement effectively.) I guess it all comes down to philosophy - yours and your docs. Some people don't want to have anything other than the bare necessity level of protein in as few calories as possible, while others (like me) seek to get as much balanced nutrition in as makes sense with whatever caloric restrictions we are using. I preferred to eat as normally as reasonably possible during the loss phase to help make the transition to maintenance easier.

Mine was purees and soft proteins for the first month with everything else added as tolerated after that. Pre-op was clear liquids the day before surgery.

My doc's plan has liquids, puree/mushies and soft proteins as tolerated from the hospital on out. I think I was served scrambled eggs and yogurt in the hospital and did yogurts, puddings, boiled eggs and tuna in addition to the typical protein shakes, soups and jellos those first couple of weeks (got tired of soups real fast!) The doc and his brother have been doing sleeves in their practice for around twenty years, so I figure that they know what it can handle. My wife was on the same program when she went through this several years ago though she progressed a little slower - just some of the variations between us all.

I was having small salads with leftover meat and some salad veg after 3-4 weeks. I normally used chopped spinach instead of lettuce for its somewhat better nutrtional content, but I would sometimes have a bit or two of my wife's restaurant salad to no ill effect. As with everything else, try a little to test for tolerance and if it doesn't work, try again in a couple of weeks.

I have used thinly sliced strips of bell pepper and onions as a spaghetti noodle substitute. Another approach is to go with a cacciatore type stew using chicken or Italian sausage with veg like peppers, onions, tomatoes, shrooms, carrots, etc. Reduce it down to a thick sauce and it doesn't really need any pasta accompaniment.

That must be another guy thing - I was pushing 900-1000 calories within a couple of weeks, though I was able to move some semi-real foods at that time and not just liquids (doc was adding veg to the diet at the 10 day mark because protein consumption was more than adequate at 90g.)

It is quite normal to lose quickly at first - I lost about 32lb the first month (I started at 292), then 14-15lb each the next two months, then about 10lb per month thereafter. What happens is that the initial loss from any serious weight loss effort comes primarily from your quick reserve energy stores of glycogen (basically carbs) which burn at a rate of about 2000 calories per pound. Then, once the glycogen is exhausted and your body decides that you are serious about this caloric deficit/famine thing it starts drawing from your long term energy stores of fat, which burns slower at about 3500 calories per pound. Many people experience a stall at about that time (the dreaded third week stall, but the timing can be variable,) as it can take the body time to kick into fat burning mode, and restoration of the needed glycogen reserves involves hanging on to some Water to keep it in solution. Rapid weight loss is stressful on the body, but so are a lot of things. Ideally, we should lose our weight at a slower more sustainable pace but that's not how things are structured - either the WLS themselves or our psychological makeup (I would much rather lose it over two years than six months, but who has the patience or confidence that it will actually work if we don't have the constant reinforcement of the measurable loss?) That is in good part why I went with a more moderate balanced dietary program than many do, averaging in the 1100-1200 calorie range with no particular carb considerations, and still hit goal in a little over seven months - gotta love that guy metabolism, I guess! Good luck with the continued loss - it will moderate shortly,

I wasn't on any specific carb restrictions beyond the general avoidance of simple carbs and things that otherwise qualify as junk foods. Most of the fruit that I had during my loss phase were of the low glycemic index type - tomato and avocado in my salads and an ounce or so of raspberries in my greek yogurt. I tried a bite or two of banana when my wife was having one but they didn't sit well with me at that time - seemed to be a similar sugar rush as piece of straight chocolate. I tended toward more complex carbs when possible - more fibrous veg and whole grains.

In addition to the well known "good" fats, having a minimal level of dietary fats is useful in helping to absorb the fat soluble vitamins (A,E,D,K); I'm working on getting in around 60g in fats in maintenance mode. You also need a lot of the nutrients that come along with carbs, but that's out of fashion at the moment (unfortunately, our bodies don't understand these fads, so they still insist on this nutrition.)

Carb intake depends upon your surgeon's plan - some have jumped onto the low carb bandwagon while others have not. Some find low carb diets to be helpful while others find them not so useful, but there's nothing about the sleeve, or weight loss in general, that requires it.

If you need to use NSAIDS like aspirin, ibuprofin or naprosyn for any of pain issues, those are a big no-no for bypass patients, and are often used in appealing insurance decisions that favor the bypass over NSAID friendly procedures like the VSG or DS. 100 lb loss is very do-able with the sleeve and almost seems to be a sweet spot where the sleeve works very well while the RNY and DS are a bit of overkill for many (I lost about 105lb in a little over seven months with little effort, and could have lost more had it been healthy for me to do so; many have lost 200 or more.) Why BCBS approved you for the bypass and not the sleeve is anyone's guess, unless they provided some reasons in their correspondence; some companies reserve the sleeve for patients with a BMI of 50 and above (who knows why - tho there are some years' old ASMBS position papers to that effect though those are long obsolete and some of the staff or consulting docs for the insurance companies are just old like RNY guys and aren't familiar with other procedures. But if you need occasional or continual use of steroids or NSAIDS, that is often enough to force the issue with them, or to get their decision overturned by higher authorities Good luck in your efforts.

Based upon the common questions that I see on these forums, and how much variation there is between different surgeons' programs, beyond your basic questions, I would ask for:: Calories, carbs, fats, etc., if they specify (some docs give specific numbers while others don't want to get too wrapped up in numbers and prefer that patients concentrate of food types and quantities.) If you're a numbers type who needs such details and your doc isn't, try to get some ballpark figures, or at least try to understand the philosophy of their plan - establishing healthy long term eating habits, being ultra compliant with some specific diet plan like Atkins, figuring out what works best for you.... What is the intent of any specified pre-op diets - some docs do low carb (liquid or not) diets for "shrinking" or otherwise improving the condition of the liver prior to surgery, while others do a diet to get you used to the post-op regimen, while others want a certain amount of weight loss pre-op irrespective the method while yet others have no particular pre-op diets. I find it easier to stick to a plan when questions and variations arise if I know the intent of the plan, then if, for example, I can't get or run out of a doc's specified Protein drink (if he specifies) then I can find an equivalent product that will fit his requirements. What specifically is included in the various post-op phases or stages? Docs have various phases they specify for different amounts of time - Clear liquids, full liquids, mushie/puree, soft Proteins, firm proteins, etc., and one of the most common questions in these forums is "can I have XYZ during puree stage?" where some docs may consider XYZ to be puree while others would put it into their soft protein stage. (My doc made it easy by lumping everything short of hard proteins together in one month long phase depending upon individual tolerance.) Your doc's guidebook should give you a good idea with suggestions of what is included where, so if you don't have his guide yet, try to go over a copy with the NUT so that you understand it. I'll try to throw in more questions as I think of them. Good luck tomorrow, and with the rest of your journey,

2 days. It might have been one day except that they didn't have the report from the leak test filed yet so I was still on the IV at Breakfast time the day after.

I had one sometime in the middle of the second month, though I probably could have had one earlier given all the other "normal" type foods that I had been having before that. I have evolved into having the Quest bars when I have one as they have one of the best protein per calorie ratios out there, I like several of their varieties, they have little or no sugar alcohols in them (depending on variety - many people have problems with sugar alcohols), and they have a lot of fiber which most of us can use.

My doc's plan was two basic stages, with liquids, purees and soft proteins including eggs and seafood the first month, progressing as tolerated, then everything else as tolerated the second month and beyond. I had scrambled eggs served in the hospital and hard boiled eggs at home the first week.

1 day pre-op, none required post-op.

String cheese and the like was on my first month list, though I'm not sure when I had it; I did have some of the babybel mini cheeses within the first couple of weeks and had some melted swiss cheese in some french onion soup around the end of the first week, so I guess that counts.