RickM

I would ask your program to make sure, but often some of the soft canned meats like tuna or chicken are acceptable to some. We didn't have a discrete puree phase (it was just lumped in together with all of the liquid to soft things and we could move between them as we could tolerate,) so I can't say for sure how your program wants to run things.

It is a bit of a tricky thing, as you can see, some programs will still have their patients on a liquidy diet while others will have them on steak, chicken and other regular foods. Our general rule of thumb was to try new foods one at a time to test for tolerance - if it goes well, great, if not, try that food again in a week or two. While some programs are adamant about staying on only three meals per day (they're afraid that more can lead to grazing,) most fall into the 5-6 meals per day (some say three meals only, plus a couple of "snacks" - of you can tell the difference at this stage (I couldn't, I just called them feedings.) I started at six but soon dropped it to five as a snack between my breakfast and lunch didn't make much sense and I could get all that I needed comfortably on five. I added a sixth back in when I needed to ramp up my intake slow things down going into maintenance, and still vary between five or six depending on my needs, dropping one if I need to cut back some. If you are not meeting your nutritional goals, primarily protein, then you should probably add in a meal or two - just be watchful of the overall calories, Continue to think in terms of protein rich foods primarily. I had little problem with protein, so I could back off of that a bit and go for more variety - I started playing with small salads, including some meat and cheese in there, at around this time, but wouldn't have gone there if I was still struggling on the protein front. Since you have seen your surgeon and the ER about your BP problem I will assume that it is not due to medication - BP meds often need to be adjusted fairly quickly to compensate for the changes in you body systems - you have excess cardiac capacity now since you are supporting a smaller body, even a month out. My PCP was lowering my BP meds early to avoid this, preferring it to be a bit high if necessary rather than too low. Presumably, what you are seeing is orthostatic hypotension, where you feel faint or worse when you stand or sit up rapidly, so take that a bit more slowly, Things should adjust over time. As to meals, at that time I was mostly on single foods as you were noting, with occasional combination meals depending upon what my wife was having. As noted, I started playing with salads then, and sometime some other protein rich single dish meals with meat and veg, like a chicken teriyaki or cacciatore to liven things up a bit Good luck on your progress...

Yep, Kaiser can be tough - which is how they keep their rates low(ish). They would never approve the DS, as they don't have the capability in house,, but they lost the appeals to the state so frequently that they finally contracted with our surgeon to do them for those who got through the gauntlet and the state forced them to cover it. Just have to keep pushing with them, but many just give up (which is what they are counting on.)

Yeah, I had one like that, too - he was continually frustrated that I wasn't diabetic or insulin resistant despite being morbidly obese. He also was always promoting the latest fad diet highlighted in the local media (different one each time.) I think that this is a subset of those docs whose stock answer to any problem you have is "if you'll just lose some weight, this won't be a problem..." They don't seem to like the question "what do you tell your normal weight patients who have this problem?" He also didn't like the idea of WLS, preferring to use off label diabetic drugs for weight loss (as long as you take them, then the weight comes back...) and if needed after that, a lap band. Thankfully, I didn't need to pay any attention to any of his advice outside his rather narrow circle of competence.

While this is classically a bypass problem (look up the "Al Roker White House Shart" story - yes, it happened to him at the White House) it can certainly happen to sleevers early out. This is mostly due to the radical dietary changes and the body working to adapt to it. I had both diarrhea and constipation at the same time for a while. It passes (so to speak) fairly quickly for us as out diets and GI tracts get to know each other again. Probiotics may be helpful in helping the gut flora adapt to the changes.

I would be careful about moving your intake up too quickly, simply because it is very difficult to cut back once you get used to a higher intake. I have seen many who have done well in the 6-800 calorie range during their loss phase, so this doesn't seem to be too low metabolically. That said, I settled fairly quickly in the 1100 range, but I am a guy, with a guy's metabolism that remained fairly intact. (as ms.sss noted, this isn't a one size fits all game.) Prior to WLS, my weight was stable in the 26-2700 calorie range, so I had a fair margin to work with. Do you know what your metabolic stability point was before surgery (real world for you, here, not some online calculator that's appropriate for someone else)? Your weight loss rate will trend lower over time, simply because there is less of you to move around 24/7 so, on average, you burn fewer calories per day, so you won't, on average, lose as much per week or month after six months as you did after two, and fewer still after nine or twelve months. It is not unusual for some to go into "early maintenance" because they increased their intake at the same time as their caloric burn decreased. When I finished at goal, I was stable at around 21-2200 calories per day, or about a 1000 calorie deficit that I had to make up from my 1100 per day that I was consuming during the loss phase; most don't have much margin, particularly most smaller (shorter) women. Another reason to be careful about increasing intake too quickly (or at all) On doctors advice on these programs. Some doctors advise their patients that they will typically lose around 60% of their excess weight (an overall average for the industry,) while others will push their patients to lose 100% of their excess. Guess which programs advise increasing calorie levels over time and which advise overall low(ish) stable levels while losing?

I would be eternally grateful that the surgeon has you on a diet of real food rather than one of these liquid things (which I still haven't figured out what they really do.) As noted, low carb is the main functional requirement for "shrinking the liver" (to the extent that such can be done in a couple weeks' time - there is still debate on that amongst the docs,) and as you see, even on the liquid diets aren't necessarily all that low carb. Go figure. Many of us never had any diet at all. It all comes down to the surgeon and what they are comfortable with. I would be more concerned if the surgeon was one of those who threatens to "close you up and send you home..." if you haven't shrunk the liver enough (and occasionally one actually follows through with that) as that is a good indication of some deficient skills on his part. For some docs, liver condition is not a major imperative for them - they can handle whatever you throw at them - and they devise diets for other purposes, or as noted, none at all. Go with the flow and enjoy the ride. It seems to me to be an thoroughly sane diet that will likely lead to a more rapid recovery and better outcome than the liquid diets that others impose. Good luck

Generally, the sleeve will be less fussy than the malabsorbing procedures when it comes to supplement requirements, however, they will all have some initial requirements for the first few weeks or months as you need some additional nutrition since you won't be eating much for a while. Shakes are a part of it, for a variable amount of time, as that's the only way other than real food to get our needed protein. Over time, there will be little that you can't eat with a sleeve -which is good and bad. Good in that you can, in principle, be able to get all of your nutrition from food if you are so inclined (most aren't, which is why they still need to supplement some.) Bad in that you can still eat junk that goes against your weight maintenance goals. Some people need supplements, even with no WLS at all, simply because that is how their body works. Some programs impose the same supplement regimen on their sleeve patients as they do for their bypass patients, not out of necessity for the sleeve but for their own (the practice's) convenience. Periodic lab checks will tell you what you personally need to stay healthy. Are you having your WLS done here in the States, or in MX? The mini bypass is rarely done here in the US and is rarely covered by insurance and AFAIK has not been endorsed by the ASMBS as an approved, mainstream procedure. I would do some further research as to why this is before proceeding. The mini is done in MX, primarily as a cheaper alternative to the RNY, and is also more commonly done in some other countries. Here in the States, I would shy away from it for the same reason that I wouldn't own a French car (irrespective whatever merits they may have) as they haven't been sold here for decades and finding parts and service is a PITA. Likewise, should you have problems with a mini sometime down the road, finding someone who knows how to treat it can be a problem; if you have a sleeve or RNY, any bariatric practice at any hospital will know what you have and how to treat it.

-It is not an unreasonable position for her to keep, as the bypass does indeed provide very similar weightloss and regain results to the sleeve but at a somewhat higher cost in potential problems, limitations in future medical care and increased fussiness on supplements. The bypass is overall a very good procedure that is mature technology - it has been around as a WLS for some 40+ years, and its basis dates back some 140 years, so it is a well known quantity, both good and bad. Her concern about ulcers is well founded, and that is something that one lives with, or at least the threat of them, with the bypass as it is intrinsic to it. One may never experience one, and most don't, but everyone is living to avoid them - it is the basis of the "no NSAID" policy that is common in the bariatric world as one needs to avoid any medications that promote stomach irritation and NSAIDs are the most common class of drugs that we encounter (but there are others that one may encounter through life.) Occasionally someone will come through with an ulcer problem that defies resolution, and their main course of action it to reverse the bypass. This is rare, but it happens. Marginal ulcers are to the bypass what GERD is to the sleeve - you can't fool mother nature and there will always be potential consequences to fooling around with her. One needs to balance what one gets from a treatment against what might possibly occur on downside. Iron infusions are also a fairly common need after bypass, as it malabsorbs minerals in particular, and while some can get away with simple oral iron supplements, many can't and need periodic infusions. This is rare with a sleeve as there is no particular malabsorption. Another factor that weighs on some is the "plan B" factor - what does one do if things don't work as expected - complications, inadequate weight loss or regain? While we don't like to think in terms of getting revisions, they are sometimes necessary, and the bypass is difficult to revise if it doesn't work right; as noted above in the case of intransigent ulcers, the usual is to reverse the bypass and put you back where you started from, and likely still needing help in weight control. The sleeve, on the other hand, can readily be revised to the bypass if needed - typically for intransigent GERD problems - or to a duodenal switch for continuing weight problems. Again, not something we like to think about, but the options are there. The bypass also presents some additional limitations in future medical treatment, as it leave one with a blind remnant stomach and upper intestine, which can't easily be scoped endoscopically as with the natural GI system or with a sleeve. Again, something that may never come up, but likely will sometime in your future life. A further note, your surgeon is in good company, as my doc rarely does bypasses as well, though his preference leans toward the duodenal switch as his primary, with VSG as a second choice. He does, however, do a fair amount of business revising problematic bypasses to the duodenal switch, and will do the odd bypass when it is specifically indicated for a patient, but that is fairly rare.

Do they actually make you sick, as in nausea and/or diarrhea, or you just can't take the taste (not uncommon)? It is not unusual for people to become lactose intolerant after surgery, which can make you more sensitive to various whey based protein drinks. Those that are 100% whey isolate are usually well tolerated as the lactose is filtered out in the processing, but it is more expensive, so many products, including the popular Premier brand, use a cheaper whey blend or concentrate that is only partly isolate, so are not as well tolerated by those sensitive to it. There are other protein drinks that are based upon other proteins such as pea, egg, soy, etc., which may not be quite as well absorbed as whey, work OK if that is all one can tolerate.

Is the revision a two step process (remove the band, wait a few months for healing, then do the RNY) or all at one time. Some surgeons do them all one way or the other, or depending upon circumstances. what kind of pre-op dieting requirements do they have (some want their patients to lose a certain amount of weight before surgery, while some don't care; some impose a stricter to "shrink the liver" for a couple of weeks or so before surgery, while others don't)? What problems do you frequently encounter with this type of procedure (as the bands often damage the stomach, and that's why many such revisions are done.)

The drinking thing is something that I have noticed that most programs don't handle very well. The "sip, sip, sip, all the day long" thing is necessary for most for some period of time, depending upon how much inflammation we may have in the stomach after surgery. If it is seriously inflamed, then yes, it takes small sips to get fluids through - think of drinking through a pinched soda straw. If there is not significant inflammation, then your new stomach is more like a normal, or even large soda straw, so fluids will go down fairly easily, though it will still be a restriction from real chugging or gulping. I didn't have any significant inflammation, so I could sip a bowl of broth (maybe 6-8 oz?) and a juice box (with straw) within a half hour or so sitting - in the hospital. I still diligently sipped away for the month and a half or so when I too a drink from my bottle between swimming laps, to no distress. I probably could have done that a few weeks before but was still scared into sipping everything. No, I couldn't (or didn't) gulp or chug it, but just normal swallows of water. Lesson here is to gingerly try little larger sips, working up to "drinks" and see how things go down. If things are backing up, or not going down promptly, back off a bit and go at a bit lesser rate for a while. The not drinking before/during/after meals thing is also a bit flexible. The before meals thing is again, and inflammation concern, and they want to make sure that the fluids are clear from your stomach before eating so that it isn't competing with the limited food that you can eat. Once fluids are going through fine, drinking up to the point of eating is fine (and some surgeons recommend this practice.) Drinking during a meal again, competes for space with the limited food that you can eat, so should be avoided (small sips if something is dry is OK.) Also, drinking with and after a meal has the effect of "washing through" the food that should be staying in the stomach for a while to provide satiety - drinking too soon can lead to earlier hunger and overall over eating during the day when we are trying to keep eating to a balanced minimum for weight loss. After ten years, I am still not comfortable drinking much of anything for a while after a meal.

It can be done, but the feasibility really depends upon what is wrong with your sleeve and how experienced your surgeon is with sleeves (most these days are reasonably capable of making decent sleeves - at least in the US - but quite variable on repairing or revising them.) Many prefer to just revise to an RNY as it's easier for them if their sleeve skills are sketchy. What is the reason for your interest in a re-sleeve? Poor original weight loss or regain, or are there complications possibly resulting from shape problems with your sleeve? I would usually expect a resleeve to be more expensive than the original sleeve, as is the case with most revisions owing to it usually involving more surgical time; a higher skill or more specialized surgeon is also likely more costly, but much of that depends on location and local rates. One of the surgeons I am associated with usually just does them as part of a conversion to a DS, and sometimes it involves doing an open procedure rather than laparoscopic one, so that influences the cost as well. In short, yes, it can be done, (though maybe not by just anyone,) is unlikely to be cheaper, but all really depends on the reason and what is involved in your particular case.

My wife had hers removed along when she had her duodenal switch, and there wasn't anything unusual that one could point to regarding that part of the procedure. Our doc routinely removes the gallbladder (and appendix) when he does the DS as he doesn't want some future surgeon going in there and getting lost in the weird anatomy. With his VSG patients, he leaves it alone unless he feels stones in there when he is doing the surgery, then he deals with it if necessary (much like the liver thing, if the patient has fatty liver, he deals with it, no point making a big fuss over it as some surgeons might do.)

I've been in this WLS world for close to twenty years, since the initial work up to my wife's DS and then my VSG some years later, and from what I have seen from many in our support groups, most everyone can lose up to around 30lb of regain - it takes some effort and a few months, but it comes off more or less like a "normal" person. 50lb or regain is more a a 50-50 proposition - some can lose it on their own, and some need a revision to help it along. My general feeling is that the revision should be your last step rather than your first. Go back to some basics and try to understand where your regain happened, as if it happened, once, it can happen again after a revision., so you need to get your head around the root of the problem. Is it a head problem, meaning that maybe some therapy is in order, or not really understanding the nutritional side of things and how to eat and live to maintain a healthy weight - an RD can be helpful for this. Or, maybe a bit of both. Unfortunately, our WLS, and by extension a revision for regain (rather than for complications) is really more of a "do over" rather than a cure for the problem Very commonly, before we had WLS, the most frequent reason for failure in dieting is that the diet will yield some weight loss, maybe even to normalish weight, but then the person declares success and goes back to their old habits, and diet, that helped to promote the weight gain in the first place - they never really learned how to live, and eat, to maintain that healthy weight. This is why we frequently see people regaining fairly rapidly after notionally successful dieting. The same basic profile often happens after WLS, only it takes a while longer to happen owing to the lower volume that we can eat, but that tendency is still there. Another consideration is that every time we go inside to do surgery, we back ourselves further into a corner, limiting our options for future treatment should that be necessary, whether for regain revision or for something completely unrelated; you have limited any future surgeon's options in what they can do to help you with some future problem. This is why I am very shy about "wasting" a surgery if I can possibly treat the problem some other way. Again, let it be your last choice, rather than your first.

Assuming that your insurance is associated with your husband's job, then you will be offered a continuation of it under COBRA - it's a legal requirement for the employer. You pay the full cost rather than the partial cost you paid as an employee, but it's usually much less than what you will find on the open market or Obamacare exchanges (unless you qualify for a substantial subsidy - you have to check it out and run the numbers.) Under COBRA, it will be the same insurance and rules that you are already used to in your husband's plan, so there should be no problem requalifying for the surgery; under an Obamacare (Covered California, here) the benefits, costs and deductibles may be different, and varied depending upon plan chosen, but it should still be covered here in Calif. Good luck in working through this, despite the current bad luck!

It could be a number of things, most common this far out would be a hiatal hernia that could cause these problems. Is your protonix once a day, or split into two doses, morning and evening? If it is consistent with the labelling, try taking it in the evening, as that is where your biggest problem seems to be, or splitting it morning and evening (if it is two 40mg pills.) Short term to help with the overnight problem, try elevating the head of your bed 3-6", or elevate your head and torso with a wedge pillow, or sleep in a recliner if you have one - anything to get your upper body (not just your head) angled down toward your stomach. Avoid eating anything 2-3 hours before bedtime. These are classic DIY reflux mitigations that the gastro will probably also suggest. You can consider going to the ER and hopefully they can get some of the tests done necessary to diagnose your problem (likely an endoscopy and/or barium swallow imaging. The may also just send you home with a larger dose of protonix or maybe a switch to dexilant and possibly carafate. An urgent care clinic may be able to help, particularly if you have one affiliated with your hospital - they may be able to short cut getting the tests done that you can then take to the bariatric surgeon (who would likely order the tests anyway. Many hospitals run these clinics for just this purpose - not really an emergency, but too urgent to wait a week or two for an appointment. This may save you a couple of weeks. Don't worry about insurance coverage as if a revision is needed, it would not be considered a second WLS (which some insurance limits) but as corrective surgery for you complication. Good luck in getting some resolution soon (er, rather than later)

Colonoscopies aren't normally needed (I've never seen anyone mention it being required for their program) as they aren't working on that end of things. An endoscopy (EGD) is sometimes specified as that can give the surgeon some advanced notice of what's going on where he will be working - some docs like to plan ahead while others take what you present to them. ( I don't think that an EGD is a bad idea, as it may give you some information that can sway the decision as to what procedure might be better for you.) Liver scans, or ultrasounds, are sometimes done - this is also a doctor's preference as some docs are very sensitive to that (maybe requiring additional pre op dieting, etc.) while others are entirely comfortable working around a fatty liver - just another day at the office for them. Do what your doctor wants, and worry about what he worries about, and not what he doesn't. Holiday meals are going to be different this year, no question about it. You might be able to eat a bit of some things, you might have to mash things up or puree them, or stick to soups, etc., depending upon how your doctor's program allows you to progress and how well your body allows you to progress. I went to a wedding (local) a couple of weeks after surgery without any big problem. Liquids go through your stomach readily (unless you have an unusual amount of lingering inflammation in your stomach that slows things down) but will be collected in your bladder as normal. Most will often have some problem with constipation and/or diarrhea for a while as your system gets used to things, Fatigue will be there for varying amounts of time as you recover. Your diet is mostly protein as a priority until you can eat more variety, and usually little carbohydrate, which helps provide you with energy; some people go overboard on low carb dieting which can compound the problem, while some programs encourage some early carbohydrate via things like soupy oatmeal, cream of wheat, mashed potatoes or some watered down fruit juice to combat the low energy. Good luck in this adventure!

Absolutely - I haven't needed anti-perspirants/deodorants for years. Likewise, my resting (and active) heartrate is much lower - always gets the attention of nurses when they take my vitals.

The first is likely nothing to worry much about, but to stay on top of - with COVID around I'm sure this is a common thing (though TinDE is right in that these things are usually pre-approved for some period of time, as delays happen. It is likely a matter of box checking and the surgeon's insurance coordinator needs to get with the insurance company to get the correct box checked on their forms so that their computer can do its job. It may even be routine enough that they don't even bother changing the pre-auth date rather than doing it retroactively. Again,, not likely a big deal, but it is their problem to work out - that's what they get paid to do. On the second issue, this is one of the semi-legit "scams" in the medical world, where we get these trail of bills from out of network "providers" we never heard of. Kick this back to the anesthesiologist (why does he need a nurse assistant for a simple bypass job?) More and more various hospital workers, seemingly down to the floor sweepers, who used to be covered under a general surgical or anesthesia charge seem entitled to charge you insurance separately My wife had an orthopedic surgery a couple of years ago and we got an EOB from a surgical nurse charging more than $16k (over double the surgeon's fee - for a half day job) of which the insurance paid $300.. We couldn't get any response from her billing service (an RN needing a billing service?) so we asked the surgeon about it in a follow up appointment (she must be damned good to bill double your rates!) and he texted her while we were there and the excess charge was removed by the time we got home. These underlings have an incentive these days to try to get away with what they can, but ultimately, they don't want to cross their boss - the guy who specifies their services. Similarly, on a shoulder job I had, the insurance rejected the claim for a PA surgeon's assistant, claiming it wasn't necessary for that surgery; the surgeon told me "we'll take care of it", and they did. In short, let the relevant providers know of the problem and let them take care of it before panicking, If it doesn't resolve within 2-3 months, then panic. As a final note, let your surgeon know of any of these problems, as he is the ultimate boss, (or at least higher up the food chain). He may feign disinterest, (there's nothing I can do about that...) but anything that impacts the public perception of his practice is in his interest. He can't technically tell the anesthesiologist how to run his practice, but he does have influence over using his practice, so it may just be a mention over lunch ("Hey Bill, your nurse is hassling my patients again - have her knock it off...")

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, Typically we see a few weeks to a few months sited for this. 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 to 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.

I would definitely give some push back and ask for a different prep - there are many. Does he know that you have had WLS since your last scope? I just had one last month and they prescribed SuPrep, which is a low volume, two step prep - two 8 oz (IIRC) bottles that you drink fairly quickly, followed by a couple of bottles of water the next hour, done the night before and then again the morning of the procedure, and that seemed to go well - for both me and the doc. Should be little problem for a 1 year post op. My wife had a bad scope some years ago despite being compliant with the prep, It turns out that others with the DS like her reported similar problems - it seems that the wacky intestinal configuration needs a bit more time to clean out, as we discussed in one of our support group meetings. One of the other vets in the group who had a similar problem worked out a revised routine with his gastro that basically involved doing the clear diet for two (or possibly three) days before the bowel prep, and that did the job. When it was time for my wife's next scope a couple of years ago - new gastro since we had moved - we hit him up with the problem, and while he was focusing mostly on the WLS needing a low volume prep, which he prescribed, she did the modified longer liquid (not strictly clear the first day, just liquidy) and all went well with that one, too. So, while I am not an MD, it is clear that there are several ways to get the job done, and you gastro should be sensitive to your needs as well as his own. It kinda sounds like he is punishing you for what he may interpret as non-compliance the last time, or maybe this potion is what he is most experienced with for a more challenging case, and while he may be aware of newer preps on the market, he isn't experienced with them and goes with his old tried and true. Again, I would push back at this, tell him that you can't comply with this and why. Discuss what other options there are to get the job done that works for both of you. Your medical care, as with most things in life, are a negotiation and you have a say in this. If the doc doesn't want to comply with your needs, then it is entirely within your rights to go to a different doctor to get what you need. Ask your PCP or your bariatric practice for a referral to someone more bariatric friendly, if necessary. Good luck,

Yes, they bypass is more prone, or predisposed to, ulcers than the sleeve (just as the sleeve is predisposed to GERD.,) but they are a different sort of ulcer than what you have. The bypass tends toward marginal ulcers around the anastomosis (junction) between the new stomach pouch and intestines. This is because the part of intestine that is now immediately downstream of the stomach is not resistant to stomach acid like the duodenum - the upper part of the intestine immediately downstream of the normal stomach, which gets bypassed along with the remnant stomach in the RNY. Consequently, that anastomosis is very sensitive and prone to ulcers, which is the root of the "no NSAID" rule that permeates bariatrics - you don't want to take any medication that could irritate that anastomosis (there are other meds that may be limited, too, but NSAIDs are the most common class.) What I would be concerned about is what caused your ulcer, and whether that cause would be relieved (or exacerbated) by your surgery. Similar to your hiatal hernia and GERD - fixing the hernia will likely correct your GERD and you will be back to "normal" - no more predisposed to it if you get a sleeve, but still possible. One of the problems with the bypass is that it leaves you with a blind remnant stomach and upper intestine, which can't be easily monitored with an endoscopy, so if something develops in that blind section, you may not know about it until things have progressed more than you would like them to progress (possibly to a cancer.) Some express a dislike for the sleeve because if they have a resultant reflux problem then it could lead to Barret's esophagus and possibly cancer, which is a fair concern; however, that is something that can be easily monitored endoscopically if those symptoms develop, and can be treated; problems that may develop in the blind stomach or intestines of the RNY may not be caught until it is too late to treat effectively, so there is a trade off there. You are somewhat caught in the middle, with some contraindications for both of the common WLS procedures. This is where some serious talk, and understandings, with your medical team is appropriate to really get a good handle on your problems going into this, and how those may play out in the future. I/m not so sure that I would be comforted by the matter that the surgeon may be able to work around a problem (such as an ulcer) if that problem is likely to reoccur 5-10 years in the future, and possibly worse - the surgeon is out of the picture by then, but you aren't. There is another alternative that might be worth considering, which would be the duodenal switch - it uses a sleeve, so it doesn't leave a blind remnant stomach, but due to its' malabsorption component, they typically use a larger version of the sleeve which is less prone to GERD problem. Your surgeon may not offer it (it's a more complex procedure, so many surgeons don't offer it) but it may be worth looking into to see if that fits your need. Good luck,

Absolutely. When I had my VSG ten years ago, most bariatric surgeons were just learning how to do them - while they are in concept simple and straightforward to perform, like anything else technical, there are subtleties and techniques in doing them correctly - "twenty years of doing bypasses and they think they know how to do a sleeve..." was the refrain from one prominent surgeon at the time. While the sleeve does have some predisposition toward GERD (much like the RNY is predisposed toward dumping, reactive hypoglycemia and marginal ulcers,) this was compounded in the early days by surgeons who hadn't yet figured out the technique to consistently get them right to minimize that predisposition, and to some extent continues today in areas that were slower to adopt the sleeve and are behind the learning curve. This is a good part of the reason that I travelled 400 miles to a practice that had been doing them for twenty years (at that time) rather than a local practice that had been doing something else for twenty years. Talk to your doctor on interpreting this. Hiatal hernias are common with morbidly obese people, and a common cause of heartburn. They can easily be fixed during the WLS procedure, so if that is the cause of your heartburn, things look better for you. A hiatal hernia can be described as a diaphragmatic hernia, but not all diaphragmatic hernias are necessarily a hiatal hernia - so get some clarification on that.

Most practices have support group/information seminars - online these days but some may be going back to in person soon - where you can get some idea of how the practice works, their biases and philosophies, which are useful in helping to make a decision. Looking at their websites is OK< but that's a bit like choosing a car dealership based upon their website - they are heavily marketing oriented; they are designed to bring you in the door rather than provide much useful information. Many list all of the WLS procedures, including some of the obsolete ones that haven't been done in years, while in reality they only offer one or two of them. It helps to be familiar with the different current procedures that are offered in the industry (the ASMBS website has good coverage of all of the commonly approved procedures, as well as some of the newer, more investigative procedures.) Have some idea which one or ones may be most appropriate for your needs, and then go to the seminars or do some surgeon consults and see what their opinion is. They will want a lot of information before a doctor consult, as will any doctor, so that they can better see who you are and what your issues are. UCLA is good by reputation, though I haven't had any dealings with them. I have had some dealings with Cedars Sinai bariatrics and would be comfortable with them, though I never went through the whole program with them. Most programs offer the VSG and the RNY; some now offer the SIPS/SADI/Loop DS which is gaining acceptance (though doesn't seem to quite be there yet,) and a few rare ones offer the BPD/DS, which is more complex than the others (hence fewer practices offer it) but generally works better than the others, particularly for those in the higher BMI range or with more severe metabolic problems. For the VSG or BPD/DS, I would go to Dr. Ara Keshishian, who is in the Glendale/Pasadena area working through USC. Patients travel from all over the country to see him for the DS or complex revisions. When I had my VSG ten years ago, I went up to SF to have it done as no one in the LA area at the time had much experience with them yet (and Dr. K was still working out of the Central Valley at the time.) As a start, I would try to attend, online or in person, as many of the informational seminars as I could, and get a feel for the personality of the practice. Good luck,