RickM

No direct experience, as I'm out here on the left coast, but by reputation I would want to talk to Dr. Mitchell Roslin. He gets mentioned occasionally in our support groups from the doc's interfacing with him at the ASMBS conferences, and I like the papers and talks that I have seen him present online and response from other patients of hisi; I like his approach. He is capable of doing all of the major bariatric procedures, including the complex RNY to DS revision, and like most DS capable surgeons, he is not a big fan of the bypass (because there are better things out there,) I have heard patients for whom he specifically recommended the bypass because that is what was the best procedure for that case. Most bariatric surgeons give you the choice (maybe) of the sleeve or the bypass, whether or not either of those are really the right thing for you. Again, short answer, I would have a consult with him as part of the process of deciding. Good luck in this venture....

I don't know the specific hoops that need to jump through with Kaiser as I have never been with them, but your PCP is the primary gatekeeper, and they do have an incentive to keep things cheap, while keeping you alive, so the system does make it difficult. There should be some form of appeal process that lets you go around the PCP without endless doctor changes, and there is an ultimate appeal to the state department of managed healthcare to override insurer's decisions when appropriate, but you aren't there yet. My surgeon is (or was) contracted to Kaiser Norcal to do the DS for them when they lost those appeals, as they don't do that procedure in-house, but it is part of the accepted standards of care for obesity, so they are obliged to cover it (they just don't make it easy.) A bypass will be more straightforward to get as they do those in-house, but they're hoping that all the hoop-jumping will get you to lose enough weight that they don't have to do it! Good luck and perseverance.

Yes, as catwoman says, it is common for them to have you on a PPI, or increase the dosage of the PPI after any of out bariatric procedures; I've been put on pantoprozole (Protonix generic) after other minor procedures unrelated to the GI tract because the body often reacts to the stress of surgery by increasing acid production. Talk to your surgeon's team to get it resolved.

The DS as a virgin procedure is more challenging to perform than a VSG or RNY, which is why relatively few bariatric surgeons offer it, despite its' demonstrably better performance (the RNY is "good enough" for most patients...) That's your first challenge - finding a reliable DS surgeon. Converting a VSG to a DS is straightforward for any DS surgeon, as the DS uses the VSG as its basis, so it's mainly a matter of adding the "switch" part - the malabsorptive part - to the VSG. Revising an RNY to a DS is another, much more complicated matter, and surgeons who can do that are few and far between. It used to be, a few years ago, that there was maybe a half dozen surgeons in the US that reliably did them, and I have seen references to a few more have joined the ranks in recent years. Rabkin and Keshishian in CA have both done them for many years, as has Roslin in NYC. I've heard that someone in Salt Lake has done some, along with some docs at Duke University in NC, possibly Kemmeter in MI. Some surgeons who don't do the DS will offer to revise to a distal RNY instead - that is a "long limb" RNY that has malabsorption more akin to the DS. However, it does not have a great reputation, and is usually not approved by US insurance as a primary procedure (but often will as a revision under the right circumstances.) My take on why it seems to be more problematic than the DS is that it is rarely done, and the surgeons and their practices aren't all that in tune with its' long term requirements. A DS, and by association the distal RNY, has a quite different nutritional and supplement requirement to the standard proximal RNY, which is well known to those in the DS world, but not all that well appreciated by those in the RNY world. Like with the RNY, and much more important with the DS, is to commit to having annual labs and follow ups for life - with the altered absorption and nutrition/supplement requirements, things can go askew in sometimes if you don't stay on top of them. Those who do stay on top of things typically have minimal long term problems. I would not go to MX for a procedure like this, as you really don't know what you will end up with. Historically, there has only been one reliable DS surgeon in MX - Gilberto Ungston - who, if not retired, is heading that way. He has trained a couple of others to do the DS, but I haven't heard of him doing the RNY to DS revision. There are, of course, the various horror stories of MX surgeries gone wrong, and in particular of those seeking a DS and getting "something else" (who knows what.) There are great, reputable surgeons down there for the VSG and RNY, but I wouldn't go there for something more complicated like a DS, unless it was someone well vetted in that procedure (such as Ungston,) - the differing legal systems leave one with no recourse is something doesn't go right (and the chances of that happening with something as complex and an RNY/DS revision are high there.) Good luck - it is a long search for what you need, and be prepared to travel. Being in CA myself, and my wife is a Rabkin DS, we have seen several successful revisions like this from both Rabkin and Keshishian, so it is viable when done by someone experienced with it. It, also, is not a simple outpatient procedure, and Rabkin's standard practice for travelling patients is to remain in town until at least the 10 day post op follow up. Most everything else can be done remotely (and they are set up for doing so.) Keshishian is similar in this regard.

It sounds like something is out of balance to be that lethargic at six months - most tend toward the energizer bunny side of things with a big chunk of weight off. Have you had labs done recently (six months would be a typical time for most programs)? Low iron or B12 are common bypass problems, which is why they usually recommend extra, but the recommendations tend to be an average and may not be enough for everyone (while being too much for others.) I would certainly check in with the surgeon or RD on this.

The good news is that this seems to be fairly normal - our weight loss when we start a major effort, surgical or not, tends to be front loaded - lots of initial loss, mostly water weight, and then slows down. Plus you are just getting in.to the "three week stall" window where weight loss typically slows or stops for a bit while the body absorbs what has happened to it, and then resumes (though usually at a slower rate.) The not so good news is that as a revision, weightloss is typically slower and less than with the original surgery. My simple minded thought on this is that originally, our stomachs will hold 32-64 oz, but now after your original WLS and whatever stretch and adaptation it goes through over the years, it might hold 4-6 oz, yet you have adapted to that (learned how to eat around your sleeve/pouch) and still regained. So things will be slower. And, the biggest loss tends to be around surgery time when we are stuck with the highly restrictive pre- and post-op dieting. Additionally, the RNY is metabolically similar to your original VSG, so it doesn't provide a big change over what you had - so it is much slower going the second time around. (The DS, duodenal switch, is stronger metabolically than either of the others, so does work somewhat better on regain, but few surgeons offer it, or mention it.) Those who I have seen who have done really well with revision weight loss are those who take the "I'm not going to let that happen again" attitude and really knuckle under and get, and stay with, the program.

This is a big maybe - talk to your surgeon and see what their position is. They may have one thing published in their guidebook (don't take them, ever...) and something else if you talk to them directly about your specific condition. NSAIDs are a big NO NO for a bypass, which has been well established owing to specific problems with that configuration, which doesn't exist with the sleeve. When things started with the sleeve, most docs simply carried over their same instructions to their sleeve patients - intellectually they knew there was a difference, but their experience didn't tell them how much. Many now consider them to be a small no no for the sleeve, while still prohibiting them for the RNY, but that still varies. Occasional use is usually approved, but they want to avoid consistent use. Our team had been doing sleeves for some twenty years, mostly via the DS, when I had mine done twelve years ago, and their experience indicated no problems with NSAIDs even shortly after surgery (more recent conversations with him indicated waiting a couple of months or so.) I like to be conservative on such things, so I avoid them mostly, but use them occasionally. These days I mostly use Rx meloxicam for occasional orthopedic issues, which is a Cox-2 inhibitor and supposedly somewhat friendlier to the stomach than NSAIDs.

Yes, absolutely possible, as Catwoman suggests; indeed, many talk in terms of this as being a "completion" of the DS rather than a "revision". I don't know specifically of anyone in those states who does it - DS surgeons are still fairly few and far between, at least ones who do the "traditional" or Hess DS. The simpler SADI "loop DS" has more who do it, but that's really a distinct procedure that should be considered on its own merits. In earlier years, Dr. Rabkin in SF (who did my VSG and my wife's DS) had an active support group in the Seattle area as he had a fairly large contingent of patients there, though they have dissipated in activity, as we tend to do over time. For a DS, one should usually count on having to travel for them, even if one is in a major metropolitan area. Fortunately most DS surgeons are very used to travelling patients and are equipped to do remote consults before and after surgery, so it's mostly a trip of a couple weeks time for the surgery and everything else can be done remotely.

Yeah, as Arabesque said, NSAIDs are a big no no with your bypass, but better tolerated with a sleeve (our doc doesn't even restrict it to occasional use like that, though it's still a good idea to restrict it.) It is definitely a check with your surgeon thing, as they will differ as to what their experience tells them - some are OK with NSAIDs for an occasional day's use and many aren't, but a month would very likely be a big NONO. There are COX2 inhibitors like meloxocam that might help, they tend to be somewhat better than common NSAIDs on the stomach, but not entirely safe. The narcotics are a lot more restricted than they used to be, even at low doses, so those may or may not be appropriate these days. The warm rinses help with open tissue problems (like recent incisions or cavity) but this is likely more inflammation which tends to respond better to cold - try ice packs (or a bag of frozen peas) around the area for 10-15 minutes at a time in addition to the Tylenol until you can get a reading from your surgeon.

First, your BMR is a bit of a guesstimate, but 2100 isn't unreasonable for a guy. Some calculators/formulas are way off because they simplify things by using body weight, while it is lean or muscle mass that is the important factor (all that extra fat we carry around does little to BMR, though whatever extra musculature we may have to carry around that extra fat does help. There are some tests that they can do (VOx, etc.) that can give a closer reading to your personal BMR, and many body composition scales give an OK estimate based upon their reading of your lean mass. The most important thing is at what caloric level is your weight stable - that gives the best clue as to where you stand metabolically. My BMR was probably around 2100 also, though my stability point by experience and tracking intake was in the 2600-2800 range (consume more consistently and I would gain, consume less overall and I would lose.) BMR represents our resting metabolism, while the extra burn if from exercise and daily activities; most calculators and tables (and ourselves) tend to over estimate the burn from exercise. After surgery, and you lose what you are going to lose, you will likely have lost some muscle mass, I lost around 10 lb) as you aren't carrying that extra 100, 200 or whatever pounds around with you 24/7, so your BMR will likely decline some, but not a lot (maybe down to 2000). This is why most programs emphasize getting in adequate protein, and doing some load bearing exercise, to minimize the loss of muscle mass, to keep our BMR up. If you can maintain a diet of 1100 calories (not at all difficult for the first year or so post op) that will yield a caloric deficit of around 1000 calories to your BMR (and likely more considering activity burn,) which will equate to an average loss of around 10 per month (more initially, and tapering off over time) - that's about what I did at 1100 calorie average, and my final few months before goal was a consistent 10lb per month loss; after goal and into maintenance, I settled into around 2100-2200 per day to maintain a stable weight. Some people, particularly the shorter ladies, may be stable at 11-1200 per day after all is done, so they will need to go much lower to lose their excess weight - this is why we see 6-800 calories as a common intake for the loss phase, and they will often lose more slowly because they have a lower caloric deficit (figure about a pound per month per 100 calories in deficit, on average.) In short, figure on 1000 calories or so while losing, and probably around 2000 or so, give or take, to maintain, as a quick guesstimate.

My wife is coming up on 18 years out on her DS, but can't offer any real advice on the preop diet as we didn't have one. The best general advice on the shakes is to try several ahead of time (some manufacturers/retailers have sample packs of different varieties that you can get to try). Try both the RTD (ready to drink) and mixes as suits your needs, but there is more variety in the mixes. Generally, 100% whey isolate is preferred to the cheaper whey blends or concentrates as it is better absorbed (and also more expensive...) and is also better tolerated by those who are or develop lactose intolerance as the lactose is filtered out in the processing. But if a blend or concentrate fits your tastes better, one that you will drink is preferred over one that just sits on your shelf. An additional option is unflavored powder (though there is no such thing as one without taste...) and flavor it with one of the sugar free flavor syrups that are available. Also, when just to complicate things further, when/if you hit on one that you like, don't load up on too much of it, as your tastes may change post op (or they may not...) Good luck in getting through this - lots of changes in these next few weeks pre and post op, but things settle out over time.

A general gastroenterologist should be fine for starters - with the bypass being the most common current and legacy bariatric procedure, most should have a reasonable amount of experience with cases such as yours, and be familiar with the common maladies (such as marginal ulcers.) They are usually the ones to do an initial EGD (endoscopy) to take a look and see what's going on inside. If necessary, they can then refer you to a specialist interventional endoscopy center, usually associated with a major regional cancer center hospital. Such hospitals usually have a bariatric practice associated with the cancer center, and they are often a good place to go for more unusual cases as they tend to see a wider variety of odd cases; while they, too, tend to be primarily surgeons, they usually have a broader staff of specialists beyond surgeons, though sometimes they may require a referral from a generalist - step one, your general gastroenterologist. Another step you can consider is to try to establish a relationship with a local bariatric practice for annual follow ups - some practices actively encourage this, while others are more cut and done type of practice. My wife and I still see (12 years out for me, 18 for her) our bariatric practice, which is 5-6 hours away, but they have long done telephone consults, but it does serve as a means of keeping them "on retainer" in the event that questions such as this come up - we, or our PCP, can call or email the doc with questions about these types of situations (is this a common thing for your patients, is there something else I should be looking for, etc.?) Check and see if any local practices have support groups open to others beyond their patients as an entry point, and to see if they have a long term interest in their craft.

Are you working with your bariatric surgeon on this or your primary care family doctor? While this may well be unrelated to your WLS, a bariatric doctor will, of course, be more sensitive to issues specific to their specialty than a generalist. My thoughts, not as an MD but just from having been around the WLS world for a couple decades, is that if it is WLS related, then given the fairly rapid onset of this, I would be looking for some bloodloss somewhere. With an RNY, the likely place would be the stoma, as that is a delicate structure that is easily irritated - if the semi-common marginal ulcers occur, that is where they usually happen. It may not be particularly symptomatic, but some minor blood loss can occur unnoticed until something like this shows up - one of those simple fecal smear tests can show whether there is any blood in your stool. If there is, then an endoscopy can show where it's coming from, and if there isn't any, then you have eliminated one possibility. Iron supplements may or may not do much for an RNY person, as most of our mineral absorption occurs in the duodenum (part of the small intestine immediately downstream of the stomach) which gets bypassed along with the stomach; this is why iron infusions are not uncommon for malabsorbing WLS patients with iron problems. Were you on iron supplements to begin with and then increased the dosage, or just started when this problem showed up? I had an internal bleed a few years ago (non-WLS related, though certainly symptomatic) that sapped my iron levels, but not quite to the point of needing an infusion, and they came back after a few months of doubling my normal iron supplement (but I have a VSG, so not the same absorption problems as an RNY or DS will have,) and now I don't take any at all. For now. Good luck in getting this worked out....

We started them again within the first week. Never had any particular problem with tolerating them, though some do, The only chewables I used were for calcium as those tend to be horse pills (though some brands do have petite versions), but the other pills worked ok when taken one at a time with a sip of water (as opposed to taking them all in a handful as before, and later after things settle out in time.)

We didn't have any liquid only diet; we had puree and soft things (yogurt, scrambled eggs, etc.) in the hospital along with a lot of liquids, of course. The general rule the first month was to move between liquids, purees and soft solids as we could tolerate them; if we came across something that wasn't tolerated, then move back to proven foods and try that one again in a week or two. Some progressed more quickly than others. With protein shakes as a staple to ensure adequate protein, I started with broth, then graduated to thicker soups like vegetable or chicken noodle or rice with the chunks strained out, then just mashed the chunks as the next trial, then went unmashed and well chewed, etc. As the group had around twenty years experience in working with the sleeve (at that time), I wasn't about to argue with them being different than others online.

I was low a few years ago after an internal bleed (not related to the WLS) but not down to infusion level, or particularly symptomatic of anemia, but I (under direction from PCP) doubled by iron supplement and that brought it up over a few months. I'm not a big fan of the iron used in most multivitamins as it is usually the cheaper and less well absorbed forms, but normally use a chelated iron bisglycinate sold by Solgar under the "gentle iron" branding. Even at a doubled dose it didn't yield any objectionable side effects for me (typically constipation, which we usually don't need more of post op!) These days, I don't use any iron supplement as everything is stable in that regard, but that is what I use when needed. https://www.amazon.com/Solgar-Bisglycinate-Non-Constipating-Vegetable-Capsules/dp/B0001OP028/ref=sr_1_1_sspa?crid=1A814LJNJAFJ6&keywords=solgar+iron+gentle+25mg&qid=1677253207&sprefix=solgar+iron%2Caps%2C162&sr=8-1-spons&psc=1&spLa=ZW5jcnlwdGVkUXVhbGlmaWVyPUE3UDZOTjZONU9SS1gmZW5jcnlwdGVkSWQ9QTA4NzQ3MjIyTDhYRUpONUhKSElKJmVuY3J5cHRlZEFkSWQ9QTA5MDg3NDUyVDE5SVVWM1JSTDJTJndpZGdldE5hbWU9c3BfYXRmJmFjdGlvbj1jbGlja1JlZGlyZWN0JmRvTm90TG9nQ2xpY2s9dHJ1ZQ==

Hopefully, they are flexible, I know of one program that is seriously into the low carb thing, as published in their guidebooks, and preached in their seminars, etc., but individually are more flexible with their more athletically inclined patients, as that is more appropriate for them.

When I was running into similar problems - not specifically light headedness, but an energy wall - after about an hour in the pool, my RD at the time suggested that a common recommendation for pre workout is something that his relatively high in complex carbohydrate, moderate in protein, and low to moderate in fats. Extra protein ahead of time did not do much by my experimenting, but that bit of extra complex carb did - it allowed me to break through that wall. It seems that with the complex carb, you will get that extra bit of insulin lift an hour or two after consumption, so that helps to fill in the energy gap you get at that time; at least it worked for me. I also didn't find that I needed it on days that I was only doing weight work, even when that lasted 90 min or so, only on swimming days. YMMV. For convenience, I ultimately settled on a small meat and cheese sandwich, with a good quality multigrain bread (or toasted.) That may or may not fit with your needs at two months out (I was about four months out when I was playing with this.) IIRC, my now RD nephew used to use some of the original CLIF bars that had a similar profile for this, so that may be something to look into. But that rough macro profile seemed to be the main trick - more fat or protein didn't do much for me, but the complex carb did (and I was never agonizingly low carb to begin with.) Calorically, it was mostly just a reshuffling of what I was already consuming, just rescheduled. Your plan at this time is somewhat limiting, but maybe some high fiber fruit - berries or the like - as the complex carb may do it, Talk to your RD, as you may get some adjustments to your allowance to accommodate your needs - this would not be unusual for those who are more active than average, as the plans are written with the averages in mind. Good luck, and have fun, but also don't overdo it - it's easy to do, particularly with trainers!

Almost certainly this year some time. The wait can be highly variable depending upon the practice - some have a longer backlog than others while some may require some amount of pre op dieting, specified weight loss, or nutrition education (one practice I know of, the RD, nutritionist, has a sign off before the patient sees the surgeon for scheduling (do you think you are really ready for this...?) This is not necessarily a bad thing, as most of us need some kind of guidance in how to maintain ourselves after we lose the weight, and that is very much a mental/habit game.

Exercise helps, but is not absolutely essential. Many don't bother or feel like it until they have lost much of their weight, if ever. My wife is still quite averse to it, and does suffer some from it as she is getting older, but that didn't greatly impact her weight loss from the surgery (some say that the loss you achieve is 80% diet, 20% exercise, if that.) Exercise if great, and needed for simply maintaining our various body functions, so do what you can for your needs, but don't think in terms of your weight loss being overly influenced by it. Do what is needed to tend to your other issues, and let the surgery and diet take care of the weight.

Ordinarily, no, it's hard to get the companies to waive that - it's one of the roadblocks that they like to use to encourage patients to go on their own and self pay, so they don't have to pay for it - but if there is a viable medical reason for skipping it, then it's a matter for the surgeon to convince the insurance company of it. Usually, that takes about as long as doing the 6 month diet, so one should plan on it and get started, and just hope that maybe they can shorten things a bit.

I have not had the problem, but know that one of the surgical treatments for it, when appropriate, is a total or partial gastrectomy, which is fundamentally a bypass by a different name, so I can understand that there would be some push in that direction. As the sleeve still maintains most normal stomach functions, while the bypass largely eliminates them, I can see that the sleeve might be a problem down the road (just semi-informed speculation, not an MD here). I wish I had more to say about it, but I have only run into this tangentially when looking at other problems in the past. There are some Facebook groups that cater to gastrectomy patients, who seem to be mostly split between gastroparesis and cancer patients, so that may be a place to look for further experience insight. Good luck, and hope you get through this extra roadblock.

Something isn't adding up here. If she's getting in 109g protein, that's 436 calories right there. If she's only taking in 662 calories, then her protein would be about 65% of that. Maybe some misinterpretation of what MFP is reading? I can see that they might "recommend" 35% protein for her low calories - a typical normal diet might be 15-20%, and a bariatric weight loss diet might well be 50-60% (or more, at the beginning when we are eating little else other than protein.) 60-80g would be a typical recommendation for a woman with a sleeve, as there is no significant malabsorption involved, though some go higher than that as a means of avoiding "carbs", or under the false assumption that the extra will help avoid loss of muscle mass (it will to the point that one is actually working to build muscle mass, but the only thing the excess does, other than make expensive urine, is to avoid deficiency, but one doesn't need much extra to avoid that - the typical bariatric recommendations will cover it.) It does sound like a bariatric RD would be a good person to consult, and if she is truly only getting 6-700 calories and still struggling, then there may be some other metabolic issue going on, and some other appropriate specialist may be in order. But a good RD would be a great start in getting a good baseline of what is really happening dietwise. Starting at 400 lb, a sleeve is often somewhat marginal for getting to normal, particularly for a woman of that size (how tall is she - that's a factor as well in determining an appropriate goal and understanding metabolic issues.) You say that she recently moved cross country - where is she now - that can be a help in finding new specialists. It might be that the VSG is indeed marginal for her needs, and she really needs something stronger. A DS is a straightforward conversion from the VSG (as it uses the sleeve as its basis) and is typically the strongest metabolic tool of the mainstream procedures, so that is also a longer term consideration.

You probably can go through with your bypass, but that is a call for your medical team - the surgeon and cardiologist. Typically, they want you stable and under control when you go in for surgery - they don't want surprises on the operating table - that's what these various specialist clearances are for. If we were all in perfect health with no pre existing conditions, no one would ever get WLS. I hear you on the Eliquis - it's the new kid on the block which makes it expensive, but the older meds are a lot more inconvenient to use (when my father was still alive, he was always needing blood draws to adjust the doses of his coumadin/warfarin blood thinner, which isn't necessary with Eliquis.) The drug companies often have discount programs for these expensive drugs to drop the copays for the patient (they don't mind sticking it to the insurance companies, but they want it cheap enough for the patient to use the med rather than a cheaper generic alternative,) so check into that. It's not the end of the journey, but it is a detour. At the beginning of this year, my PCP found that I was in Afib when I was getting a clearance for cataract surgery, which put that off for a while until it got treated, but it did happen, though a few months later than expected.

Yes, it is quite normal - some don't do a liquid diet pre-op diet at all, preferring just low carb and/or fat, calorie restrictions, or no dieting at all - we didn't have any restrictions until the usual day before general surgery thing. A big YMMV thing. While I wouldn't go overboard on starting a liquid diet early, transitioning to more protein drinks and the like to get used to them and find your preferences is certainly useful. I don't find the getting used to post op idea all that compelling, as you likely won't feel like having much else other than liquids, but some programs go overboard on the back end with extensive liquid dieting post op, so for them, it might be useful. Our program had liquids in it, but transitioned us as we could tolerate thicker and more solid foods, with their findings that their patients tended to do better as they moved into more real food. But programs vary widely, so go with their instructions.