RickM

With a sleeve, your really don't need much of anything as it doesn't have a great impact on our vitamin/mineral absorption. B12 is good to do because many programs suggest supplementing that because that's what they do for their bypass patients, who do tend to malabsorb it. But occasionally a sleeve patient winds up being short, too, because they naturally are short on it. Several years before I had my VSG, our doc added vitamin D to their pre op screen because of the amount of deficiency they were finding post op (they primarily do the DS which malabsorbs D along with others, so that was expected,) but they didn't really know how prevalent it was pre op, and they wanted to get a better handle on how much of the post op deficiency they were seeing was existing pre op, and how much was a result of the surgery. This to lead into better tailoring their supplement recommendation. The only other thing would be the iron levels, which I expect are part of your annual draw.

Most insurance companies will have a "policy bulletin" (or some such term, that was Aetna's) for weight loss or bariatric surgery on their website that spells out the details of their requirements to qualify. BMI of 40, or 35 with certain comorbidities, and a psych evaluation are pretty much industry standards - they all do that. More specifically, they will get down to what procedures they cover (and maybe some that they specifically do not) and what other hoops they want you to jump through - a three or six month diet program of some kind is fairly normal, but not always, and they will spell out what they require from those. Some companies or policies may limit you to one bariatric procedure for a lifetime, and others don't. Beyond that, your surgeon or PCP may have other requirements to sign off on depending upon your health history - clearance from a cardiologist, pulmonologist or other specialist - and the surgeon or hospital program may have specific diet requirements or nutrition classes of their own. While being eager to get this over with, I wouldn't necessarily shy away from a six month diet requirement, depending upon how it's structured. Done well, either with a good RD's guidance or self guidance, correcting old bad dietary habits and establishing new healthier ones pays off in the long run, as that is really what helps to keep the weight under control in the years ahead; a quickie diet to lose a few more pounds (maybe) the first couple of months or pre-op isn't of much long term value.

IIRC, I used a straw in the hospital - one of those little juice boxes. I never used any particular bariatric vitamins as the sleeve doesn't really have any special requirements that a normal good quality multivitamin doesn't cover. I did use the Bariatric Advantage chewable calcium for a while as the normal pills tend to be so large, but I used them a lot longer than I needed to because I bought such a large box of them.

I assume that your bariatric surgeon is in the loop on this, as elevated liver numbers are not unusual for a while after bariatric surgery - all that extra fat being metabolized by the liver puts extra stress on it - but I would expect that your surgeon would now what is "normal" elevated vs. abnormal, while a PCP may be freaked by any elevated numbers. If this is beyond the comfort level of your bariatric surgeon, then a consult with your GI doc, or a hepatologist (liver guy) would be in order. My bariatric surgeon was also a biliopancreatic transplant surgeon, so high liver numbers were second nature to him, but if he was concerned, then that was something to be concerned about! Good luck in getting an answer to this...

It sounds like a surgery center, which are usually set up on an office building or industrial park, and are good for minor outpatient procedures that don't normally need full hospital services, including overnight stays. It's not too unusual to see VSGs done outpatient and go home the same day; I'm not sure I would want to plan on anything more complicated than that in that setting. My concern is that, while in the nominal setting the procedure and recovery may go well enough to go home the same day, but if it doesn't, then they need to transport and check you into the hospital. If there is a "minor" concern, will they go through the hassle to do that rather than take their chances and send you home? if you're already in a hospital, then the decision to stay the night is an easy one. Usually, outpatient in a hospital is anything under 24 hours, so an overnight is an easy decision if necessary. I've had a couple of orthopedic procedures done as hospital outpatient, and the first one I did stay overnight, as I was still running a bit of a fever and felt it would be better to stay there until that settled - if I went home and it got worse, then I would have to go back and check in again as a new patient. It didn't and I went home in the morning. The second one I went home that afternoon as all felt fine. I would rather have the option. When I had my VSG, I was definitely not ready to go home that same night; the pain of straightening out to roll our of bed, even with assistance, and IV pain meds, was too high. The next day it was fine (but I was kept another day after that because the hospital was slow in doing some of the routine post op tests that the surgeon had ordered - he was not amused.) In short, unless your doc's clinic or surgical center has provisions for overnight stays, I would much prefer a hospital environment for a bariatric procedure, particularly with the slightly more complex ones where they are slicing and dicing the intestines as well as the stomach. As an added note, I did have my plastics done at a surgery center, which is a much bigger deal than the original bariatric procedure usually is, but that included transportation and stay at a private nursing facility as a planned part of the package, so that can be an offsetting factor if that is part of the deal.

My doc's perspective on this, when we were discussing this leading into my VSG 11-12 years ago (the prospect of "completing" the DS as a plan B to the stand alone VSG, was that you are in the ideal situation - do it before any substantial regain sets it. With the added metabolic issues that you are having with your PCOS, the extra metabolic strength of the DS would seem to be appropriate, When we discussed the two procedures in the pre op groups "back in the day" one of the rules of thumb factoids was that one should think of the sleeve as getting the weight off, while the switch keeps it off. That's not entirely true, (maybe 80/20) but illustrates what the doc was telling me later, which is not to depend on the switch part to provide substantial reversal of a regain problem (or implicitly, count on it to provide some additional weight loss, but not a substantial amount. It sounds like it is consistent with your goal of some more weight loss without going overboard. This assumes the traditional BPD/DS rather than the SIPS/SADI/Loop DS, which I would assume to yield a similar result, if not quite as extreme owing to its usually lesser malabsorption.

Some programs encourage a bit of low level "carb loading" post op to counter the fatigue and lethargy that many experience after surgery. Oatmeal, cream of wheat, refried beans - as appropriate for different phases - and dilute fruit juices are common for those programs. They often suggest diluted juice, both to cut down the sugar and calorie hit, and also pure fruit juice might be a bit of a sugar shock to the system that has been purged of it pre-op. Our program didn't have any pre-op diet requirements other than the usual day before surgery thing, but insurance required six months of a "medically supervised" diet and exercise program, which for us was just a self directed effort documented by our PCP with roughly monthly visits. I didn't do anything special that I had not been doing the previous few years in what was essentially a WLS maintenance lifestyle (my wife had her WLS several years before, so were already in the habit.)

Yes, you are over thinking this. During this phase, the first month or so, there is virtually zero correlation between your loss rate and what you are doing, as there is a lot going on with your body changing states trying to adapt to this big caloric deficit that you have thrown at it. Do a search here for the three (or third) week stall and you will see lots of anxiety over what is my weight loss doing and what have I done? Your loss will slow, often stall and maybe climb a bit before going down again. It often happens right around the time that our diets are moving from one stage to the next, so "that mush be it!" but it isn't - even those of us who never had all those stages go through something like this. Short answer is that when you go into a serious caloric deficit like this, your body first starts drawing on you glycogen reserves, short term carb reserves stored in you liver and muscles, which give you your quick response bursts of energy. There is a lot of water weight associated with glycogen. Once that is largely consumed, your body usually pauses to see if you are really serious about this caloric deficit thing. Then it will start to draw on your fat stores, which is what we are here to do in the first place. Fat also burns more slowly than glycogen/carbs (its that 9 cal/gm vs 4 cal/gm thing,) and it has to rebuild some of your glycogen reserves again (water weight on) so weight can be real flaky here for a while. If you really feel that you aren't eating enough, then a bit more wouldn't hurt and may be helpful, though that won't be what gets your loss moving again. I was up around 1100 calories fairly quickly, within the first couple of weeks, but I was also progressing on food types more quickly than your program suggests, and we had no specific caloric guidance. Others on these forums at that time were insisting that anything more than 6-800 calories would be death to your weight loss. I did fine, at least with my decent guy metabolism, and they did fine as well. I wouldn't rush things on too much, as it is much easier to add more later if you feel the need to than to cut back once you get used to eating a certain amount. I didn't increase my average calories from there until I was within about 10 lb of goal weight (at about six months) and needed to slow things down.

We had scrambled eggs in the hospital, so as others have noted, every plan is different and if your doc is fine with it, then go for it and try it. Our general plan philosophy was to try new foods one at a time to test for tolerance, and if there was no problem, then great, if there was, then try it again in a week or two. I had boiled eggs that first week, too. We could have anything within the liquid, mushy, pureed or soft regimes that first month. Some could progress quicker than others - that's life. My wife went through this a few years before I did and progressed more slowly, with not even liquids going down as well at first, and that was fine with the doc, well within the expected spectrum of results. When I tried things like beef veg soup, the first time I strained out the chunks, the second time I fork mashed them, and the third time just had it as is, soft chunks and all. So go with what your docs direct, and enjoy the ride.

Probably not, as that is usually overkill with a sleeve, assuming some kind of liquid diet the day before (or at least the night before.) Our program did a clean out, similar to what is done with a colonoscopy, but their standard WLS is the DS which does operate on the lower part of the small intestine, so it is good for that procedure, but admitted overkill for us sleevers.

It is a not uncommon result of rapid weight loss (not just from surgery, but that is the most common means of accomplishing rapid weight loss,) maybe 10% have that problem, give or take? My surgeon routinely removes it when doing the DS as he doesn't want some other surgeon going in there and getting lost in the altered anatomy (which is weird for them, not so much for the bypass folks.) With the sleeve, he leaves it alone unless he feels stones in there when he is doing the surgery. So, I still have mine, but my wife, with her DS, doesn't, and we haven't noticed any great difference beyond what the WLS is already doing (there's always changes when you alter the body's default condition.)

When I was going through this early post op phase, there was a group on one of these forums from a particular surgeon who did very well with combining the sleeve with extreme dieting, and he got overall very good results with even very high BMI patients (lost track as they all disappeared, so have no idea how they are doing now, however!) There was one guy on there who was very similar to my stats who was following this program and got to his goal weight at a bit over four months. Wow, but so what? I was working on slowing things down at six months to ease into maintenance, and wasn't doing any of that extreme dieting. I wonder now how well that guy is doing - did he learn how to maintain his weight over the long term, or was he one of those who "gained it all back"? It really isn't a matter of whether you can do better, or lose faster, but can you meet your goals, and maintain yourself in the long term? This is a marathon, not a sprint. so what happens to you over the next 5, 10 and 20 years is a lot more important than how you lose over the first 4, 6 or 12 months.vsg Overall, the bypass has very similar performance to the VSG in overall weight loss and rate, so there isn't much to choose there - one might lose a bit quicker with the bypass owing to its' malabsorptive component, but that dissipates after a year or two and you are metabolically in the same basic place that you would be with a sleeve, but you still have the added nutritional deficiencies to make up for. Have there been some challenges in maintaining my weight over time? Yes, much the same as there would have been had I gotten a bypass (my second choice was the DS, which does make weight maintenance easier as it is metabolically a stronger procedure, but I felt that it would have been overkill for my needs then, and still do.) We see just as many come through here who struggle with being "slow losers" or "gained it all back" with the VSG as with the RNY. With the VSG, I do have a bit of GERD, which is easily controlled with low level OTC meds (some are not so lucky, others are more so and have no problems.) OTH, I do not miss having any of the comparable RNY potential side effects - dumping, reactive hypoglycemia, marginal ulcers, bile reflux (pretty rare these days with how they structure RNYs) low iron requiring periodic iron infusions, osteoporosis (already have a family tendency towards that, so don't need more risk added,) or the other limitations in medication and medical treatment options as I get (even) older that come along with a bypass. These are not insurmountable problems if one needs to go with a bypass owing to preexisting conditions, but are things that I don't think are worth risking for whatever very small difference there might be in weight loss performance. I don't miss that at all. YMMV

Many programs lump everyone together with a one size fits all supplement regimen, irrespective what procedure they had, and then sort it out later with post op labs. That's why some, like the OP has a fairly scant regimen (which fits the VSG fairly well) while others with the VSG are put on an RNY regimen that is overkill for them. It's mostly a convenience for the practice that everyone be told the same thing pre-op, and maybe they don't have to do as much pre-op screening to see what each individual needs.

There is some water retention associated with exercise, particularly if you continue to challenge yourself and increase things over time, as inflammation occurs where tissues are rebuilding themselves after the exertion, and inflammation requires......water. So, yes, it is not unusual to see such things, particularly when people increase the amount of exercise they do in an attempt to boost their weight loss rate (and get the opposite effect, at least temporarily.) As noted above, exercise is great for your overall health and longevity, but doesn't seem to make a big dent in weight loss (the experts are still debating exactly why that is!) at least at the relatively moderate levels that most of us are working at.

This doc gives a pretty good layout of the progression that you should expect: I'm not so sure about his books and green smoothies, but his progression is consistent with my experience after 10+ years, though my wife is still somewhat more restricted in volume, so there is a YMMV thing going on there. I can eat about half of what I could before surgery. This is good and bad, in that it is plenty to be able to get the bulk of our nutrition from food (at least with a VSG), but it is also plenty to get into trouble with if you don't learn to eat right - that "gain it all back" threat is a real one if you don't pay attention. Volume can also be highly dependent upon what you are eating, as there are slider foods out there that are virtually unlimited, mainly highly processed junk foods (think chips, pretzels, etc.) One of my takeaways from Dr. Weiner's piece above is if you feel the need to increase your volume over time, try to do it with bulky, low calorie veg as a way of dealing with this. I've been having a salad for lunch most days since early post op, using a couple ounces of leftover meat, bit of cheese and, at the time, maybe 3 oz of salad veg - chopped spinach, pepper, tomato, avo, scallion, etc. My lunches are still just a couple ounces of meat (thats all I need along with all of the other protein in the day) but the veg content is a lot higher now, maybe 7-8 oz. Still pretty moderate in calories, but very high nutritionally. I avoid buffets as they don't provide good value anymore, but can handle them when presented with one. I have never vomited (at least from over eating.)

You will likely soon hit the "three week stall" (do a search for it here) where your loss will slow or stop and possibly even increase a bit. This is entirely normal and totally unrelated to what food phase you are in (people who are still on liquids as well as those who have been on soft foods since the start go through it.) It has to do with the matter that initially you are losing a big chunk of water weight associated with your glycogen stores (basically stored carbohydrate) being depleted due to your low calorie intake. Once that is depleted, your body shifts gears to burn your stored fat, which burns more slowly, so the weight loss slows a bit, too. Entirely normal. In our program they specifically tell us that their patients tend to do better as they move into real food - not strictly from a loss rate perspective, but for the sake of feeling better and more energetic, which leads to being more active and helping to maintain a more sustainable loss over the long haul. I was starting to nibble at the gym again after a couple of weeks, not for the sake of boosting loss rate (it didn't need it...) but for maintaining the habit (and not allowing my wife to use me as an excuse for not going!) I was certainly not burning any more calories there than at home, but more just starting to get a bit more variety in activities.

I wouldn't worry much about it. With only a seven day diet like you describe, it doesn't seem that your program is all that concerned with the "liver shrinking" aspect of it as some programs are, that do longer and more intense diets (some surgeons are seriously intimidated by that issue while others don't care in the least.)It sounds like they are mostly working to transition you to their early post op diet. While they probably don't want fruit in there owing to sugar content, raspberries are on the benign end of the scale there (which is why you may see them on a "keto approved" list somewhere. Which is another lesson here - just because something may be "keto" doesn't mean that it is right or good for your needs. Keto is not necessarily healthy or weight loss oriented (but it can be, if done right - as with many popular diets.) There is plenty of junk food out there that is "keto approved". Most here who want to do keto do something called bariatric keto, which is basically old school Atkins because the macro ratios typically seen in most keto references don't make sense with the small amount that we are eating during our loss phase (generally too low in protein.) Not to mention the dubious nature of being in ketosis - K specifically avoided that owing to its side effects and was still working to slow my weight loss after six months, so it really isn't necessary for successful weight loss, and generally a bad habit to get into for long term health and weight maintenance.

20mg is the standard OTC dose in the US for omeprazole. Esomeprozole (Nexium) was more advanced in that it was a minimum change from omeprazole in order to establish a new patent when omeprazole (Prilosec) lost patent protection and they moved it to OTC. Physicians were hounded by the drug reps to change their patients Prilosec Rx over to Nexium, and there was a major marketing campaign to the public to establish demand for the new pretty "Purple Pill." Doctors who were overly aggressive in switching their patients were often chastised by their peers for "caving in" to the Pharma marketing push. The general advice then, as now, is that if there isn't any side effects noted with the older med, there was (is) no compelling reason to go with the newer, more expensive med. Pantoprazole (Protonix) was a different med in the same class by a different manufacturer that did have notably different characteristics that were often useful (ie, "better") but again, if the older, cheaper med works without problems, that's fine.

The VSG is somewhat predisposed to reflux, meaning that a greater proportion of those with that surgery will have that problem than the general population. The sleeve reduces the volume of the stomach much more than its' acid producing potential, and sometimes the body doesn't fully adjust to that. The bypass in comparison is predisposed to dumping syndrome, reactive hypoglycemia, marginal ulcers and mineral deficiency disease, so there are trade offs with whatever route one chooses (and with doing nothing, given all of the obesity related diseases that we are trying to avoid!) This is not unusual when we change things in our body - surgery of any kind changes things and sometimes there are negative aspects, or risks of, along with the positives. Medications change our body chemistry to solve a problem, but sometimes there are side effects that are negatives. It is routine for patients to be given a PPI for a while after any WLS, or even on GI procedures - I was put on pantoprozole for a month after a minor cardiac procedure I had a few months ago simply because when the body is under stress (like form surgery) it tends to over produce acid. So, being on a PPI at this point is normal, and nothing to worry about.

Pantoprozole (Protonix) is also available OtC. Depending upon insurance details, OTC may or may not be cheaper than Rx - OTC omeprazole is usually around $15 at Costco for 42, sometimes on sale for a few bucks less. Use the one that works best for you. Also try Pepcid, which is an H2 inhibitor and is generally considered friendlier to our systems long term than PPIs such as the -azole meds above. The PPIs are also known to have a problem with rebound reflux if you stop them suddenly, so it is usually better to wean off of them over a couple of weeks - cut the dosage in half or spread the dose timing, or intersperse a dose of PPI with one of H2I. Some may never have a problem with dropping them, but if one does, try tapering off the med.

I can certainly understand that, as they tend to be familiar with different dodges used to get around their exclusions. There are a number of procedures that are used to treat GERD, depending upon what the cause is. Fixing a hiatal hernia, for instance, doesn't require a bypass to accomplish, though such repairs are commonly performed in conjunction with WLS, either a sleeve or pouch type. When I had my VSG, it was just starting to be routinely approved by US insurance companies -some did, others still called it "investigational", As a legacy of that, insurance commonly excluded the 2 step DS (as the DS uses that sleeve as its basis, in extreme cases they would do a VSG first, and then once the patient had lost enough weight to undergo the longer switch part they would do that as a second procedure - that was the origins of the VSG, as some found that they lost enough on just the VSG that they didn't need to go through with the second part. Insurance got wise to the dodge of getting approval for the DS but only doing the first VSG part, so they blocked that approach. Of course, for those who really needed to go that route, it was still available but they needed to jump through more hoops to get there. Had your surgeon approached them, it might have flown (assuming that it was a justifiable approach for your GERD, as they would not be asking for an RNY WLS, but using different terms and codes. The same basic procedure (it's called a Billroth II) is used for treating several different maladies, and the rules and codes are different for each. The sizes of limbs and the pouch are different for an RNYGB WLS than they would be for a partial gastrectomy used in treating gastric cancer or gastroparesis, though they are the same basic procedures.

This is something that should be covered as a complication from an previously covered procedure, rather than a second WLS; it may takes jumping through some hoops to get there, but you should (eventually) get it. This likely got an automatic denial as claiming a second WLS and needs to be appealed, first through the BCBS internal process, and then, failing that, through your state insurance regulator. The first appeal step will usually involve a peer to peer review, where your surgeon talks to their staff doctor to explain the medical necessity on a doc to doc basis.. Once it is apparent the ramifications of your situation (and their liability for not covering it...) it should go through. Your doc should be able to discuss with them what steps have already been taken to resolver the (medical) problem - what meds have been tried and failed, what tests have been done, what your prognosis is without surgical intervention, etc. Good luck again, it should go through, they just need to be slapped around a bit to realize their obligation. Another possibility is that your surgeon's office coded it as a standard RNY, and there's a different code to use as a GERD treatment (the basic RNY procedure is used for several different maladies beyond its basic WLS function, but it goes by a different name (and code).

You are right to be looking around for second and third opinions when contemplating a repair and possible revision with a higher than average complexity. If indeed you are in the "gained it all back, plus" camp, then the traditional RNY fixed probably won't be strong enough to do the job, and adding in the hernia and additional scaring compounds things. The surgeon I would suggest looking into would be Ara Keshishian, who is in the Glendale/Pasadena area of So Cal. He is one of the handful of surgeons who can do the complex RNY/DS conversion, should that me necessary, and I have seen some on these forums who have had some fairly involved RNY reworks from him (though his preference is usually to go for the DS if it makes sense.) Rumor has it that he isn't dealing with insurance anymore (haven't verified that, though,) so if that is an issue, another good choice to talk to would be John Rabkin in SF, who is similarly qualified in complex procedures., As both have long drawn patients from around the country (and beyond) they have long routinely been able to do their early screening discussions and longer term follow ups remotely. Another doc I would talk to if you want to look East would be Mitchell Roslin in NYC; he also seems to have a very deep toolkit, capable of doing a number of different procedures as appropriate Most bariatric surgeons are pretty good at doing RNYs and variations of that, but don't go very far beyond that, and it sounds like you need someone with rather broad (and deep) skills to get what you need. Good luck,,,,

See above - many programs put all their patients on the same regimen, either out of their convenience, or because they haven't yet figured out what a VSG needs vs. an RNY, or they haven't bothered to update their guidelines yet.