RickM

It is probably overkill, and it does sound like more of an RNY regimen than one for a VSG, but many programs combine the two out of convenience (their convenience, not yours!), and then tailor things more as your labs come in over the next few months. Also, it's usually easier to start at high levels and cut them back than trying to play catch up later on. With a VSG, you really aren't malabsorbing anything like one is with an RNY, so you can usually cut way back on a lot of those as your diet improves over time. For instance, though I target 2000mg of calcium per day (which is above normal RDAs but appropriate for my needs,) I only need to take one dose (2 pills) to achieve that along with my normal diet, and I don't need any iron or B12 (which is more of an RNY thing) and B1 comes naturally from whole grains; it is arguable whether I need any multivitamin at all (but isn't bad insurance, just in case.) It's all a big YMMV thing that settles out over time, but likely you won't need nearly that much over time, but in the short term, with a protein intense and little else diet for a while, a bit too much is better than not enough.

With a sleeve, you really don't need anything overly special, as we don't have the malabsorption of certain nutrients that you get with the malabsorbing procedures like the RNY or DS; we mostly have to make up for the poor diet that we have during weight loss when we are concentrating on protein at the expense of the fruits, veggies, grains and legumes that typically flesh out our nutritional profile, so a good quality general multi if usually fine. To that we add some calcium and iron as needed (since they need to be take apart from each other) and whatever else we individually may need. With a sleeve, we generally don't need extra B12 (that's more of an RNY thing) but some programs specify it out of convenience, as many just use the same recommendations for their sleeve patients as tehy use for their RNY patients, and then make adjustments later on as labs indicate. Personally, I just use a generic Centrum from Costco, add one or two doses of Calcium citrate depending upon my other intake (I shoot for 1500-2000mg per day from diet and supplement) plus vit D3, K2 and magnesium citrate (al part of the osteo complex) as I have some history with osteopenia. Overall, the bariatric vits (or double multi vit as some programs recommend instead) are largely overkill for us, but it's generally better to start high and then whittle things down as labs indicate and diet stabilizes.

Going to your original surgeon, if you are still in the same town, is a good start, but that should only be a start. As Tomo suggests, getting a second (and third, even,) opinion is a good idea, particularly for a revision where the needs and solutions are more varied than the original surgery. Talking to a non-surgeon or two (such as a gastroenterologist) is also a good idea as there may be some non-surgical interventions that can do the job, and it is usually preferable to start there anyway, and then consider surgery if those don't work. Be suspicious of a surgeon who immediately tells you that if you have a sleeve, with GERD, that you need a bypass revision, without first doing some tests to find out what's really going on inside you. It may be a hiatal hernia which commonly causes GERD in WLS nd non WLS people alike, and that can be repaired without going through a revision (though some surgeons may not be comfortable or capable of doing so, or it can be a poorly shaped sleeve that inhibits good flow, and that can often be resleeved to correct that (though I probably wouldn't be depending upon the original surgeon to fix that, as it implies technique issues with the original surgery.) In short, don't be too quick to self diagnose - let the professionals do that (though it pays to be well educated on it,) and play the field to get multiple opinions - they all can have somewhat different background and experiences, and that drives their opinions; don't settle for the first one that you come across. goo luck in sorting this out....

Certainly, potatoes are about the most calorically efficient real food sources of potassium that we have (and potassium isn't supplemented well without an Rx. Many programs suggest mashed potatoes as an early soft food (along with things like oatmeal and cream of wheat) as a means of countering the common early to mid post op lethargy from a diet that's overly low in carbohydrate ( a popular thing in the fad diet world.) As with salads, the main dietary problem with potatoes is the high calorie junk that is often piled on them, rather than the basic food itself. Enjoy.

I used a straw in the hospital after surgery. This seems to be one of those "if it bothers you, don't do it, but if it doesn't, don't worry about it" things Some programs or docs claim they're death and you should never use them ever, while others are "huh? what's wrong with a straw?" I think that the worry is that you will suck up air, or too much air, when trying to get the last bit our of the cup, which might be a problem for some early on, in which case, don't use them, or don't suck up the last bit with the straw.

As you note, programs differ, (and sometimes wildly!) both in their progressions and also in how they define food types (what's a liquid, what's a puree, etc.) and also in how much they trust their patients and in their own communication with their patients. We had yogurt and scrambled eggs in the hospital - if we could tolerated them, that was great, but if not, liquids were fine too until we could do more. As to the OP, it is concerning that at three months there has not been more progress. A stricture does sound like a possibility - that's not uncommon with a bypass (scar tissue forming around the stoma overly restricting things) and from what I have seen, they're usually fairly quick to do an endoscopic dilation (or two) to open thing up - twenty years ago, this was so common that it ceased being considered a "complication". With a sleeve, it is less common, and more indicative of a surgeon who hasn't quite got the technique down yet, so they may be more reticent about correcting it (if they know how) and just seeing if it will fix itself. I would be a squeaky wheel and get after them to address the issue, as this isn't normal.

Do you even have to do one (many do not) and you are assuming by other posts that you do? Many programs that do them tend to wait until the last minute to tell their patients (for fear of scaring them off, understandably.) Some programs specifically don't want their patients doing any of those fasting diets, preferring that they concentrate on learning how to eat sensibly. If you do need to do one, then yes, playing with different protein shakes to find one that you like, or at least tolerate, is a good idea, but it's not worth going overboard on it. If liver shrinking/condition is their goal (it usually is) then simple low carb will do as well as anything - lean meats and green veg; the liquid aspect is pretty much irrelevant to that goal (and I have never understood why some insist on that, other than they don't have to do it themselves!)

Unfortunately, revisions tend not to do all that well for regain problems - I like to think about it as your stomach started out being able to hold 32-64 oz, and after WLS it can hold 1-4 oz typically; even after it stretches some and/or adapts, its capacity of maybe 4-8 oz is still just a fraction of what it was, and we have gotten used to living with that. So, going with a "do over" revision just doesn't have the same power as the first time around. Further, the bypass is difficult to work with, so typically the best they can do is to either put a band around the pouch to restrict it, or tighten up the stoma, neither of which have a great track record of success. Probably your best shot at getting on track again and losing a substantial amount in a revision is to look into a duodenal switch (DS) which has much better regain resistance than the RNY or sleeve. Unfortunately, that is a very difficult revision, that maybe a half dozen or so surgeons around the country can do. Fortunately, two of them are here in CA - Dr. Ara Keshishian in the Glendale/Pasadena area, and Dr. John Rabkin in SF. I have seen several patients come through our support group over the years that have had quite reasonable success with that revision, so it is definitely worth a look. The other approach that you might find is to convert your (conventional) proximal RNY to a distal RNY, which basically involves moving the pouch much farther down the intestine, bypassing more of it. It does not have a great reputation for being trouble free (from what i have seen, most insurance will not cover it as a primary WLS procedure, but will consider it for a revision.) I suspect that a big problem with it is that the surgeons don't really appreciate the nutritional/supplement differences with it, (it is much closer to a DS than an RNY in supplement needs) and the patients suffer as a result as they may not get the aftercare that they need over the years. The DS tends to be much less of a problem in this regard as the surgeons who do it do so as their primary or preferred procedure, so they know all of its subtle needs by experience. Good luck in finding a solution to your problems,

I've seen everything from 800ish to close to 3000, depending... One thing to remember (or learn, if they didn't tell you,) is that the caloric malabsorption tends to dissipate after a year or two, so you may need more to maintain a certain weight now than you will in a couple of years, so stay flexible, keep tracking what you are eating and make adjustments along the way.

Building on my comments above, if you got along well with your band - it seems like you did - but just had mechanical problems with it, then the sleeve is a good replacement as its' character is similar, being strictly restrictive, but without the foreign object problem potential of the bands. The bypass is a good procedure that has been done for over forty years as a WLS, based upon procedures that are about 140 years old developed for gastric cancer, so it is a well established and understood procedure, both the good and bad. There has been a continuing effort in the industry to develop better procedures (as there should be) and a number have come along, with some remaining and becoming established as viable alternatives (such as the BPD/DS and VSG) and others falling by the wayside, never getting traction (such as the mini-bypass,) and others where the jury is still out (the SIPS/SADI/Loop DS.) The BPD/DS generally works better, being stronger metabolically, but is also technically more challenging to perform, so few surgeons have adopted it; the VSG came out of the DS (the DS is based upon the sleeve, and adds malabsorption) and has established itself as being comparable to the bypass in average performance - overall weight loss and regain resistance - in a more straightforward procedure that has fewer long term compromises for the patient. GERD is the main potential bugaboo with the sleeve, which compares with the bypass's predisposition toward marginal ulcers, dumping and reactive hypoglycemia. The ulcer potential is what presents restrictions on some medications with the bypass, the biggest group being NSAIDs, but there may be others that one encounters in life that will also be off the table, or severely restricted, with a bypass. There is also the blind stomach and upper GI loop with the bypass, which makes those areas more difficult to monitor and evaluate through life (can't just stick an endoscope down there to take a look,) and there are an increasing number of endoscopic treatments for a variety of maladies available these days that would also be off the table. If one needs periodic monitoring in that region, for instance for a history of stomach polyps or family history of some cancers, the bypass becomes much less interesting. Another factor to consider is what I call the "Plan B" case - what to do if things don't work out as expected and things need to be revised? While the bypass is technically reversible, that is rarely done as that in itself is another fairly complicated procedure. The bypass, overall, is something of a dead end procedure in that it is difficult to revise into something else is need be. As weight regain is similarly possible with either the sleeve or the bypass, there isn't much to be done to correct that with the bypass - installing a band over the pouch or tightening up the stoma are the most common revisions, and neither has a very good track record for resolving regain problems. The VSG, on the other hand, can be revised (some would say "completed" into a DS fairly easily as it is the first step in a DS, or it can be revised into an RNY if GERD problems can't be resolved with meds (the RNY is usually reversed if an ulcer problem can't be resolved with meds. So, more options are available with the sleeve should a "plan B' be necessary. These are the reasons why the sleeve is building in popularity; there are good reasons to choose either, but one needs to take a close look at one's circumstances going into it to determine what is the best trade off for one's needs.

Generally, with the sleeve, we will have less need to supplement than with a bypass, all other things being equal; if one is inclined to try for the ideal of getting all nutrition from food, then the sleeve is the way to go - one may not quite make that ideal, but will be closer. The first couple of years, our diets are protein heavy and little else, so supplementing if a good idea, from a belt and suspenders perspective, if nothing else. Labs should be the determiner of how much supplementing is needed, and that takes some time to establish trends, rather than just a snapshot "my labs are fine." One of the problems that we have in going through this is that not everything shows conveniently in our lab tests. Some nutrients, calcium being the most notorious, do not show as deficient until one is in deep trouble, as the body works to maintain serum levels at nominal levels at the expense of body reserves. The body will leach calcium form our bones to keep the serum levels "correct" until it can no longer do so - they you're falling apart. There are other tests that can be done that give us hints as to our status - is calcium depositing or leaching from bones? Talk you your doctor about these things if you are not supplementing as recommended Many programs recommend the same supplements initially for both sleeve and bypass, primarily out of laziness, and then make adjustments over time as labs come in, and you can cut back as indicated. Again, trends over time tend to be more informative than simple "normal" levels. Surgeries do not always correct the need for some medications; After WLS, one may still need meds for BP, cholesterol or diabetes as well, though usually at lower levels. Bypass patients often take PPIs either for GERD that they develop over time, or for the marginal ulcers that are endemic with the bypass (marginal ulcers are to the bypass, what GERD is to the sleeve - you may avoid one potential problem with your choice of surgery, but it is usually at the expense of risk of something else - that's life!)

As noted, the patches seem to work OK for some, and not at all for others. I would stick with the pills for now, as much of a bother as it may seem. You probably won't need to be taking all that many for long - many programs overkill on their supplement recommendations for the sleeve, based upon their bypass experience, which is fussier in that regard. It usually isn't a big deal, as subsequent lab tests show what you really need, and you can probably stop taking many of them - most of us with a sleeve don't need to supplement as much as those with a bypass (but there's usually something that we need, so we need to find out what that is.) The problem with starting the patches now, is that when you start getting lab results back in a few months showing that you are fine,, that's great - but how do you know whether it is the patches that your are using doing the job, or that you don't need them at all? So, I would stick it out with the pills for a while to find out what you really need and get your labs stable on them, then try the patch(es) if the pills are still too much of a bother.

Yes, post and pre-op, vary widely from practice to practice. Ours was similar to above, with most anything in the liquid, mushy, pureed or soft categories acceptable for the entire first month, then moving to solids after that. Some may be on liquids only for a month or more; or anything in between. A big YMMV thing.

Yes, it sounds like reflux; do they have you on any anti acid medication for it (omeprazole, pantoprazole, etc)? Those are commonly prescribed for the first few months after any bariatric surgery (and many other surgeries, for that matter.)

I've had a number of them over the years, and haven't had any such problems; typically, one might have a bit of a sore throat for a while (can happen anytime they stick things down there, whether endoscopy, intubation, etc.) The jaw sounds like they may have been a bit ham-fisted with moving things around to get the scope in. Most of the time, I have had a plug that I bite on (like a baby's pacifier) with a hole in it that they pass the endoscope through, and they strap the jaw closed around it (so it doesn't move when you're under anesthesia). The bloating seems a bit odd - they do inflate the stomach to see around in there (same with the colon in a colonoscopy) but that usually comes out quickly with a bit of belching, if I have noticed at all. When they do the actual surgery, they do inflate your abdomen to give them working space, and that can take a couple of days to work out as there is no direct vent to the outside world as there is in your GI tract.

Keto is no better or worse than any of the other fad diets out there - it's just the one that's currently "in". As with the others, maybe 5% of people on it can lose, and most importantly, keep, a substantial amount of weight off. If it floats your boat and you can keep with it as a "lifestyle" (think vegetarian or vegan) over the long term - even after your loss has stalled and stopped - go for it. But, do realize that Keto in and of itself is not a weight loss/maintenance diet - you have to learn how to do that within the restrictions of the diet, just like any other lifestyle choice. Good luck

Have you ever had a colonoscopy? That's what ours was for the day before surgery. As noted, they're all different so ask your own program for tips and information on their specific requirements.

My surgeon will take the gallbladder of his VSG patients if he feels stones when he is in there; with his DS patients he takes it as a matter of routine as he feels the risk on another surgeon going in there and getting lost in the altered anatomy outweighs the benefits of leaving it there, That isn't an issue with VSG (and presumably the RNY, which he rarely does) as those are familiar to any general surgeon. He also doesn't routinely prescribe Urdusol, or at least didn't when I had mine done. Lots of variations in this world.

That's basically what has already happened - most migrated over to Paclap's zoom meetings. The group was a legacy of when Paclap was in the Los Angeles area before they moved to San Francisco some twenty years ago, Over time, Keshishian adopted it and then it closed up around COVID time and most moved online to Dr. K or the Rabkins' Paclap group. There are probably other DS affiliated groups one can find, but those are the ones that I'm familiar with, being in CA. Off the top of my head, there are several DS docs in the NYC area - Roslin, Pomp, Herrin that I can think of that probably have groups that one can access.

My wife is about 17 years out on her BPD/DS, and at least until COVID changed things, we were in a local support group of primarily long term veterans, legacy of her surgeon who had moved out of town, so we got a lot of feedback over years on various issues people had. Since COVID, most practices went online with their patient support, and that is often available to anyone interested. A couple of suggestions. One is to look up Dr. Ara Keshishian - dssurgery.com - who is well regarded about all things DS and BPD. There is an extensive blog library on his site that you can look over and will probably find much of what you are looking for, though it may not be that well indexed. Another is paclap.com, from Pacific Laparoscopy, who is another BPD/DS specialist; they now have a monthly zoom meeting, IIRC on the second Tuesday evening of the month, and that usually has a number of veteran patients along with the doc who can offer suggestions on whatever problems you are having. With your early 80's date, did you have a DS with BPD, or the original Scopanaro BPD? The Scopanaro did seem to be more troublesome, primarily from its shorter common channel leading to sometimes excessive malabsorption. There are people and doctors out there who can help, though not necessarily in CO, which is one of the drawbacks of the procedure. Fortunately, most who are skilled with it know of the geographic problems and are used to dealing with patients remotely. Good luck,

Under the premise that the most important component of your car is the nut holding the steering wheel, I don't have a real preference; it's a tool and the most important part is still what's between the surgeon's ears. The doc who adopted our local support group, one who is well regarded for doing complex revisions, has mentioned that he has no real preference to them - he uses them if the hospital he is at has it and it is available, but he isn't specifically scheduling himself around it. My real concern is would the robot help a surgeon who is low on the learning curve, say on doing sleeves, be less likely to make a sleeve with a stricture? Or if the surgeon is one who is apprehensive about working around a fatty liver be less likely to close up and send the patient home without completing the job?

Presumably they are going off of lab tests and not a calendar, as with a sleeve you may not even need it unless there is something about you that makes you low (it's more of a bypass than a sleeve thing.) I've never supplemented it (other than what's in my multivitamin) and my levels have always been fine.

No direct experience, as the surgeons I am associated with primarily do the "traditional" BPD/DS, but the process would be the same. As to whether or not the sleeve is redone as part of the revision depends on the surgeon's preference and what condition the sleeve is in. The surgeon who has adopted our local support group only does the resleeve if it is needed, if there are any problems or defects with it. There were a lot of sloppy sleeves done in the early days of the VSG (say, 8-12 ago) as surgeons worked up the learning curve getting their techniques right ("twenty years of doing bypasses and they think they know how to do a sleeve...." to paraphrase one prominent surgeon.) As with any revision, count on weight loss being slower and less than with a virgin WLS (I like to think of it this way - our stomach was originally 32-64 oz capacity, and after WLS, even with some stretch and adaptation it may hold 6-8 oz,, so don't expect as big of a change the second time around.) If you are doing the revision for additional weight loss or correcting regain, try to seriously get a handle on why the first one had problems and correct those before proceeding. Good luck ...

Yes, plans vary all over the map; some will be allowed steak at the same point that others may still be on liquids. Some start on soft and mushy if tolerated while others go by strict schedule. Some surgeons will advance their patients ahead of their published schedule for various reasons. Some programs will have a fair amount of individual variability while others are very cookie cutter. Our program started with mushies and soft foods, though liquids were still a staple, particularly for protein early on, and some could progress faster than others depending upon their tolerances. Other programs that are stricter with slower progressions may be so because of how they do their sleeves or pouches - maybe they are more delicate than other surgeons', or maybe they just haven't explored quicker progression yet, or maybe they have and ran into problems that other programs didn't - we, as patient, just don't know. So it is best to consult with your medical team - let them know that you feel that you may be able to progress quicker and they may allow you to explore that, or maybe not.

I went with the sleeve because, fundamentally it does the same thing as an RNY - amount of weight loss, regain resistance, etc., but "costs" less in terms of trade offs and potential problems. The sleeve is predisposed toward GERD problems (that simply means that more people in that population will suffer from that problem than in the genera; population. In contrast, the RNY is predisposed to marginal ulcers, dumping and reactive hypoglycemia.. It is also fussier in supplement need - you can get into more trouble if you are lazy about your supplements with an RNY, while a sleeve can be closer to that ideal of getting all of your nutrition from your food, if one is so inclined (and your natural body cooperates.) Even with all the supplements in line, there is still a greater risk of iron issues or osteoporosis with the RNY as its malabsorption is focused on minerals. And, the marginal ulcer risk makes it more limited with some medications (it is the origin of the "no NSAID" rule in bariatrics - the sleeve based procedures are more tolerant in that area. If I need something stronger than the VSG, then the DS is readily available, as it starts with a sleeve and adds a stronger malabsorbing component than the RNY offers, so there is better weight loss and most importantly, regain resistance provided there if needed. Finally, there is the "Plan B" factor of what if it doesn't work for me and I have/want to revise? The sleeve is readily revisable to either the RNY or the stronger DS, while the RNY is something of a dead end procedure which is very difficult to revise (it can be done, but there are few surgeons around who are qualified to do so.) Overall, that is why I would start with the VSG and move up later if needed (or if I was starting from a very high BMI or otherwise challenging metabolic situation, I would go straight to the DS and avoid the risk of having to revise the bypass if it wasn't strong enough.)