RickM

The VSG is probably the least prone to complications due to its relative simplicity. There is the risk of leaks, as with all of the stomach reducing procedures including the RNY and DS, but this is an immediate postop concern the probability of which reduces to virtually nil after the first week or two. Some, or most, surgeons do leak testing a day or so after surgery before releasing you from the hospital - something that is more difficult to do with those who do "outpatient" VSG's - check with your surgeon about their procedure. The RNY and DS are more complex procedures involving some intestinal rerouting, so there are more potential leakage points with them. Longer term, adhesions can cause problems with things sticking internally that shouldn't stick, but the chances of that happening increases with the more complex procedures. The bands seem to have less risk of initial complication due to the simplicity of the procedure, but have more complications down the road from band slippage and erosion, along with statistically poorer weight loss and maintenance. Nutritional issues are a concern with any of these procedures, particularly with the RNY and DS due to their malabsorptive components (though at least with the DS you get some benefit in return in the form of better long term weight maintenance which one doesn't really get with the RNY) but even the VSG can have some problems in this regard simply because we are eating a lot less, so there is less opportunity to get in all the nutrients that we need. So, some supplementing will probably be necessary, though not usually to the extent that is usually needed for the RNY and DS. Even pre-op, most of us need some supplementation just to make up for the typical American diet, but post-op we tend to be better educated about it so it is a bigger concern for us! Reflux is potential problem with these procedures. There is some controversy amongst the surgeons as to ideal stomach size (if there is such a thing,) as the smaller stomachs seem to be more prone to reflux problems while it is feared that larger stomachs won't produce as much success in overall weight loss and maintenance - there is not firm consensus on this as the procedure is still relatively new and longer term data isn't very available. Talk to your surgeon about your concerns and see what he can do to tailor things for your situation. My wife had an unknown hernia when she had her DS a few years ago, and they simply repaired it as part of the job. On the other side of the coin, you have to weigh the risks of not doing anything, the complcations and health issues of being overweight. Good luck with your decisions,

I think you have hit on an important point, and that is that many of the rules that are imposed on some of us are a holdover from RNY experience and many surgeons still don't have enough experience with the VSG to break out a new program for it. That video link is a good demonstration as to why the non-drinking is important for the RNYers; thankfully, the pyloris is smarter than an RNY pouch. though no doubt that effect is still there to some extent. That said, my surgeon's instructions follow the general trend of avoiding drinking before, during and after eating, despite him being primarily a DS guy, though they don't seem to be as firm about it as some practices are. I don't drink the volume of Water, milk and/or tea that I used to around meals, but I can't avoid sipping some while eating.

I can certainly understand his concern about getting into eating disorders in an attempt to hit an "ideal" number, and I can see that this may be a problem with some as it doesn't seem that overshooting the goal is as common with the VSG as it sometimes is with the DS, but I don't think that that is any reason to change your current weight loss behavior in order to avoid hitting that ideal. I would just continue doing what you are doing and let your body settle out where it does. Another consideration in this is how well your skin is adapting to the weight loss and whether reconstruction to remove excess skin is in the cards sometime in the future - that can easily result in another 10lb or more of loss. My goal has been to be still in the overweight class at around 200lbs based on my body composition - in the ideal case of losing only fat mass that would put me at around 15% body fat, which is on the lean side of normal for men. As my composition shifts and inevitably some muscle mass is lost during the weight loss period, then my goal may change some as i get closer to it, though so far, at more than half way to goal range, I'm still pretty much on track to meeting that target point. The 200 range is where I was when I was a fat boy in college too many years ago, but I'm in better shape now (and in recent years) than I was then, despite the excess weight that I've been carrying. So, with the extra work you have been doing lately you may not be as chunky at 150 than you were then. Be flexible and see how things work out as you get closer to the goal range.

Weight regain is a risk we assume by having a restrictive procedure like the VSG and from what I have seen there is little to choose in that regard between it and the RNY and bands. The more relevent question to me is for that risk, how much complication/side effect risk does one want to assume, and the RNY and bands are much worse than the VSG in that regard. To get a worthwhile improvement in the long term regain area it seems that one needs to go to the DS with its metabolic changes that move one closer to a "normal" person. Given the quality of what passes for medical "research" and the poor understanding of statistics shown by the medical profession in general, I would seriously question the sanity of a doc like this who swings his opinion based on one study. If he is having problems with weight regain within his practice, that may be a reason to shy away from the procedure, or at least figure out why it is happening and what patients are successful, and if his results are markedly differnent than his peers' results, and why.

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There is controversy within the VSG surgeon community as to how big to make the stomach - too big and there is increased risk of inadequate weight loss and regain while too small brings on the risk of chronic reflux. Since the VSG is still relatively new in the WLS field, everyone is waiting on more extended data, at least 5 year post op data, to refine things to find the sweet spot. The DS surgeons have gone thru much the same thing in working out an optimum common channel length, and as with them, I expect that experience will eventually guide the VSG guys into better matching stomach size with specific patient characteristics - an experienced surgeon will use a somewhat different stomach size for different patients. Discuss your concerns with your surgeon, and be honest about your past successes and failures. Try to get his perspective as to the advantages of the larger size and what problems might be anticipated from it, and how to prevent them. If possible, attend some support group meetings of other surgeons in your area to get a feel for how they operate - it doesn't hurt to check out the competition. Good luck in your journey,

Most docs don't mention it because they don't do it - it is a longer and more technically challenging procedure than most of the other WLS procedures. The DS uses a VSG, usually leaving a somewhat larger stomach than our standalone VSG, and then it does some intestinal rerouting that results in malabsorption of the fats you eat - you just don't absorb them very well post op. It has a long term record of very good weight loss along with good durability of the loss, generally the best of the mainstream WLS procedures that are widely accepted by Medicare and the insurance industry. Interest in the VSG as a routine weight loss procedure came from DS experience, where some of the heaviest patients who had severe health problems such that the DS surgery was too risky for them were instead given a staged DS where they first got a VSG and then after they lost some weight and their health improved some were given the intestinal rerouting as a second stage procedure. It was found that a fair number of such patients lost enough weight and maintained it that the second stage wasn't necessary for them. The vast majority of DS procedures are done single stage. The other case where you might go through this again is if you need a revision - if the original procedure wasn't successful in reaching and maintaining your weight loss goals or if other complications exist. Many people having VSGs are being revised from failed lapbands. Likewise, if the VSG doesn't work for you, it can be revised into an RNY or a DS. The VSG, since it is already a part of the DS structure, is much easier to revise into a DS than a failed RNY. All of these procedures have ups and downs to them. One needs to do their research and get comfortable with the tradeoffs involved in whichever one they choose.

I think that you can say that there are issues with any of these procedures that we may choose, but overall it is the price we pay for the tool that helps us live a better life. Much of it is dietary - you learn what foods cause problems and avoid them, or plan for the result if it's something you really value - some of it is just individual metabolism. Stool is going to tend to be looser since there is the unabsorbed fat going through there too (which goes back to learning what causes what problems - you may not absorb all the calories from the fat with a DS, but it's still going through you. A permanent Xenical, if you will. Probiotics (and the right probiotics - different ones work for different people) seems to help many people with those issues as well. I would be surprised if Dr. Hess were doing anything extraordinary to be creating the problem, as he has been doing them about as long as anyone. There are always going to be variations in the results that people get, and perhaps part of the problem is compliance and willingness to learn how to use their tool - people can get poor results with any of these procedures if they don't want to work with the tool they have been given (or bought.) You can similarly get poor results from the VSG or RNY from not learning how to use them correctly. Eating poorly with a VSG may not slap us with foul gas or dumping, but the scale will tell the tale. I've been living with a DS postop for the past 6 years, and sometimes it is a problem, but rarely since she has been able to learn what causes it and can generally avoid it. When we went back up to San Francisco for her one year follow up we had a get together with around a dozen other DS post ops in the back room of a small Italian restaurant (danger, danger!) but the place did not get fumigated by them, and I can't recall it being an issue at any of the support group meetings (that are DS intensive) that I've attended with her the past eight years or so, though it is certainly a frequent topic of discussion.

My doc's revision rate for DS with inadequate weight loss or regain is in the 2-3% range, which is a bit more than their revision rate for excessive loss; these past few years they've been doing more tailoring of the common channel length based on their experience with different patient and body types. But some people's bodies are more aggressive in adapting to the changes made, experiencing substantial growth in their common channels - that seems to be a harder one to predict.

The vast majority are done single stage; they usually only do a two stage procedure if a patient has such extreme health problems that they can't tolerate being under anesthesia long enough to do it single stage - do a VSG, lose weight, improve health and strength, then go back in and complete the DS.

That is the classic reason for two staging the DS. However, if one is getting the VSG alone, with the idea that if it fails it can (relatively) easily be revised into a DS, then what I posted applies - do it before you suffer any significant weight regain. The best results, in my doc's experience, is to do the DS in one stage, or if necessary for surgical risk reasons, a planned 2 stage procedure. Doing a later revision from something else, including the VSG, doesn't usually yield as good of a result, though certainly better than whatever failed the first time.

I have not, but it is something that I have in reserve if I need it. The word I get from my surgeon is that it is best to do the second part of the DS fairly soon after the VSG, before there is a chance for much weight regain. If you stall out and still have a high enough BMI for insurance coverage, that is ideal - it works better than if you have significant weight regain before doing the revision. The downside is that the second part is usually done open rather than lap.

i'm running 1000-1100 a day typically, with 100g protein, but that seems to be working - I'm halfway to goal at two months and averaging around 4 lbs a week loss. YYMV,

Three weeks out I was having basic salad makings - spinach, tomato, carrot, pepper, onion, avo - with some leftover meats with no problems. We all have some variation in when we can tolerate things, and our program encourages experimentation - if something doesn't work, try it again in a couple weeks - from their experience that patients tend to do better with real food.

Pills are certainly do-able post op, though they are more of a PITA than pre op - instead of taking a handful of them with a gulp of water it's one at a time with each sip, and taste becomes more of an issue. That's why chewables are often suggested but not really necessary. After a few weeks thing begin to normalize and pill taking is much the same as pre op - several at a time with a swig of water, though some of the bigger horse pill type supplements like calcium are often still more palatable in a chewable form. Overall, it is a good move to trade meds for vitamins. During this intesive weight loss period when we aren't eating much the supplements are essential to maintaining nutriional balance. As things progress and you can eat more, more of your nutritional needs can be met by your food intake. But that is something that does need to be monitored since it is unlikely (hopefully) that you will be eating the volume that you did before. Even without WLS, most of us should be taking some supplements, even if it's just a good quality multivitamin, simply because of the classic American, coupled with the lower nutritional value of many of our foods relative to historical values, doesn't provide everything we need. Many WLS post ops take additional supplements simply because they are better educated than they were before.

I was surprised to read about how long so many are on liquids (maybe it's a holdover from RNY practice?) since my doc's practice is mushies/soft foods from the hospital on out - I guess that just seems normal to me since it's the same protocol my wife was on when she had her DS a few years ago. Our progression starts with the liquid Protein drinks/yogurts/puddings/purees and introducing softer solids like tuna and seafoods as they are tolerated, then progressing to firmer Proteins like dark poultry and firmer cheeses - if they don't sit well, go back a step and try again in a week or so. Experimenting is encouraged, within reason, as they note that most patients do better as they get into "normal" foods. I had no problem tolerating anything that I tried as things progressed, and by the 10 day checkup they suggested adding some veg to the diet since I was having no problems getting in the requisite protein. On the other hand, my wife had a harder time introducing new things and couldn't get in any more liquid than her nominal stomach size which meant that the Protein drinks had to be so concentrated that they were intolerable. According to the doc, both are compeletly normal - just the variations between us as individuals. Whatever protocols our docs use, it's best to stick to whatever you signed up for with your doc. Maybe this is one more thing to research when looking into different procedures, surgeons and practices, as they evolve their procedures based on their experiences (or copy them from more experienced surgeons...) I can hardly say that my doc's practice is wrong or overly aggressive since they've been doing VSGs for upwards of twenty years (primarily as part of the DS,) and have adopted the protocols that they have found to work the best for them and their patients. Other docs whose pre-VSG experience were centered around bands and RNYs may be more comfortable with with protocols based more upon what "they grew up with".

I frequently have a mini salad to use some leftover meats. Since I'm not having any problem getting in the protein, I cut the meat down to 2oz and add in about 10g each of some chopped raw spinach, pepper, onion, carrot, avo, tomato tossed with a bit of dressing and cheese. My system hasn't complained and I'm a bit shy of 2 months out. But then, I haven't had any problems with anything that I have tried yet. Maybe not such a good thing - who knows?

I generally go with the lowest fat alternative that I can tolerate out of pre-op habit and long term post-op considerations. Since we don't have the fat malabsorption that the DS guys have, we don't have their fat forgiveness built in. That said, I am not overly anal about ultra low fat or low carb but more go for nutritional density (I don't mind throwing some avo into my salads, as its' fat/calories come with a good nutritional balance). As with fat, I try to minimise sugar and other simple carbs, but sometimes the level of artificial sweetners needed to make SF or low carb products isn't tolerable. I can't take totally plain yogurt, but do blend it with sweetened vanilla yogurt (which on its own is overly sweet) and find that to be a better compromise than the artificially sweetened SF yogurts. Alternatively, I'll throw a little bit of jam into the plain yogurt to sweeten it up a bit and add some flavor, but don't bother with the SF jams due to the small amounts used. Many of the lower fat cheeses have a gram or two more protein per ounce than the regular full fat cheeses, so I'll go with them.

My doc's insurance coordinator let me know that they had approved it - they called him first and I got a letter in the mail a week or so later. Their turnaround back in March was about a week, which shocked both of us considering their reputaion for foot dragging (of course they are dragging their feet about paying the surgeon now, saying they need "more information" despite it being approved and them paying everyone else involved. Situation normal in the insurance world!

I've never been a big carbophobe, but have long concentrated on getting the best nutritional density that I can - the most protein, vitamins, minerals, etc. for the calories/fat/carb/evil d' jour that I can, but now I can keep the overall quantity down. My doc doesn't give a particular target number beyond minimizing simple carbs but I'm generally running in the 60-70gm range (at around 100gm protein level) - which is a fair bit better than the 300+ preop

This is a common theme amongst WLS people, even long term. I've been going to support group meetings for about 8 years, though was sleeved only last month (my wife was DS'd six years ago) and it's very normal to see your reflection in a mirror or store window and think "who's that person? - Oh, yeah," My wife reports that that is fading, and she resolved the "can I fit thru that space, or in that chair?" mindblock some time ago. But just last year, when we were at a gathering of friends who never knew her before, she told me she had the thought of "these people don't know who I really am... - wait a minute, I'm still the same person!" It takes time for our brains to catch up with the rest of us.

I had to do the bowel prep regimen, too - same as for a colonoscopy. It seemed to be a bit of overkill considering what's going on in the surgery, but since my docs are coming at the VSG from the DS perspective, I can understand it. On the other hand, I didn't have to do the extensive liquid diet program and could transition to real food sooner, a tradeoff I would gladly do again.

My difficult time was the first part of the second week, when my GI couldn't decide if I should have diarrhea from the liquid/soft diet or constipation from the pain meds. Before that I was already outpacing my wife on our walkies. I was also another one who never had any problems with nausea - never took any of the anti-nausea meds that they prescribed - or vomiting, despite early experiments with solid foods.

I hear you - I'm also a May 9, and am down about 35 with just a minor 3 wk stall - maybe dropped a pound that week and then back to some reasonable movement. Likewise, I don't feel like I have as much restriction as others have - maybe I just have a looser pyloris? I have never had much restriction with liquids and even the soft stuff like yogurt and puddings go thru fairly quickly. My wife, on the other hand, had a DS about 6 years ago and even with the larger initial stomach she could not drink more than her nominal stomach capacity in a reasonable time - her Protein shakes had to be so concentrated to get enough protein in her within a reasonable time that it was just gagging, but even within the first week or two I had no problem downing a 1 cup + powder Protein Drink in a reasonable time (maybe 10-15 min), and a 2 cup drink was workable if I was running short on protein that day. Even in the hospital, 10oz or so of broth and juice in a meal was workable. Solid foods like meats are limited to 3 oz or so, but if I mix some veg into maybe 2 oz of meat then the meal may be 4-5 oz. 1000 cal days are not unusual. You might ask your doc what size stomach he left you - mine was 2.5 oz. As with others, pizza is a concern, even if tolerated, mostly from the nutritional density perspective - the crust kills what can otherwise be a reasonably nutritious meal. Even at 6 years out, my wife still only eats the toppings (incl cheese, of course!) and leaves the crust behind (and she's a bread-a-holic.) It sounds like you recognize the problem of your mindset, and now need to learn how to make healthier substitutions so that you can reach and maintain your goal. And learn to follow the first commandment - Protein First! Good Luck fellow 6 weeker

My doc is one of those that starts us on the soft diet in the hospital and nominally for the first month, transitioning to more real foods as tolerated, with some sane experimenting encouraged - which was fine with me since I was losing tolerance of Soups and Jello fairly quickly. On the other hand, they're very anal about passing leak tests before tranistioning from IV to oral fluids (they didn't even want me swallowing the Water from the ice chips) - something that probably wouldn't be possible with the outpatient VSG model. I wonder if this is a difference between practices that are going at the VSG from a DS perspective (as mine does) as opposed to the guys coming at it from an RNY perspective? Rick