RickM

The basic procedure upon which the RNY is based has been done for some 140 years for a variety of GI maladies, so it's mostly a matter of billing codes, and some minor variations in configuration, that make it a bariatric procedure vs. one for cancer, gastroparesis, etc., so insurance shouldn't be a factor if that is what is needed.
As to whether the "RNY" is needed for your case is a judgement call; try to avoid self diagnosis and let the doctors make the recommendation as to what is appropriate to treat your particular case. GERD is a classic symptom of a hiatal hernia, and given that you didn't have any particular problem with it for some years post op indicates that it is the hernia and not the sleeve that is the primary problem. Again, let the experts weigh in on this.
My preference when considering something like this would be to seek out an opinion from a bariatric practice that is associated with a regional cancer center, as they tend to treat a broader range of GI maladies than a general bariatric practice, and will probably have a wider range of options to consider. If you come across a surgeon who quickly determines that you have GERD and a sleeve, therefore you need a bypass, without looking at any imaging, I would tend to move on to someone else - they probably don't understand the sleeve as well as they should to make that determination.
My philosophy is to try to avoid going to a bypass is possible, as it does present some diagnostic and treatment limitations down the line should they be needed as we get older. The blind stomach and duodenum that can't be readily imaged or manipulated endoscopically and medication limitations (of which NSAIDs are the largest class,) are the primary things that come to mind. They usually aren't big deals if that is what is needed, but I don't like giving up options unnecessarily. RNY patients can develop GERD later on, and occasionally (though rarely,) such a revision does not correct a GERD problem, so we're talking more of a statistical improvement rather than an outright cure. If that happens, then where does one go - the bypass is something of a one way street surgically (though is can technically be reversed)? So, my inclination is to go one step at a time and treat the hernia and then go from there is that doesn't correct the problem.

Some programs want their patients to avoid them as soon as possible - within the first few months - on the premise that they don't want their patients drinking calories and would rather they work with solid food instead. Most programs don't care, but there is some merit to the liquid vs. solid argument, at least for a time. Many, OTOH, as we see above, still use them long term, often as a convenience. I still use them - my own blend, as with most things - as an exercise recovery drink after the gym. My wife uses some of the powder in the regular smoothie that she makes (20 years post op) in which she also includes some of the added supplements that she still needs (for her DS,)
So, if you can get away without them and still get the requisite Protein, and object to drinking them, then great - you can do away with them. If you like them and they still provide some benefit or convenience, there's little reason not to continue using them.

Some programs want their patients to avoid them as soon as possible - within the first few months - on the premise that they don't want their patients drinking calories and would rather they work with solid food instead. Most programs don't care, but there is some merit to the liquid vs. solid argument, at least for a time. Many, OTOH, as we see above, still use them long term, often as a convenience. I still use them - my own blend, as with most things - as an exercise recovery drink after the gym. My wife uses some of the powder in the regular smoothie that she makes (20 years post op) in which she also includes some of the added supplements that she still needs (for her DS,)
So, if you can get away without them and still get the requisite Protein, and object to drinking them, then great - you can do away with them. If you like them and they still provide some benefit or convenience, there's little reason not to continue using them.

Surgeons will have their preferences based upon their experience and background. When I had my VSG around 14 years ago, the sleeve was fairly new, but most surgeons included it in their practice, though most were not that experienced with it yet (and it often showed in the outcomes, with quite a few rapid revisions needed.) I travelled to SF to have my sleeve done as there wasn't anyone in the LA area where we lived that was very experience with them, but there were several good BPD/DS surgeons in the Bay area, and as the DS uses the sleeve as its basis, those are the guys most experienced with it - my surgeon had been doing them for around 20 years at the time.
Note another difference is that we do see more revisions of the sleeve, in part because of that "infant mortality" problem of when most surgeons were still working up the learning curve on it, but also because it CAN be readily revised, whereas the RNY is difficult to revise, so it, or reversals, are not done commonly owing to the complexity. So, if one does wind up with, say, a GERD problem, which does happen occasionally with the RNY, too, then one is stuck with medicating it, or reversing it if things are that serious.

Bile reflux tended to be the biggie problem with the MGB back in the day. When my wife and I first started looking into WLS almost 25 years ago, the MGB was a proposed alternate to the incumbent bands and RNY but it never gained traction with the ASBS (precursor to today's ASMBS). In the meantime, both the BPD/DS and the VSG (and more recently the SIPS/SADI) have gained acceptance in the US bariatric (and insurance) industry. There are reportedly some techniques that have been developed to mitigate the bile problem, and there may be something to that, and why it may have been accepted elsewhere; but in the US, it's time has passed.

When my wife and I were first looking into WLS 20+ years ago, there were several newer procedures, including the MGB mini-bypass, DS duodenal switch and the VSG vertical sleeve gastrectomy, that were circling the periphery of bariatrics, which at the time was mostly lap bands and the RNY gastric bypass. These were the only procedures that were endorsed by the ASBS (American Society of Bariatric Surgeons) - the predecessor name for today's ASMBS. Since that time, the DS, VSG and newer SIPS/SADI/"Loop DS" that have gained endorsement from the ASMBS and general insurance coverage in the US. The MGB never made it past that hurdle here in the US, so isn't commonly done or covered by insurance. Bile reflux seems to be the major legacy problem that caused the profession to move away from it at the time. There are claims that some new techniques have been developed to minimize that problem, and maybe they do, but it's a hard sell to make it mainstream in the US. It has become more accepted in other countries.
Overall, being in the States, I wouldn't be overly eager to go with the MGB as it is not commonly done here, so there are fewer MDs around who are familiar with its' care over the long term; the RNY, in contrast, has been done for around 140 years for reasons other than weight loss, so is a well known configuration in the medical world, as are the problems one may encounter over the years. If you have an unusual configuration like an MGB or BPD/DS, it can be harder to isolate any health problems one may have years down the road owing to the general unfamiliarity with the procedure -at least the DS has significantly better weight loss and diabetes results than the other procedures to make that a worthwhile consideration.
If you live in a country where the MGB is commonly done, then it would be a worthwhile consideration, but the US has too many other mainstream procedures commonly available and accepted that do as well or better than the MGB that it doesn't make much sense here.

They will in time, but these drugs are only now becoming approved for weight loss use; they formerly were strictly diabetic drugs used off label for weight loss, and a darling of the Hollywood set, and followers of them, so that didn't give them a great image on an official basis. They are basically a lifetime use drug, so the cost is a big issue with those covering them, but that will decline as more competition comes on the market and they go off patent, and as they gain respectability in the "legitimate" medical world and not just the fly by night weight loss "spas".

Our program was for 18 months of follow up as part of the surgical fee, and then annually thereafter on our (or insurance's) ticket. In normal situations, follow up with the PCP is fine as they can order labs, etc. However, we find it useful to keep in touch with the surgeon for his annual follow up as a means of keeping him "on retainer" in the event something odd happens. We all have things happen as we get older, and one of the common questions that would come up in our support group (mostly veterans of 10-20 years) is that they are having some health issue, and is that related to their WLS? Usually it is not and just part of the aging process, but if there is something questionable, our PCP can call up the surgeon and ask about it, MD to MD. It is less common for something odd in our health balance to happen with a sleeve as it would be with one of the malabsorbing procedures like the DS or RNY, but that's where some odd long term nutritional balance issue is most likely, and that's where the surgeon's experience can help out.

Our program was for 18 months of follow up as part of the surgical fee, and then annually thereafter on our (or insurance's) ticket. In normal situations, follow up with the PCP is fine as they can order labs, etc. However, we find it useful to keep in touch with the surgeon for his annual follow up as a means of keeping him "on retainer" in the event something odd happens. We all have things happen as we get older, and one of the common questions that would come up in our support group (mostly veterans of 10-20 years) is that they are having some health issue, and is that related to their WLS? Usually it is not and just part of the aging process, but if there is something questionable, our PCP can call up the surgeon and ask about it, MD to MD. It is less common for something odd in our health balance to happen with a sleeve as it would be with one of the malabsorbing procedures like the DS or RNY, but that's where some odd long term nutritional balance issue is most likely, and that's where the surgeon's experience can help out.

I can't help from any specific experience, but on the East coast, I would suggest talking to Dr. Mitchell Roslin in NYC. He is one of the big promoter/developers of the SADI (modified DS) but is also long experienced with the traditional Hess DS along with the RNY and VSG. Having all of the major procedures in his toolbox, he can give you better advice as to which procedure best fits your specific needs; certainly better than your corner "WLS R Us" practice that just does the RNY and VSG. While he may not be a big fan of the RNY (common amongst DS capable surgeons who find that procedure better in most circumstances,) I have seen him actively refusing to do a DS to a lapband revision patient because the RNY was the more appropriate procedure in his case.
Unfortunately, many surgeons will recommend whatever procedure they do as the best one, as it is the best for them even if it may not be the best for the patient. Finding someone skilled with all of the major procedures if very helpful when one has special needs.

Our surgeon does a lot of work with traveling patients, and his normal protocol for them is to stay in town for ten days until their first follow up appointment. But, he isn't in the business of doing things on the cheap, but doing procedures that others don't offer.

Our surgeon does a lot of work with traveling patients, and his normal protocol for them is to stay in town for ten days until their first follow up appointment. But, he isn't in the business of doing things on the cheap, but doing procedures that others don't offer.

I can't help from any specific experience, but on the East coast, I would suggest talking to Dr. Mitchell Roslin in NYC. He is one of the big promoter/developers of the SADI (modified DS) but is also long experienced with the traditional Hess DS along with the RNY and VSG. Having all of the major procedures in his toolbox, he can give you better advice as to which procedure best fits your specific needs; certainly better than your corner "WLS R Us" practice that just does the RNY and VSG. While he may not be a big fan of the RNY (common amongst DS capable surgeons who find that procedure better in most circumstances,) I have seen him actively refusing to do a DS to a lapband revision patient because the RNY was the more appropriate procedure in his case.
Unfortunately, many surgeons will recommend whatever procedure they do as the best one, as it is the best for them even if it may not be the best for the patient. Finding someone skilled with all of the major procedures if very helpful when one has special needs.

Our surgeon does a lot of work with traveling patients, and his normal protocol for them is to stay in town for ten days until their first follow up appointment. But, he isn't in the business of doing things on the cheap, but doing procedures that others don't offer.

Yes, the cause is often, if not usually, a mystery. I ran into an Afib problem a couple of years ago about this time of year, though it didn't get picked up until a month or so later when I went in for a pre-op exam for cataract surgery, and we were discussing the moderate shortness of breath I was experiencing while swimming, considered different things it could be until she took a listen and "Oh, that's it... you're not doing surgery tomorrow. Let's do an EKG as see what's going on." She had me in to the cardiologist that afternoon (it usually takes weeks or months to get an appointment). He had me go to the ER that evening to get the medication dosing down right (we can do this the fast way in the ER or the slow way back and forth to my office over the next several weeks to get this down...) Once the basic heart rate was under control, it was a visit with the cardiac electrician (electrophysiologist) to look at resetting things more permanently. The good news is that while he was in there burning out the short circuits he noted that my arteries are nice and clear, and while things are not back to a normal sinus rhythm, it's not Afibbing consistently so I don't need to be on the expensive anticoagulants.
Here's to them getting a better understanding of what's going on inside you so that you can get back to your planned life!

Basically, no. We do hear this from time to time but I have no idea where it came from (as far as legitimate scientific sources.} I can buy into the idea that Protein absorption would decrease some with increasing amounts in a meal, that wouldn't be unusual biologically (as in the first 30g is fully absorbed, the next 30 only 90%, etc.) But looking at it from an evolutionary perspective, our ancestors would gorge themselves on an antelope when they killed one, and then have relatively little protein for several days until they had another successful hunt. They got along just fine.
That said, I generally do break it up during the day, but that's more of a balance thing, in order to also get in the appropriate amount of fruits, veg, grains, legumes, etc., though it can take a while before one gets to the point of doing that other than in token amounts (though good for helping to establish good long term habits!)

The thing to watch out for when doing a minimally malabsorptive RNY is the prospect of bile reflux instead of the acid reflux that you had with the sleeve. When I was looking into this for a non WLS reason (it's has long been used for maladies such as gastroparesis and gastric cancer,) was that one of the most common problems reported on the patient sites such as Facebook was bile reflux. Talking to the surgeon about it, he said that as long as he keeps that roux limb at (IIRC) 80cm or more, it's not a problem; it seems that many surgeons going for minimal weight loss for such patients go overboard on shortening things. The extreme of this would be the "mini bypass" that attaches the pouch directly into the intestine without the roux limb, and that is well known for bile reflux (and why it was never adopted here in the US as a mainstream approved WLS.
However, there are also definitions and standards of care wrapped into the CPT codes that the docs use for billing, that define these things depending upon usage. I know this came up in one of the support groups with my wife's surgeon, and he noted that when he did the RNY, which he rarely did preferring the DS, he liked to make it as malabsorptive as the codes permitted. So there are standards that the surgeons are obliged to follow if it is to be a WLS procedure, and it doesn't seem to be a problem with most RNYs that we see as WLS, but could have been for what I was contemplating (but never proceeded with.) There's always an up side as well as a down side with anything we do.

Yes, the cause is often, if not usually, a mystery. I ran into an Afib problem a couple of years ago about this time of year, though it didn't get picked up until a month or so later when I went in for a pre-op exam for cataract surgery, and we were discussing the moderate shortness of breath I was experiencing while swimming, considered different things it could be until she took a listen and "Oh, that's it... you're not doing surgery tomorrow. Let's do an EKG as see what's going on." She had me in to the cardiologist that afternoon (it usually takes weeks or months to get an appointment). He had me go to the ER that evening to get the medication dosing down right (we can do this the fast way in the ER or the slow way back and forth to my office over the next several weeks to get this down...) Once the basic heart rate was under control, it was a visit with the cardiac electrician (electrophysiologist) to look at resetting things more permanently. The good news is that while he was in there burning out the short circuits he noted that my arteries are nice and clear, and while things are not back to a normal sinus rhythm, it's not Afibbing consistently so I don't need to be on the expensive anticoagulants.
Here's to them getting a better understanding of what's going on inside you so that you can get back to your planned life!

Yes, the cause is often, if not usually, a mystery. I ran into an Afib problem a couple of years ago about this time of year, though it didn't get picked up until a month or so later when I went in for a pre-op exam for cataract surgery, and we were discussing the moderate shortness of breath I was experiencing while swimming, considered different things it could be until she took a listen and "Oh, that's it... you're not doing surgery tomorrow. Let's do an EKG as see what's going on." She had me in to the cardiologist that afternoon (it usually takes weeks or months to get an appointment). He had me go to the ER that evening to get the medication dosing down right (we can do this the fast way in the ER or the slow way back and forth to my office over the next several weeks to get this down...) Once the basic heart rate was under control, it was a visit with the cardiac electrician (electrophysiologist) to look at resetting things more permanently. The good news is that while he was in there burning out the short circuits he noted that my arteries are nice and clear, and while things are not back to a normal sinus rhythm, it's not Afibbing consistently so I don't need to be on the expensive anticoagulants.
Here's to them getting a better understanding of what's going on inside you so that you can get back to your planned life!

You probably don't need to be taking all of that yet, unless your labs indicate a deficiency, but they want to make sure that you have everything ready for post op. However, some programs may want you to start taking all of that ahead of time to get in the habit. Either way, have them with you for your next appointment and if they had wanted you to be already taking them, then you can start then.

Possibly a hiatal hernia has developed, as GERD is a common symptom of that irrespective prior WLS history. An EGD (endoscopy) would establish that as well as anything else that is going on in there; possibly an imaging procedure like a barium swallow to look at shaping of the sleeve and associated connections can help to establish how things are flowing and why backups are happening. Your primary may order those things or refer you to a gastroenterologist to track down that problem, then they can start considering solutions - fix the hernia, resleeve to correct shaping problems or revise to an RNY.

First, a bit of confusion - have you hit your goal weight from surgery, as in 190 or so, or just some pre-op weight target and surgery is still in front of you? If you're still pre-op, then that is a fairly typical starting regimen, and yes, you should take extra Calcium and Iron above whatever the multi has in it - you won't be getting much nutrition from food for a while so you need the extra. If you are months post op and at your ultimate goal weight, then by now your labs will be guiding you and your doc as to what is needed - with a sleeve, a lot on that list will probably not be needed long term and will go away.

Possibly a hiatal hernia has developed, as GERD is a common symptom of that irrespective prior WLS history. An EGD (endoscopy) would establish that as well as anything else that is going on in there; possibly an imaging procedure like a barium swallow to look at shaping of the sleeve and associated connections can help to establish how things are flowing and why backups are happening. Your primary may order those things or refer you to a gastroenterologist to track down that problem, then they can start considering solutions - fix the hernia, resleeve to correct shaping problems or revise to an RNY.

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.

First, a bit of confusion - have you hit your goal weight from surgery, as in 190 or so, or just some pre-op weight target and surgery is still in front of you? If you're still pre-op, then that is a fairly typical starting regimen, and yes, you should take extra Calcium and Iron above whatever the multi has in it - you won't be getting much nutrition from food for a while so you need the extra. If you are months post op and at your ultimate goal weight, then by now your labs will be guiding you and your doc as to what is needed - with a sleeve, a lot on that list will probably not be needed long term and will go away.