MrBeeswax

I'm preOP. After reading form the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Manual of Metabolic and Bariatric Surgery (December 2024) I am confused by the diet supplement recommendations there which are very different than those from my program which they say are from ASMBS (and of course different than the statements of the vitamin sellers). The SAGES Manual of Metabolic and Bariatric Surgery says 1 or 2 regular multivitamins, calcium citrate 1200-1500, 2000-3000 IU vitamin D, at least 18 mg of iron, at least 12 mg of B1, and 350-500 mcg B12. I talked to dietician from my program today and she admitted they recommend the bariatric vitamin to everyone to keep things simple and she said it helped with compliance. I kinda feel misled because. The bariatric vitamins are not cheap, and aside from the calcium, Kirkland or Equate multi-vitamins with iron, a B1, and B12 would meet the basic needs per the SAGES Manual. The price of those three pills for a year costs as much as one month of some of the bariatric specific multivitamin supplements (not including Calcium Citrate).

My purpose of doing this surgery so late in life (I'm 46) is to be healthier. I have multiple co-morbidities including hypertension, left ventricular hypertrophy, sleep apnea, CKD 2, and hyperlipidemia. There is a family history of stroke and cancer, including colon a stomach cancer. I meet with my surgeon for the second time Tuesday. The staff said the surgeon wanted to meet with me because had questions, but that did't make sense because they've responded to my questions. The only new information was from my EGD pathology report. My EGD found asymptomatic HP negative gastritis. The GI Doc didn't know what may cause it but tossed PPIs at me and I will learned Tuesday if I need another EGD or what. If I have contra-indicators for Sleeve Gastrectomy I'm considering backing out of surgery because that means my only option, anywhere would be RYGB. I'm afraid of having a remnant stomach that could continue down the path of inflammation. Apparently I was on the path to stomach ulcers. Maybe I'm being unreasonable, I'm just afraid of my remnant stomach being a time bomb. I'm also concerned about dumping, not being able to take NSAIDs, and perhaps having to change my other medications. I've committed to having a procedure including buying vitamins, typing protein shakes, losing weight in advance, learning more and more about the procedures, my relationship with food, and continuing to exercise with my personal trainer, and attending support groups. But I have this fear of RYGB and maybe it's silly. I know people, good friends, with RYGB. I get the sense they like the results, but not the down sides. One even told me they are surprised hospitals still perform RYGB because of the issues they had. I don't really know what I'm walking into on Tuesday and I am nervous. I've been taking 80 mg or pantoprazole daily. I learned my insurance company will only pay for 90 pills, so my refill was tricky. I don't know how longer I will have to take it or what that all means, and i don't know what impact all this will have on the surgery (if any). I'm terrified of having come this far, made peace with the decision to have surgery, over come the shame, had to deal with the doubts and fears of other people including my own spouse to find myself with the possibility that it's all a no-go. I won't have surgery until the fall, and normally the second appointment with the surgeon is closer to the the surgery point. Even the program staff weren't sure why it was being scheduled. My RD follow up, last week as also much sooner than it should have been, and after the meeting the RD said it wasn't the actual required follow up. I'm left scratching my head, being coming anxious, and I feel some slight indigestion which is wild since I've been on the PPI since early last month. I doubt my experience is unique so I open to learning from others. I'm currently on Zepbound and losing weight, but it's expensive with insurance and the insurance could decide to not cover even with the insurance and a coupon it's about the amount of a car note every month. So that's not sustainable for the rest of my life. Ia also need to lose more than the 20% max it would get me to. So if surgery is a bust, I I don't know. The gastritis is a contra-indicator for Endoscopic Sleeve Gastroplasty and it's not covered by insurance anyway. Thinking about all of this makes me kinda nauseated.

The doctor responded to my question in writing a few weeks ago that there is no good answer because there is no way to know, but saw the value of having access to my stomach to monitor, i don't think she had a chance then to review the EGD pathology report and now suddenly I have a meeting with her. The program coordinator couldn't explain to me why it was so early. 15 years ago I had a bladder cancer scare, and the urologist reacted the same way after they got a pathology report. In that instance they had access to my bladder and did a scope and did not find anything really abnormal. I know the risk is rare, and I look forward to learning about the alternative ways to monitor. And I hope you're correct. RYGB in general would be something I'll have to warm up to because of the increased complications associated with it. The great news is there is a lot of data on it, and surgeons are very familiar. Sinceit's not novel, and if I move I will surely find a doctor familiar with it vs SADI-S or even BPD/DS. For example in my area very few surgeons do either of those two. My insurance doesn't cover SADI-S or OAGB. My preferred surgery is SG. If I'm not a good candidate for it, then I'm glad I'm waiting because I need to do some deep thinking. Dumping sounds terrible. Arthritis runs in my family, and at time even at my age my knuckles and joint hurt. Nevertheless the nephrologist advises against NSAID but they are not off limits with RYGB they would be mostly off limits. I'm not SG or bust really, but I just had a relative share they have precancerous cells in their stomach. That two of my father's siblings with either stomach cancer or precancerous cells. It is a little too close to home. I may be, however, more at risk of dying by slipping in the bath tub, or driving on the highway than getting stomach cancer in my remnant stomach. So I have to be realistic. If I do nothing and get kicked off of Zepbound my weight will return, and my heart will enlarge, and I could die of heart failure or a stroke (in the last 5 years 3 close family members had strokes, and my grandfather die of a stroke years ago). Those are conditions I have now. The enlarging heart may not get worse, but it likely will. My cardiologist is why I aggressively started losing weight to lose 40 lbs since my bariatric first appointment weight-in in February. I've now been taken off one of my four hypertension meds, but I'm still on three. My other concern about RYGB is how will it impact my ability to take sustained released meds. all this I'll talk to my surgeon about in my meeting Tuesday. I've been considering bariatric surgery since 2018, and i put it off. 2022 after a few health scares and being diagnosed with mild but concerning LVH I started seeing a dietician and working out. Later I battled shame to start Wegovy in 2023 and worked with an obesity specialist's practice. In 2005 due to insurance I switched to Zepbound. After my cardiology follow up in January I went for my first bariatric consult. I briefly considered ESG, but after researching decided against it and insurance doesn't cover it. I witched Weightloss clinics and aggressively started tracking and living in a calorie deficit. I'm under no illusions about being able to keep this weight off w/o surgery long term. I don't know if the co pays next year will be even higher already $500 $360 with a coupon, or if my financial situation will change. ifI do nothing, the I'm not sure if I'll make it to my mid sixties if I go back to 315-320. So I have to do something, the question is what.

Listen, I believe you honestly believe you mean well and are somehow helping. I honestly believe you believe that. Unfortunately, your efforts are proving instead to be high handed at best. I'm dumb, I'am not spreading misinformation. I'm not accusing you of spreading anything. I just think you're mistaken. I'm not attacking you character, or am I even finding anything wrong with you personally. My point is proven by the market place, the information provided in my program and countless others. The information from many bariatric dietitians, and surgeons that have information all over the the internet with rare exception. Patients are told you will need to take bariatric vitamins for the rest of your life. We are not told for the first year. But for the rest of our lives, we are pointed to or even given free samples of the ASMBS approved levels, and the vast majority of the brands closely mimic each other. They even say they are IAW ASMBS guidelines. That is what they say. Some formulations for example only offer 45 MG iron. most offer way more B16 then is stated is needed. Celebrate is one of few brands that even has a sheet specifically for SG patients. I literally have put them in a spreadsheet and compared them. So unfortunately, what you say isn't true. Patients are by and large in most programs to take one of the standard formulations. For example again with iron of the ten brands surveyed, including the most popular brands 40% sold only the 45 mg iron formulation. Even the ones that sell 18mg version most of their products have only 45mg. There is no study that I've found that says men or non-mensurating women w/o other issues need more than 18mg of iron. yet most of the products have 45mg. It's worse when you look vitamin B12 which most studies say should be 500 mcg for SG patients as the upper limit, but most exceed 500mcgI only found 2 that didn't. Again, this isn't my opinion it's based on data from the marketplace from the vitamin companies themselves. This isn't misinformation. You can look it up. Again, I'm not accusing you of anything I'm telling you where I'm getting my data, it's right there as plain as day. SG patients when told to take these vitamins are being over supplemented for some of micros. SAGES is clear, multiple studies are clear about the levels of iron needed, and B13. The upper limit of iron in men or non-mensurating women is 45mg. Yet most formulations start at the upper limit despite the dangers of taking too much iron. None of this is my opinion. You dismissing me by saying you do you or accusing me of spreading misinformation or disinformation, is simply not good. You telling me I' wrong by calling the other types of bypass, by pass. You saying that some programs don't still say RYGB is malabsorptive is just wrong. Patients are provided inconsistent, overly simplified information. There is also a terrible follow up rate after a few years. ASMBS has talks about that, I watched one on YouTube last night. Again, I appreciate that you responded. But the attacks and dismissiveness are not acceptable behavior. Not on this forum or anywhere to me. We can disagree on concepts, but don't accuse me of being nefarious, do not accuse me of spreading misinformation or disinformation, dismissing as being confused. Unlike a boat load of patients I've spent countless hour, days, weeks, months, of hours reading peer reviewed studies, watching lectures talking with multiple dietitians, reading the program materials from multiple programs. The variation between programs is startling and disturbing. The lack of consistency regarding follow-up is basically alarming. SAGES in terms of 2024 manual actually calls a lot of this out. Lastly, here's a presentation from UK NHS showing multiple variations of surgical interventions. The "History of bariatric surgery" presentation from St James University has illustrations of about 14 of them. Since per ASMBS SG the most popular surgery performed, it is startling that the vast majority of vitamins exceed what's recommended for SG patients. Again, not opinion you can look up most of the manufacturers websites.

That's awesome thanks!

TBH, I'm in a similar boat, I meet with the surgeon next week for my second meeting with them. We'll discuss surgery types. In my hometown all the hospitals only do two (SG and RYGB). So I don't really have a choice unless I got to hospitals out of state, and I'm concerned about getting medical care if I have complications and have to drive a 45 to an hour plus to get to the hospital, also the state south of me won't do telelhealth across the boarder, but they also don't have many in-person appointments because normal practice is telehealth. One hospital that does SG, RYGB, SADI-S, and BPD/DS basically said I was out of luck. My situation is a bit different because I am concerned about stomach cancer because it runs in my family. The idea of a remnant stomach freaks me out, at the same time my EGD found H. Pylori negative gastritis (antral and oxyntic mucosa with mild chronic inflammation). To be frank I didn't know how that impacted anything, and all the GI doc did was put me on a high does of a PPI. I don't have GERD, like most people I have heart burn from time to time and Pepcid complete works and i'm done. Surgery is hella scary, but these surgeries are amazingly safer than a lot of surgeries. I am more scared of the recovery and any complications, than dying from the surgery. At the same time, although I've fished my program's requirements save for the final exam I and waiting until this fall to have a procedure. If Tuesday I learn they was to do the RYGB I may very well back away and continue Zepbound. Not being able to scope my stomach is a fear of mine because the GI had no idea what as causing the gastritis and his report suggested that I was on my way to ulcers. So Joy. The human body is complicated. Take your time, it's your time, your life, your body. If you feel rushed tell them so, and if you're scared tell them so. It's okay to be scared, it's okay to be that annoying patient (I know I'm that patient) that asks questions and needs to feel settled. It's also okay to change your mind, and change you mind again. It's a big freaking deal. And living with obesity is also a big freaking deal. Only you can make the decision that's best for you right now. You'll be fabulous if you have the surgery, and you'll be fabulous if you defer.

I'll assume noble intent and not trolling, so here's a good attempt at civility. NIH has a good history and it is very informative and you may find it interesting https://pmc.ncbi.nlm.nih.gov/articles/PMC6806981/ My point was actually that it's wrong to group SG with any of those, because it lacks the magnitude of malabsorption potential. So yes SG is different than any of the ones that rearrange the small bowel. Some surgeons do not consider RYGB to be really malabsorptive, but some do. It is generally accepted that BPD/DS and SADI-S/Loop/SIPS are malabsorptive. For example those patients may need the full ASMBS recommended arsenal of supplements but SG patients don't, and RYGB patients do not unless the RYGB was done very differently than normal practice. There are also variations of all of these surgeries. RYGB patients may need more supplementation than SG patients nevertheless, which is what SAGES details in their surgical manual. Nevertheless my point stands. ASMBS should adopt the approach that SAGES has adopted and have procedures based supplementation guidelines vs one blanket one. The most performed surgery is SG, yet ASBMS's guidelines are closer to what SAGES recommends for BPD/DS. SG patients don't need that level of supplementation, and neither do RYGB patients for the most part. It is bizarre to me that the market is being set by one of the least performed procedures. That's the point.

Actually, all three are gastric by passes. But RY is the least malabsorption.

My concern is that SG patients don’t need all of that supplementation. In reality since absorption isn’t changed long term SG patients don’t need extra high doses oh ADEK like the GB patients do.

Talk to your medical provider. Yes, GERD occurs in some SG patients, in some others it improves. There are too many factors to have hard and fast simple rules. I’m pre operative and totally geeked out researching, and the more I learn the more I understand our knowledge is evolving and the best we can do is get as much information and make the best choice with the information at hand. Find a good program that does multiple surgeries and talk to them about your concerns l.

Okay, but I’m asking because if I don’t have to do a surgery I won’t. I’m thinking ten years from now. When I’m 56 will I be back here now. At 275 my weight loss on zepbound has slowed. That’s ~45 lbs drop. But I don’t want to go through surgery to only get to 250 because if I gain 20 lbs in 10 years I’ll be back here.

Good luck. I’m pre surgery and eerily. We are roughly the same weight stats. At the end of next month I’m going to pick a procedure and I’m worried about durability. The pandemic was a once in a century event, but this person’s story is not unique. Therefore, I’m worried if VSG is the best surgery for durability. Aside from BPD/DS I see VSG patients having a lot of regain on this platform and on the FB groups, there’s less, but still a fair number of RYGB patients with regain too. Most didn’t just go full on ultra terrible diet, so I am now reading and watching videos to avoid regain. Are there any books on the topic?

Is a 30% increase of lowest weight normal? I’m pre surgery so I’m trying to gauge where I could be at. This person losing 151 lbs is amazing. Just trying to gauge where I might end up in 8-10 years if I work the plan

I'm still evaluating my options (Keep dieting with my RD exericing with my trainer and Zepboundng, Endoscopic Gastroplasty, SG, RNY). I've met with two different medical teams, and my RD. I'm in one surgical in take program. Nevertheless, while I continue to research procedures, I wanted to ask about something that I won't be in any study. Is going through a bariatric procedure something people can do w/o support or consistent support. I have to plan to be on my own. How fragile are people after these procedures? How much help do people typically need? Can these procedures be done completely alone aftercare? Alone as in no one is available to help. Is it safe to be alone days weeks after the procedures?

So my EGD found inflammation. I start a zole drug tomorrow for 8 weeks to see if that help, but since I’m not an optimist. I’m trying to figure out what my choices are if I have a stomach acid problem. I have been not interested in RYGB. But if I have an acid problem I thinks my surgeon won’t do SG. So I’m not sure if any thing is left if this doesn’t resolve.

From ACS I understand it has more complications. SG also is the most convertible procedure if I ever needed a revision. I’m also concerned about too much malabsorption. I’ll talk with my surgeon, but if RYGB is my only option I’ll need to reassess my personal risks.

I’m curious if anyone has undergone Bariatric Surgery at either: George Washington University Hospital, Howard University Hospital, or MedStar Washington Hospital Center; if so what was your experience?

I have just started a program at Medstar Washington Hospital Center. The surgeon reviews well, but I am concerned because it feels like I'm on a conveyer belt w/o much support. I don't expect support from the surgeon, but there's no one to guide me through the process. The office staff seem to do great administrative work, but I feel like I'm on my own emotionally/care-wise. The classes are through an app and the support groups are monthly only via MS team and during the work day. I am wondering if I should find another program has anyone experienced the program at George Washington University, Sibley Memorial, Howard University, or Virginia Hospital Center. Are they more personal patient care. The current program I'm in feels like I'm just a commodity. Or is this level of detachment and isolation normal? If so I'm not sure what to do.