Pre-Op Advice?

Hi all!

I've been lurking for quite some time but since I now have a surgery date I am hoping to get a little advice.

Just a little background - I decided that the duodenal switch was the right surgery for me but had a lot of trouble finding a surgeon in Massachusetts who performed it.  I read about Dr. Lelan Sillin (at Lahey Clinic in Burlington, MA) who did it but when I called I was told that he had retired.  However, they said that Dr. Dmitry Nepomnayshy sometimes did DS as a revision and that I might be able to talk him into doing it as a primary surgery.  When I met with him he agreed to do the surgery laparoscopically under the guidance/supervision of Dr. Sillin with the understanding that if there are any complications Dr. Sillin will take over and it would become an open surgery (since Dr. Sillin only does it open). 

I feel a little nervous but generally okay with the thought of being kind of a guinea pig for a surgery they don't typically perform.  Especially since the alternative is either doing a different kind of surgery or getting the DS but having to go out-of-pocket and out-of-state.  However, since they don't do it often I'm being lumped in with the RNY patients and given RNY instructions.  I've done a lot of reading and feel like I have a handle on what I need to do/eat/take post-op and can pretty much ignore any RNY instructions that they give me.  Is there anything special I should be doing pre-op?

I'm currently taking multivitamins, iron with vitamin C, and calcium with vitamins D and K.  Is there anything else I should start taking now?

The rest of my questions aren't DS-specific.  I'm getting conflicting guidelines from the surgeon and the RN regarding pre-op weight loss.  When I met with Dr. Nepomnayshy he said that my abdomen felt good, my weight loss was on track (I'd lost 5 lbs at that point), and that I should lose 10 to 15 lbs more (15 to 20 lbs total) by surgery with a 2 week liquid diet. When I met with Pam (the RN) less than two weeks later she said that my abdomen felt "squishy like the Pillsbury doughgirl", I'd need to lose more than the 15 to 20 lbs that the surgeon said (at that point I'd lost 9 lbs), and I'd need a 3 week liquid diet.  Any idea which one of them I should be listening to?

Part of my reason for asking is that my surgery date is not until mid-May rather than the April date I discussed with both Dr. Nepomnayshy and Pam.  Since I'm going to have extra time I'm tempted to have one meal a week that's something I won't be able to eat post-op.  So far I've been good about sticking to the nutritionist's instructions - three meals a day each with 20 to 25g of lean protein first, 0.5 to 1 cup of fruits or non-starchy vegetables second and then (if I have room) up to 0.5 cup of whole grains or starchy vegetables.  In addition, I’m doing 30 to 60 minutes of exercise at least 5 days a week.  I end up eating an average of 800 to 900 calories per day but since I have two more months to go I may want to bump that up some.  It has been about a month and I've lost 15 lbs so I'm not worried about meeting Dr. Nepomnayshy's guidelines even if I have one "cheat" meal per week.  Pam never specified how much more than 20 lbs she thought I should lose so it's hard to get a goal in mind.  I have about 7 lbs more to lose before I hit the point where, traditionally, no amount of diet or exercise can seem to get me any lower.  That said, I've never done a liquid diet before so that would probably help me break that barrier.

If I did one food funeral a week I would end up with 5 or 6 (depending on whether I do 2 or 3 weeks of liquid diet).  I'm hoping that if I make sure to keep the portions reasonable and don't keep any leftovers it'll be okay.  Any thoughts?

Thanks in advance!

Hi Lex and welcome!  You have a lot to learn and research.  Start reading at DSfacts.  Some of the best DS surgeons give awful advice on postop diet.  Your surgeon's office does too.  You need protein and honestly if you want to drop all the weight that's pretty much all you will eat.  Period.  Down the road you will be able to eat some carbs but if you really want the weight gone you will avoid them like crazy while you are losing.  In the first postop stage what's really important is hydration.  Gatorade G2 is great because it is low carb and give you the electrolytes/salts you need.

Your basic diet should be high protein, high fat, and low, low, low carb.  Think Atkins Induction Diet.  Most of us eat 100gr or more protein per day.  In the beginning or perhaps forever you may chose to do shakes for part of this requirement.  Over time you will figure out what's right for you.  We use butter and full fat everything.  BTW you won't be getting this in right away.  The general rule to shoot for is 30gr protein at 30 days, 60 at 60, and so on.  Think of fat and protein as free food.  Why fat?  Because we don't absorb it.  Some do lower fat in the very beginning because of poop issues.  And if you get diarrhea, treat it.  Imodium is your friend.

Forget the supplements your surgeon's office sells.  They are not for a DSer.  We have serious not optional needs.  Go to vitalady.com and check out her DS package.  No matter where you purchase this will give you a good idea what you actually NEED.  Do not take ADEKS.  Great idea but not enough for us.  You need dry, water miscible vites.  No oil based gelcaps.  Why?  Because you don't absorb fats!!!  If you want to be successful long term you will be taking a lot of pills every day of your life.  If someone tries to tell you to take Flintstones, run!  Exception, when you are brand new, maybe for the first couple weeks, 8 or 10 Flintstones a day may be a little better than nothing!  Beware of chewables.  Some of them are loaded with sugar you don't need.

You need to talk to your doc about stomach size and Common Channel.  How long will your Alimentary Limb be?  You will understand these terms after you spend some time on DSfacts.  Personally I would go for the shortest possible.  More malabsorbtion.  My CC is 75 and if I had it to do over I would want 50 and the smallest possible stomach.  The stomach will always stretch over time.  Probably the most prevalent CC is about 100CM.  Bring a diagram to your surgeons office to facilitate discussion.  Make sure you are getting a REAL DS...not something 'just as good'.  Beware of oddball configurations like the SADI.  If you and your doc are not on the same page run fast!

You are right there are no DS surgeons in MA.  Your body, your decision but I would want an experienced surgeon.  There is Roslin in NYC.  Many of us traveled for surgery.  Some to foreign countries even.  My S and H went to Spain for surgery.

Would it help you with the food funeral thing if I told you that down the road you will be able to eat anything?  There is nothing I can't eat.  And our diet isn't miserable at all.  Here's an example:

Breakfast

Scrambled eggs with cheese, bacon, coffee

Snack

cheese and sausage cubes, Greek yogurt

Lunch

chicken salad and iced tea

Snack

pepperoni slices and cashews

Dinner

roast beef, green beans

Snack

Sf pudding and cheese cubes

Yesterday I ate peanut butter, prime rib, shrimp,  HB eggs, pistachios, and some cheese.  I'm more than 11 years postop.  That was enough and I got my protein in.

As far as the preop diet goes, the ASMBS says we shouldn't have to do this.  But with an inexperienced surgeon trying to do the op LAP, I would take the diet seriously and try to shed as much as possible.  A pound is NOT a pound.  What they are trying to do is decrease the size of your liver.  The best way to do this is NO CARB.  Glycogen deprivation is the best way to shrink that liver to the max!

Best of luck to you!

Thank you for your reply.  As I said, I already feel that I have a firm grasp of the post-op procedures in terms of what I should and shouldn’t eat, take and do at various stages out.  I did a lot of research before deciding on the duodenal switch and it wasn’t something that I jumped into quickly or blindly.  Given my history, both dietary and medical, I feel that DS would be the most beneficial surgery for me.  Of course I would feel more comfortable with a surgeon who performed it regularly but it’s the difference between paying a $250 copay and paying $30,000 to get it done in NY.  I discussed the surgery at length with Dr. Nepomnayshy and Dr. Sillin and both they and the clinic have a very good track record.  If they feel comfortable in performing it, I am comfortable having them do it.

My primary concern at this point is pre-op procedures.  While all of the post-op instructions I’ve looked at seem to be fairly consistent, the pre-op instructions seem all over the place depending on the surgeon or hospital.  I’m generally happy to follow my nutritionist’s guidelines but I’d like to know if there’s anything DS-specific that I should be doing pre-op.

In terms of food funerals for things I won’t be able to eat post-op, I’ve looked at what a lot of people can and do eat long term and know it’s very flexible.  From what I’ve read people’s tolerances for simple carbs seem to vary but whether or not I will be able to tolerate them I still shouldn’t eat them post-op.  I did Atkins for a couple of years so I know that while there are a lot of very tasty and healthy ways to satisfy cravings for simple carbs there are some foods that there really are no substitutes for.  Those are the things I’d like to have one last time.

I know they want me on the pre-op diet not only to reduce my liver size but also to give them more room to maneuver in my abdomen.  What I’m unclear on is how much harm one carb-filled meal per week would really do.  I could skip the bad meals but if they wouldn’t really make a difference I’d just as soon not.

In regards to your suggestion of going no carb I could give up the carb portion of my meals but I’d need to add something.  Right now I only eat the carb portion of a meal if I’m still hungry after eating the protein and fruit/veggies.  This means that I always end up skipping the carbs with breakfast, usually skip them with lunch and sometimes skip them with dinner.  That said, I don’t think I could completely cut out the carb portions without adding in more protein or veggies.  In addition, I haven’t been counting the carbs in the protein, fruits or vegetables.  Going no carb would mean cutting out the fruit and changing my proteins since I have been doing a lot of fat free yogurt and cottage cheese.  Should I be worried about straying so far from what the nutritionist laid out?

More protein is good.  It's a good idea to get your protein levels up before surgery.  Helps speed up healing.  Dump the fruit for sure.  It's all sugar!!!!  And sugar is sugar.  Doesn't matter if it's in a doughnut or green beans or strawberries.  A carb is a carb is a carb.

Read the label on your fat free yogurt.  Almost always they take out the fat and replace it with sugar!  And chemicals!

Shrinking the liver is what has to happen to give them more room for surgery.  Most people who are heavy have large livers.  Ketosis shrinks the liver like crazy.  No carb will do it for sure.

I hope you are taking at least a multivitamin already?  Start adding a full dose of calcium citrate(usually 4 pills a day) and extra D now too!

hi there,

first congrats on your decision, second I would not go to MA  for the DS---NO WAY.  the ds is not something to mess around with and seriously you want to be a guine pig for a DS-?  really?  look at the DS in a diagram?  this is not a judgement, but please be very careful.  I flew to Dr Roslin in NYC.  I had a HMO and he was out of network-HELLO APPEALS.  I am from the northeast also, no way would I go to MA for my ds, none.  you have to do what is best for you, please be careful to have a safe and uneventful surgery..i wish you well... 

You need to find a different surgeon.  You are not going to end up with the Duodenal Switch.  Many of us had to travel to find a surgeon who actually PERFORMS the Duodenal Switch.  Many of them PROMISE they will do it, but you will wake up with just the sleeve, or some horrid variation they unvented (like the SADI Loop) that we hear of on these forums more and more lately. 

The fact that this surgeon has not done a Lap DS alone yet is alarming.  The fact that IF he runs into trouble another RETIRED surgeon will be doing it OPEN is even more alarming.  There is no reason to do it open if you are a virgin weight loss surgery patient.

Supplementing vitamins without knowing your lab results is like peeing in the dark.  Were your D and K low?  Normally, D and A are low pre-op, and possibly iron or ferritin.  But I've never heard of K being low pre-op.

Good morning  Lex,

Every doctor seems to have different ideas for preop diets. I had to eat a certain food for 2 weeks before my surgery. I know you have been doing research (how i remember those days) but is there no way you can go out of state to get the DS surgery if there is not a doctor in your state that really does it? I am from Maine and I flew to MI for my Ds I could not find anyone in the New England States that did the DS and was told by my weight loss program there were no doctors that did the DS. Be careful and I wish you the best.

Trish

I am having a DS revision April 1, and I would warn you that it can be very difficult to get a revision with someone who is not your original surgeon/a partner of theirs. I had a stomach stapling 20 years ago, and lucked out that, while the original surgeon had retired, his partner would do my revision because he was familiar with his techniques. If somehow this doesn't come out the way you hope for some reason, you will have to find a doctor willing to revise another doctor's work.

Also, I am in the middle of a pre-op diet, and it really isn't as bad as I thought it would be. The big thing is... DON'T CHEAT.  I find that any carbs I consume (such as allowed fruit juices) make me hungrier after a half hour than I was to start with. I will admit that I'm not in the best mood, and it sucks, but it's not impossible. I'm not having constant hunger pains, just a mix of head hunger and some real hunger, but less than I expected. I would definitely not have food funerals during the pre-op diet phase, it will just make it harder to stick to. As my therapist said, "Close the door on cheating. Don't let it in, even a little bit. Pushing the door shut is much harder than holding it shut."

Are you aware of Juarez' reputation?  Did you do ANY research into your choice of surgeons?

Is thre something I should know about?

So far, I know that it's a Center of Excellence, and I have heard only good things about Dr. Juarez. I looked at the reviews here, and asked around in town. I heard some negative things about his office staff, but I have had a patient care coordinator *****plies to questions by email within 15 minutes and has helpe me with everything above and beyond the call of duty.

My revision is weird because my original procedure was non-standard so other doctors have told me to go back to Bridges Center.