I already posted my reasonings for wanting to go down the bariatric surgery route, particularly as I learned more about Gastric Sleeve surgery. I also read literally hundreds of people’s opinions and experiences (mostly on Reddit but also other blogs and writings), and was very encouraged by the overwhelming majority of people that stated “my biggest regret is not doing it sooner.” That sentiment is incredibly common. I was excited and surprisingly impatient to get started.

I think it was early May when I asked my doctor for a referral for entry into the Kaiser bariatric program. I’m actually a bit on the lower end of the weight spectrum to qualify for the program (40 BMI is typical, and I hover right around there, sometimes dipping below int the 35-39 range. But if you have related issues (sleep apnea being one of them, and high blood pressure), then you can qualify even at 35+ BMI.

My primary care physician told me that Kaiser Richmond was the closest center to me, and recommended me for an orientation class there. I had read and researched so much about VSG (Vertical Sleeve Gastrectomy) at this point that I largely expected the orientation to be covering only things I already knew. On hindsight, I was only about half correct on that, and it was well worth going.

Orientation Day

The orientation was on May 16th in the Kaiser Richmond medical building. There were about 40 people in the class, and the first thing I noticed was how many more women there were than men… (I think there were only about 5 of us dudes there.) Again, I noticed I was probably on the slightly smaller size than most of the people there.

I won’t cover everything they talked about that day, but I think for me it all came down to a major reality check and what to expect. I don’t know if it’s intentional, but the class (it was about 4 hours if I recall correctly) seemed designed both to inform and also weed out people who aren’t very serious/committed to such a big change.

They do go over the most common options, Gastric Bypass (GB), Vertical Sleeve Gastrectomy (VSG), and Laparoscopic Band (LB)…. (the latter of which I don’t think they do in Richmond Kaiser, even before the class I’ve read that while LB is reversible, it also averages higher in terms of complications, and lower in terms of long term success rate. That said, from my own reading of statistics, LB is a perfectly valid option for some… again, I would still take just a 50% or 60% success rate for long term weight loss over 1% without any bariatric procedure.

The class was given by 4 people: one of the Kaiser Richmond surgeons, a case manager, a nutritionist, and a psychologist. A *lot* of ground was covered by these people.

Surgical Discussion

The surgeon mostly went over VSG and GB, and talked about the pros and cons of each. I would characterize this as follows (keep in mind these are just from my memory and notes, don’t take anything I write here as gospel):

Gastric Bypass

Most mature of the common procedures, historically the most popular option for the last few decades.

Bypasses most of your stomach and part of your intestine (see image above), leading to not only decreased food consumption, but also decreased processing and nutrient absorption from the portions of your stomach/intestine that are no longer going to be used.

Despite mostly the same vitamin supplementing program for GB and GS, it seems to me that the chances of nutrient deficiency with GB is higher.

Seems like this is the “all in” approach. Both VSG and GB are not really reversible (especially VSG since part of your stomach is completely removed from your body), but VSG can still be turned into GB later if needed. More on that below.

Vertical Gastric Sleeve

Relatively newer procedure, used to be much less common that GB, but has caught up rapidly.

In a lot of places, VGS now is the most common option in recent years.

Keeps the original digestive pathway pretty much intact, though obviously most of the stomach is removed (again, see image above).

Carries a decent risk (30%-ish?) of increasing heartburn and acid reflux, as your new sleeve (mini-stomach) is quite little, and if you already suffer a lot from heartburn/reflux, this will likely only increase. This seems to be the biggest downside by far for VGS, but I thankfully never really had heartburn/reflux issues so I felt good about my odds.

Felt like the more “natural” sort of route for me… same basic gut structure, but just less stomach to prevent over-eating.

Still allowed to take NSAIDs (think, Advil/Ibuprofen). Certain drugs like these are no longer okay to take if you go down the GB route.

Case Manager Discussion

This felt like the part where you really get weeded out – this was the “reality check” portion of the orientation where our case manager went over the hard realities of what you would need to do in order to be admitted for surgery. Some things to expect:

Even before surgery, you must cut out ALL of the following Caffeine (causes heartburn/reflux) Carbonated Beverages (overfill your pouch/sleeve with gas) Smoking (prevents good healing of stomach) Alcohol (causes heartburn/reflux, and also ingests way too many calories per ounce for someone trying to lose weight) Sugary drinks (punch, lots of sweet juices, etc) Chewing Gum (too easy to suck down air, which can cause probs for your mini-stomach) Using Straws (leads to air swallowing)

Increase exercise so that you are in shape and have built up strength for the surgery

Lose weight and keep it there until surgery day. While this may seem a bit odd (after all, we were all there because we had so much trouble losing weight), there are couple of major reasons for the weight loss: Keeping on-track for all the pre-op regimen takes some discipline and commitment. Kaiser has found that statistically, starting a pre-op meal plan and sticking with it (and losing weight) is the most reliable measurement of whether or not you are staying on track. Anyone can lie about their commitment, but the scale doesn’t lie. The more fat there is around your stomach (and fatty liver, which makes your liver very soft/injury-prone), the more difficult it will be for the surgeon to get in there and do his/her work without accidentally injuring some other organ.

Stay on top of all your pre-op appointments, there are lots of them.

Practice eating and drinking water separately, your mini-stomach won’t have enough space for both, so it’s important only reserve your stomach for food during meals.

Attend support groups (the attendee list includes both pre-op and post-op people).

Take small bites and chew 30 times before swallowing (this is incredibly hard for me)

A bunch more behavior suggestions/modifications that revolve around how mindful you are of your food.

After the case manager had given us all the info, this is definitely the point where I could feel a lot of the class just wanting to NOPE out of there. People were already bargaining like crazy “what if I just had a couple of shots or glass of wine only once a week”, or “what if I just cut my coffee intake down” – these were very common. While it is very understandable people don’t want to give up all this stuff, all I could think to myself was “no way these guys are going to go through with this.”

Towards the end of the session, someone did ask… how many people go through orientation and never come back? The case manager told us that roughly 80% of us wouldn’t return. I expect that number is fairly accurate.

She also told us that the minimum time period between that first class and surgery is about 2 months, and that the date was largely dependent on your ability to follow up on various tasks, stick to the meal plan, make all your appointments, etc. She also repeated several times that if you start eating everything in sight because you are thinking “last chance to pig out!”, that you would be dropped from the program, or at least very delayed, until you can get your eating under control again. Every follow up session includes a weigh-in to make sure you are within the goal weight recommended by the surgeon.

While this all seemed like a lot to manage, it actually made me feel better about the whole thing. I wouldn’t expect this sort of major change to be a quick fix to weight loss, and they liked to remind us repeatedly that the shrinkage of stomach is only one tool in the process, and that mindful eating, exercise, supplements, and a range of lifelong behavior modifications are needed for long term success.

Nutritionist Discussion

This is the section where I thought I’d get most bored since I read up so much about it, but our nutritionist was very engaging and informative. Again, I was glad I attended. She went into more detail about each of the things we needed to cut out of our diet.

The nutritionist reminded us that quantity (and quality) of food intake is by far the most important factor in weight loss. That is not to downplay the importance of exercise which has so many health benefits, but no amount of exercise will lead you to significant weight loss if you are still stuffing your face constantly.

She also explained how a typical bariatric diet differed from other “healthy” diet types we are accustomed to hearing about:

You do not focus on veggies, in fact – you will likely not have much room for them until later.

Protein is king. If you are supplementing correctly, most of your vitamin needs will be met, but if you don’t have enough protein, you’ll start to lose muscle mass and it may cause all sorts of issues.

They want you to pick apart your food like a kid (if it was prepared w/out your dietary needs in mind). Pick out the meats, beans, cheese, etc. and eat those first. Veggie and carbs come later.

You probably won’t have any room for traditional comfort-carbs any more (breads, pasta, rice, etc.) On the plus side, she said your craving for those should go down as well.

You are not so much counting calories, but instead measuring food volume, keeping in mind that your stomach pouch/sleeve is only going to be able to hold a half cup of volume at first. Keep thinking the size of a thick sharpie permanent marker – that’s what your sleeve is going to be able to hold.

She then told us about the benefits/necessities of following the pre-op meal plan, which gets you used to the kinds of food you will be eating, the prep and measurement of it, and the benefits of pre-op weight loss (reinforcing the surgeon’s warning against going to town and fattening up while you can prior to your surgery.)

She also warned us of head hunger and chewing hunger vs. “real hunger” – meaning, your sleeve will fill up pretty quickly and easily and send your body signals that it is full, but your brain will miss all the eating and chewing you used to be able to do, and tell you that you are still hungry. This will improve over time, but she said to expect the mental challenges from this to last for some time after surgery.

Psychologist Discussion

At this point, the program psychologist came in, and expanded upon our nutritionist’s warning about head hunger, and whether or not we were truly good candidates for this procedure. Everyone has their reasons for wanting to lose weight, but he encouraged us to think deeply about it, and to write it down (which is how I opened with this blog).

He talked about the psychological problems we could expect to face: skepticism from acquaintances as well as friends/family, jealousy, people saying you’re taking the “easy” way out, your own insecurities as you lose large amounts of weight and have a lot of eyes on you talking about your body and making observations (even if they think it’s positive, it can still mess with your head how much people are paying attention to the change.)

He told us about the importance of support, whether it was the support groups, or trusted and supportive family/friends, people you know who have undergone the same procedure, and generally taking care of yourself.

It is recommended that we take a month of work. That sounds like a lot of time, considering they expect you to be back on your feet the day of surgery, and heading home the following day. Most people don’t feel much pain at all by the third day afterward, and by two weeks you’ll almost feel “normal” again physically. But he said the mental portion of this change is very significant, and not to be underestimated.

You will have a lot of fatigue, since you’re eating so little at first. Your body will be switching to your fat stores for calories, and your brain is going to do crazy things to you. Depression is not uncommon in the first few weeks, and a lot of people end up switching their food addiction to other things (alcohol, sex, drugs, gambling, etc.) In fact, of the repeated figure of 30-ish% of people not able to sustain long-term weight loss even after the surgery, a significant potion of that is due to people who greatly increase their alcohol intake as a coping mechanism for the food that they miss. (This made me really thankful I don’t enjoy getting drunk very much anyway.)

He re-iterated that most of the folks who gave us a talk that day (surgeon, case manager, psychologist) would have to sign off on us having the surgery. If there were any physical, logistical, or psychological red flags, our surgery date would be pushed out accordingly.

By the end of class, those who were still intent on going through with this, were assigned a bunch of lab work (blood tests, EKG, etc.), as well as follow up appointments with the surgeon, the psychologist, and the case manager. It looked like I’d be spending a lot of time in the Richmond Kaiser center for the next couple of months.