My 2016 DS Journal

trace

Well-Known Member
Joined
Sep 6, 2016
Messages
82
I had my consultation with Dr. Srikanth this morning. Things are moving rapidly, so I wanted to check in here to get some opinions.

1. This whole pre-op diet thing . . . I went back and read what people told @Duckman, and I just want to clarify -- if my insurance isn't requiring any kind of pre-op plan, but the doctor is, now what? He wants me to do a "sandwich" plan, which means I eat HPLC for a week, and then do a liquid diet for a week, alternating continuously until surgery. That sounds . . . rough. But Srikanth insisted weight loss will make surgery easier (for him and for me). Is it in my best interest to adhere to the pre-op diet then?

2. We talked about his method. He used to do Hess, and now doesn't. Some of this is still over my head, but I understood his current method to be one that leaves a 150cm CC. This was the length, he said, that resulted in significant weight loss, but kept most people from nutrient deficiencies and re-operation. He did say we could discuss going shorter, however, I needed to be aware that I would be opting for additional risk. In other words, I would need to understand that my compliance with supplements, frequent testing, dietary requirements etc., would forevermore be paramount. Thoughts?

Box 1 --> ticked.
 
I'm not a scientist in any way so I can't address your question with any authority. My surgeon also wanted me to eat HPLC. I had lost thirty pounds to meet my insurance's absurd requirement to lose 10% of my weight and an additional 10 pounds before surgery. It is supposed to make the liver smaller and thus give more room in the abdominal cavity for the surgeon's tools.

I'm glad you realize that testing and adherence will be tantamount to your continued health. Maybe you'll need less or at least smaller amounts, but you'll need them.
 
Last edited:
2. We talked about his method. He used to do Hess, and now doesn't. Some of this is still over my head, but I understood his current method to be one that leaves a 150cm CC. This was the length, he said, that resulted in significant weight loss, but kept most people from nutrient deficiencies and re-operation. He did say we could discuss going shorter, however, I needed to be aware that I would be opting for additional risk. In other words, I would need to understand that my compliance with supplements, frequent testing, dietary requirements etc., would forevermore be paramount. Thoughts?
Okay, mine is 175...and while it is true my vitamins are not as extensive as many here, who knows if it's because of my slightly longer common channel or just ME.

My husband's is 125 and he takes about the same amount of pills (altho slightly different ones).

BUT I am beginning to think my slightly longer common channel is not doing me any favors...I still have blood sugar issues as my A1C stays in the above normal range. (normal is below 5.7). Is it because of the longer common channel or am I truly part of the 2-3% that just won't resolve my diabetes with the DS?
 
Was he implying you would have to be less careful, the longer your channel? I hope not. It's a lifetime commitment regardless of the length. Mine is 100 cm, and I am happy with my weight, but less happy about bone loss and anemia. If you have diabetes, though, I agree with southern lady, the impact of CC length on diabetes should be discussed, because my diabetes disappeared the week of surgery.

Sometimes, even careful supplementation doesn't prevent nutritional deficits, so I kind of agree a longer channel is worth considering. This is about improving your overall health and that requires balancing these factors. It's hard to predict the future, but 10 years from now, you might take an extra 15 pounds of weight in exchange for maintaining bone density. From the perspective of being 11 years out, I would pick bone health over a little extra weight loss.

I don't know about the pre-op diet, but if he thinks it will help him and you get through the surgery, I would take that discussion seriously. This is major surgery and it is not without risk. Good that you are being so thoughtful about all of this!
 
Did you talk about the pre-op diet with him other then the conversation above? He was *adamant* with me that if I walked into the hospital the day of surgery having NOT lost the 10% he required he would not preform the surgery. Having said that I also carry my weight in my abdomen and belly so he would have had a difficult time with my liver had I not lost the 35 pounds (10%).
 
Did you talk about the pre-op diet with him other then the conversation above? He was *adamant* with me that if I walked into the hospital the day of surgery having NOT lost the 10% he required he would not preform the surgery. Having said that I also carry my weight in my abdomen and belly so he would have had a difficult time with my liver had I not lost the 35 pounds (10%).
I call bullshit on that statement. I mean not on him having said it. I'm sure he did but it was just a scare tactic I think. To cancel a scheduled surgery on the day of surgery is a huge loss of revenue and his ass would be well kicked by admin. Just my thought.
 
Was he implying you would have to be less careful, the longer your channel? I hope not. It's a lifetime commitment regardless of the length. Mine is 100 cm, and I am happy with my weight, but less happy about bone loss and anemia. If you have diabetes, though, I agree with southern lady, the impact of CC length on diabetes should be discussed, because my diabetes disappeared the week of surgery.

No, no, not at all. I think he just wanted to be clear that I would be accepting more risk. Especially since I would be asking him to deviate from the length that he has found to have the most benefit with the least negative side effects. I don't have diabetes, so is it not as big of an issue for me? The thing is, I hope to lose about half of my current body weight, so should I opt for something slightly more aggressive?

Did you talk about the pre-op diet with him other then the conversation above? He was *adamant* with me that if I walked into the hospital the day of surgery having NOT lost the 10% he required he would not preform the surgery. Having said that I also carry my weight in my abdomen and belly so he would have had a difficult time with my liver had I not lost the 35 pounds (10%).

He kind of off-handedly said that if I didn't reach 30 pounds, he wouldn't necessarily NOT do the surgery, but that it was ideal for me to get as close to that as possible. Here is what I don't understand: If I weigh 300 pounds, and the requirement is to lose 10% of my body weight prior to surgery so that it's easier for him to perform the surgery, then why doesn't a patient who is 400 pounds need to lose 25% (or more) of their body weight prior to surgery? Won't my liver be more easily accessible at 300 pounds (assuming I don't lose a thing) than a patient's liver would be when they weigh 360 pounds?
 
Respectfully I think his logic for not doing Hess is flawed and here is why I say that.

Dr k did a study of I believe 373 of his patients ...he has done nearly 2,500 DS surgeries...He only does Hess, and there was not one case of malnutrition long term.

Additionally it isn't just the common channel that is important. My cc was actually 125 cm and I was severely malnourished because my Alimentary Limb was too short. Itbis a pet peeve of mine when patients & Dr's focus on the CC only, because it is no more or no less important than the alimentary limb and bilo pancreatic limb lengths. If he doesn't measure your total small bowel length and just gives you a 150 cc common chanel it guarantees nothing because it is just a guess. If he does Hess or measures then adjusts slightly so not exactly 10% and 40 % cc and al, you will not lose too much or too little. It optimizes the DS for you the individual.

I can't get it to copy from my phone so please go to dssurgery.com and under About Us and publications you will find the study I am referencing. It will have low protein in the title. Please print or copy and show to your Dr. Please don't let him do surgery without measuring your small bowel length and then making an educated decision about you CC and AL lengths.

BTW if your total sbl is 500 cm and he gives you a 150 cm CC that will be 25% of total sbl and say he gives you a 150 cm AL...fairly common with standard limb length guys..you will have 300 cm of 500 cm total sbl as absorbing channels. That is 60% which is too much and you will very likey not come close to losing to your goal weight.

Best wishes


I am passionate about this because a,standard limb length DS surgeon really did great damage to me causing severe malnutrition where I was hospitalized for a week because they thought my heart was damaged. It wasnt. I was manourished from too short of an AL because the surgeon didn't measure my total small bowel length and follow the Hess parameters. Others haven't lost as much as they want and I highly suspect that the standard limb length they received left them with too much absorption. I don't ever want to see anyone go through the health struggles I have unnecessarily had to endure, nor do I want to somebody frustrated because their DS didn't allow them to lose enough. One surgery is all you want, not a second to correct an incorrect first surgery that gives bad results. There are no guarantees in life but Dr K's data that I asked you to review, shows that with the Hess your malnutrition risk is almost zero.

Again best wishes
 
Last edited:
About liver-shrinking diets: Dr. John Rabkin (who is also a liver transplant surgeon) said he didn't need patients to "shrink their liver" pre-op, and something along these lines: "Bariatric surgeons should expect to find an enlarged liver, and should know how to deal with it."
 
About liver-shrinking diets: Dr. John Rabkin (who is also a liver transplant surgeon) said he didn't need patients to "shrink their liver" pre-op, and something along these lines: "Bariatric surgeons should expect to find an enlarged liver, and should know how to deal with it."
Along the same lines Dr Keshishian is on record saying something along the lines of I have never met a liver I can't operate around, it is part of what I do.
 
I thought about this a lot more last night, and to be fair, I'm wondering if the pre-op weight loss is preferred because it could make a difference between an open vs. laparoscopic procedure? So, it's not that he wouldn't operate, but it could mean a more difficult recovery due to an open operation?

As for the Hess method, I am utterly confused. I mean, I totally get what you're saying @DSRIGGS, and it makes sense. So if I use a surgeon who admits he does not utilize the Hess method, am I shortchanging myself? The reality is that I don't foresee myself traveling anywhere to get this surgery -- it's going to be difficult enough to juggle the logistics with three young children, a dog, a husband who works full-time, no family nearby, simply to see a surgeon 30 miles away. Let alone someone in another state or country. Plus, time is critical for me. Every day that goes by where I'm at a MO BMI is another day that I'm hobbling around on a bad hip.

So I will definitely talk to him more about his method, but should it be Hess or the highway? Do I stand a chance of convincing him to revert to the Hess method for me?
 
@DSRIGGS Sorry, I can't find the study you are referencing. I'm looking at the right site, but I can't find that particular study.
 
Does anyone have access to this full study? I would really like to read more about it.

Obes Surg. 2007 Nov;17(11):1421-30.
Duodenal switch: long-term results.
Marceau P1, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S.
Author information

Abstract
BACKGROUND:
This report summarizes our 15-year experience with duodenal switch (DS) as a primary procedure on 1,423 patients from 1992 to 2005.

METHODS:
Within the last 2 years, follow-up of these patients, including clinical biochemistry evaluation by us or by their local physician is 97%.

RESULTS:
Survival rate was 92% after DS. The risk of death (Excess Hazard Ratio (EHR)) was 1.2, almost that of the general population. After a mean of 7.3 years (range 2-15), 92% of patients with an initial BMI < or = 50 kg/m2 obtained a BMI < 35 and 83% of those with an initial BMI > 50 obtained a BMI < 40. Diabetes was cured (i.e. medication was discontinued) in 92% and medication decreased in the others. The use of the CPAP apparatus was discontinued in 90%, medication for asthma was decreased in 88%, and the prevalence of a cardiac risk index > 5 was decreased by 86%. Patients' satisfaction in regard to weight loss was graded 3.6 on a basis of 5, and 95% of patients were satisfied with the overall results. Operative mortality was 1% which is comparable with gastric bypass surgery. The need for revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%). Failure to lose > 25% of initial excess weight was 1.3%. Revision for failure to lose sufficient weight was needed in only 1.5%. Severe anemia, deficiency in vitamins or bone damage were exceptional, easily treatable, preventable and no permanent damage was documented.

CONCLUSION:
In the long-term, DS was very efficient in terms of cure rate for morbid obesity and its comorbidities. In terms of risk/benefit, DS was very sucessful with an appropriate system of follow-up.

PMID:

18219767
[PubMed - indexed for MEDLINE]
 
I would suggest asking your surgeon to do the Hess and explain your reasoning and then have him explain why he thinks Hess is not safe because that is a 100% false statement. I will go to my computer and find Dr K's study that was presented to the ASMBS and you can show that to him. As far as final decision if he won't do the Hess and insists on a 150 cm CC (that is very long) that has to be your call. There are a lot of people who have done fine with the standard limb length DS, but there are some like me who fared very poorly with that method.
 

Latest posts

Back
Top