You all know I love DrK (who was not my surgeon, but I have gotten to know him professionally), but this seemed a little strange to me (from a FB DS group):
I was kind of shocked that DrK apparently had suggested this drastic surgery for this situation. So I wrote to DrK, and asked about this – in a HIPAA-compliant way, of course.
I told him that I had understood that the metabolic effect of the DS primarily came from bypassing the lower portion of the duodenum and the jejunum, and that I didn't think the length of the common channel was directly related to the metabolic effect of the DS, but more the maintenance of weight loss. I pointed out that this person weighs 180, and at 5'2", that is a BMI in the low 30s – and commented that resleeving and shortening the common channel seemed pretty drastic in order to lose at MOST about 35 lbs., especially given that the patient ADMITS that s/he isn’t restricting his/her diet and apparently doesn’t want to, and asked whether the patient would be better off trying to control his/her diet first, before recommending surgery.
These are his answers, including some follow-up questions (corrected with his permission for typos and his Armenglish, and with emphasis added (in blue)):
I also asked him how a change in a long term DSer (who already has had intestinal adaptation) from 100 cm CC to 75 or 65 would be likely to affect weight, and whether a resleeve would be necessary to actually effect some weight loss. I also asked how much experience he has had doing this, to base his answer on.
His answer:
I also asked the following, with respect to the LCHF diets:
His response:
To be clear, I don’t know what the specific issues are for the person who initially posted that suggested to DrK that a revision is appropriate in that particular person’s situation – or even that the person posted exactly what was discussed – DrK of course did not discuss that person’s situation with me, and I deliberately framed the question in more general terms. Perhaps that patient has (or plans to have, at insurance submission time) an actual BMI higher than is suggested by the post that was made (he did not recall having recently recommended revision to someone with a BMI <35).
In any case, I think this is important information for current and prospective DSers to know about, in particular the fact that SOME DSers can regain their metabolic issues along with their weight, which is a bit more common than I thought it was. And that there may be a surgical revision that is appropriate, even at a relatively low weight.
I understand that DrK has gave a webinar recently on the Crap Cycle (too much fat in the diet causes calcium and vitamin D malabsorption, then overuse of calcium and that causes constipation, so more fat added to the diet and the cycle continues) and may make it into a blog post on his website.
Bottom line:
The other thing is he is suggesting a revision to shorten my common channel and tighten up my sleeve. I am not sure how I feel about this - my diabetes is back, my blood pressure is up, and I am still obese. (I got to 155 for 5 minutes in 2010, but since then average about 180). My SW was 230 (also my high weight.) I'm only 5'2" on a tall day so that works against me too. My common channel is 100 cm - he thinks that if we shorten that up the metabolic syndrome will clear up again.
...
But, maybe it's like when you're a surgeon you always see surgical solutions... I am aware of the LCHF and IF groups and haven't been able to commit to that lifestyle change. It just doesn't fit with my family and my needs.
...
But, maybe it's like when you're a surgeon you always see surgical solutions... I am aware of the LCHF and IF groups and haven't been able to commit to that lifestyle change. It just doesn't fit with my family and my needs.
I was kind of shocked that DrK apparently had suggested this drastic surgery for this situation. So I wrote to DrK, and asked about this – in a HIPAA-compliant way, of course.
I told him that I had understood that the metabolic effect of the DS primarily came from bypassing the lower portion of the duodenum and the jejunum, and that I didn't think the length of the common channel was directly related to the metabolic effect of the DS, but more the maintenance of weight loss. I pointed out that this person weighs 180, and at 5'2", that is a BMI in the low 30s – and commented that resleeving and shortening the common channel seemed pretty drastic in order to lose at MOST about 35 lbs., especially given that the patient ADMITS that s/he isn’t restricting his/her diet and apparently doesn’t want to, and asked whether the patient would be better off trying to control his/her diet first, before recommending surgery.
These are his answers, including some follow-up questions (corrected with his permission for typos and his Armenglish, and with emphasis added (in blue)):
The metabolic effect is partly because of the duodenal and jejunal exclusion; however the long term outcome, from a metabolic perspective, is related to the weight regain, which in turn is a function of the common channel. It is also related to the amount of weight regain, in that the higher the weight regain, the higher the chance of recurrent metabolic issues years later. We also need not to forget that we all age and that plays a role into this.
I have operated on a number of patients with no weight to lose, only to resolve their diabetes and high cholesterol issues, and a patient presenting with diabetes and metabolic issues may benefit from DS. The size of the stomach, length of the alimentary and the common channels are the three variables that I can play with to minimize weight loss (if the patient does not have any or a lot of weight to lose) while maximizing the chances of the resolution of the co-morbid conditions.
With all of this said, I have never recommended revision to any patient who has just gained some weight (all patents will). We follow the NIH guidelines with respect to BMI and co-morbidities, because the risks are so high. I have, however, recommended revision for metabolic conditions if they are progressively getting worse, in patients with a BMI>35 and co-morbidities, or a BMI> 40.
On a related note, one of the problems I am concerned about is the unscientific pushing of the high fat diet that is causing a whole bunch of weight-related issues. I do not subscribe to the fat bomb diet that is being pushed by some patients, who advocate for it as if they are experts. I do recommend water, protein and everything else. On this front, if a patient presents and honestly goes over their diet history in the documentation that they present to me, then I do try to optimize the healthy diet (no carbonated drinks, no artificial sweeteners, water, protein and everything else, avoid processed food, avoid excessive fat and carbohydrates) and with those guidelines in place, if there is a reason for revision, then we might proceed; if not, the patient is asked to follow back up in some measured time for reweigh after making the proper changes – not with the expectation that their diabetes will go away (which will not) or for their hypertension to resolve (which will not), but to make sure that the problem is not being exacerbated with the crazy diet.
I will not do a revision if there are not justifiable risks based on BMI and comorbidities, and the patient is not eating a healthy diet, based on what I think should be a normal DS diet.
I have operated on a number of patients with no weight to lose, only to resolve their diabetes and high cholesterol issues, and a patient presenting with diabetes and metabolic issues may benefit from DS. The size of the stomach, length of the alimentary and the common channels are the three variables that I can play with to minimize weight loss (if the patient does not have any or a lot of weight to lose) while maximizing the chances of the resolution of the co-morbid conditions.
With all of this said, I have never recommended revision to any patient who has just gained some weight (all patents will). We follow the NIH guidelines with respect to BMI and co-morbidities, because the risks are so high. I have, however, recommended revision for metabolic conditions if they are progressively getting worse, in patients with a BMI>35 and co-morbidities, or a BMI> 40.
On a related note, one of the problems I am concerned about is the unscientific pushing of the high fat diet that is causing a whole bunch of weight-related issues. I do not subscribe to the fat bomb diet that is being pushed by some patients, who advocate for it as if they are experts. I do recommend water, protein and everything else. On this front, if a patient presents and honestly goes over their diet history in the documentation that they present to me, then I do try to optimize the healthy diet (no carbonated drinks, no artificial sweeteners, water, protein and everything else, avoid processed food, avoid excessive fat and carbohydrates) and with those guidelines in place, if there is a reason for revision, then we might proceed; if not, the patient is asked to follow back up in some measured time for reweigh after making the proper changes – not with the expectation that their diabetes will go away (which will not) or for their hypertension to resolve (which will not), but to make sure that the problem is not being exacerbated with the crazy diet.
I will not do a revision if there are not justifiable risks based on BMI and comorbidities, and the patient is not eating a healthy diet, based on what I think should be a normal DS diet.
I also asked him how a change in a long term DSer (who already has had intestinal adaptation) from 100 cm CC to 75 or 65 would be likely to affect weight, and whether a resleeve would be necessary to actually effect some weight loss. I also asked how much experience he has had doing this, to base his answer on.
His answer:
Shortening the length of the bowel will not do as much as resizing the stomach alone – it is bound to be that both will be better. In my very limited experience with this (in my opinion), it all has to do with the lengths that were done the first time around. IF the CC and AL were just guessed and left too long, then revising them to a shorter, more aggressive Hess method will yield better results. In a patient with lower BMI, the revision should be only considered if there are co-morbidities present.
I also asked the following, with respect to the LCHF diets:
You know, the low carb, high fat diet is not “one” diet, especially with DSers. I have seen the “fat bomb” posts and they don’t look right to me – MAYBE if someone is constipated despite adding fiber and/or a dose of Colace, as a one-dose, occasional clean-out, but as a steady diet? I don’t think so.
When I discuss LCHF, I mean simply not LIMITING fat in a normal delicious diet – NOT deliberately adding huge amounts or drinking olive oil or eating a stick of butter. I’m talking about adding as much butter as reasonable (and not wasteful) to steamed veggies; dipping crab meat into butter; putting as much full fat salad dressing on one’s salad to make it yummy (but not drinking salad dressing like soup!). (BTW, I’m in Las Vegas right now, and went to a buffet last night and ate crab with butter and a slice of prime rib, and I am pooping like crazy today – I don’t need fat bombs, and I doubt most DSers do!)
When I discuss LCHF, I mean simply not LIMITING fat in a normal delicious diet – NOT deliberately adding huge amounts or drinking olive oil or eating a stick of butter. I’m talking about adding as much butter as reasonable (and not wasteful) to steamed veggies; dipping crab meat into butter; putting as much full fat salad dressing on one’s salad to make it yummy (but not drinking salad dressing like soup!). (BTW, I’m in Las Vegas right now, and went to a buffet last night and ate crab with butter and a slice of prime rib, and I am pooping like crazy today – I don’t need fat bombs, and I doubt most DSers do!)
His response:
I agree with the fat position that you are suggesting- but that is not at all what is being advocated [referring to the message boards]. A patient that I have butted heads with for some time, finally admitted that after s/he stopped doing the very high fat bomb diet, not only was his/her bowel functions regulated for the better but actually weight started coming off - too much coconut oil with medium chain FA get absorbed no matter what, with no BPL juices needed. It is also important for patients to remember that it is ironic for a DS patient to have to have extra fat to have a bowel movement.
We should all go back and ask the question “why is a patient with DS, where it is scientifically proven to result in looser more frequent bowel movement (by Crooks and Anthone paper) constipated to begin with?” Maybe it is something in the extreme diet that is causing the problem? I think it is a chicken and egg thing - too much fat in the diet causes them not to absorb calcium and vitamin D, then they start overusing the calcium and they get constipated and then the cycle continues. (This mechanism of loss of calcium is well described in pancreatitis patients whose calcium drops significantly because of the increase in the undigested free fatty acids in the gut, which binds their dietary calcium and prevents absorption, which in turn causes clinically significant low calcium.)
We should all go back and ask the question “why is a patient with DS, where it is scientifically proven to result in looser more frequent bowel movement (by Crooks and Anthone paper) constipated to begin with?” Maybe it is something in the extreme diet that is causing the problem? I think it is a chicken and egg thing - too much fat in the diet causes them not to absorb calcium and vitamin D, then they start overusing the calcium and they get constipated and then the cycle continues. (This mechanism of loss of calcium is well described in pancreatitis patients whose calcium drops significantly because of the increase in the undigested free fatty acids in the gut, which binds their dietary calcium and prevents absorption, which in turn causes clinically significant low calcium.)
To be clear, I don’t know what the specific issues are for the person who initially posted that suggested to DrK that a revision is appropriate in that particular person’s situation – or even that the person posted exactly what was discussed – DrK of course did not discuss that person’s situation with me, and I deliberately framed the question in more general terms. Perhaps that patient has (or plans to have, at insurance submission time) an actual BMI higher than is suggested by the post that was made (he did not recall having recently recommended revision to someone with a BMI <35).
In any case, I think this is important information for current and prospective DSers to know about, in particular the fact that SOME DSers can regain their metabolic issues along with their weight, which is a bit more common than I thought it was. And that there may be a surgical revision that is appropriate, even at a relatively low weight.
I understand that DrK has gave a webinar recently on the Crap Cycle (too much fat in the diet causes calcium and vitamin D malabsorption, then overuse of calcium and that causes constipation, so more fat added to the diet and the cycle continues) and may make it into a blog post on his website.
Bottom line:
- Metabolic issues can come back even with the DS, more than rarely, with weight regain, and even just with aging.
- Revision for weight loss can be necessary when metabolic issues come back.
- Resleeving when doing a revision to shorten the CC may also be necessary, to effect more weight loss even in a lightweight, because of the need for metabolic correction.
- Extreme LCHF diets are probably self-destructive in the long run, because it leads to the Crap Cycle.
- Some self-appointed DS experts who espouse extreme diets who we should probably NOT be listening to (and frankly, to me, sound like eating disorders).
