My Surgeon just debunked everything I have learned on here..

Someone posted in response asking:
  • The experts say that the DS is the best revisional surgery after a "failed" sleeve gastrectomy. But why the gastric bypass is still the first choice surgery in the patient wit BMI >40 kg/m2 or in patients with BMI >35 Kg/m2 with co-morbidities?

  • In any surgery, gastric bypass or DS, a patient with nutritional deficiences is because the patient didn´t follow the treatment and advices about the vitamins and trace elements.
    Do you know any patient with appropiate follow up with such deficiences?
My response to the question (which was probably aimed at Gagner, but that didn't stop me from answering), and which hasn't yet posted:

It is my understanding that the DS is not offered by the vast majority of bariatric surgeons, because it is difficult to learn and perform, and has "bad press" caused by (a) confusion with bad outcomes of the very different BPD; (b) poor compliance by some surgeons with providing adequate education and post-op follow-up; and (3) more rapid consequences of malabsorption that is not monitored or treated adequately.

While lack of compliance by bariatric patients of all types is always an issue, I submit that lack of adequate and appropriate nutritional guidance by (uninformed?) DS surgeons and their staff is a pervasive problem. The patient following poor nutritional advice and ending up with nutritional deficiencies is not being non-compliant.

I further submit that EDUCATED online patient support groups, comprising numerous long term DS patients with scientific and medical expertise, provide in most cases superior nutritional advice, and have rescued many many patients from the misinformation promulgated by DS surgeons who have not taken the time to learn a sufficient amount of the long-term malabsorption issues and how to address them, including saving them from miserable side effects and unnecessary revisions (which provide a misleading positive feedback loop to "evidence" of the intractable issues with the DS).

I suggest that the DS surgeons convene a panel of such long term DS patients with scientific and medical expertise to provide them with guidance for (1) practical approaches for advising their patients regarding nutrition; and (3) suggestions for proper clinical studies to formally evaluate and improve on what we know.​
 
TakeIII said:
Hi Newanatomy,

Did you ask his office for the operative report or did you get it from the hospital?
Click to expand...

I got it from the hospital. You will have to fax authorization to the medical records department then it takes a few weeks. The number to call is on the hospital's web site. It also cost me a few dollars (around $10.00) because I was getting it for my personal use and I wanted all my lab results too.
 
OK...the average human has @ 20 FEET of small bowel. And a BARIATRIC SURGEON comes along and says a 100cm CC is plenty long to absorb everything you need. Pop a couple Flintstones and call it a day. He may be a great cutter, but he needs some remedial physiology work stat. He is not going to get away with giving out bad postop information forever. Good grief! He does not understand the consequences of the malabsorbtion he creates surgically.

We didn't come up with "fat is your friend" either. That came from Dr. Hess.

I can be quick to forgive misinformation handed out by those not in the business. Everyone has a horror story to tell about their husband's cousin's aunt's nephew. And I am smart enough to know to disregard that advice. Advice from professionals should be worth what you pay for it and be completely correct. There is no excuse for a surgeon performing the DS on real people for big money to not understand or give out correct information to his patients.
 
Munchkin said:
OK...the average human has @ 20 FEET of small bowel. And a BARIATRIC SURGEON comes along and says a 100cm CC is plenty long to absorb everything you need. Pop a couple Flintstones and call it a day. He may be a great cutter, but he needs some remedial physiology work stat. He is not going to get away with giving out bad postop information forever. Good grief! He does not understand the consequences of the malabsorbtion he creates surgically.

We didn't come up with "fat is your friend" either. That came from Dr. Hess.

I can be quick to forgive misinformation handed out by those not in the business. Everyone has a horror story to tell about their husband's cousin's aunt's nephew. And I am smart enough to know to disregard that advice. Advice from professionals should be worth what you pay for it and be completely correct. There is no excuse for a surgeon performing the DS on real people for big money to not understand or give out correct information to his patients.
Click to expand...

I completely agree. Unfortunately, that is not what is happening with most of the surgeons available.
 
DianaCox said:
I am in an ASMBS group on LinkedIn - these is a LONG-ASSED thread going on regarding the DS, malabsorption/malnutrition, surgery choices, etc. Most of the comments are by non-DS surgeons.

I posted this:
  • All these misinformed comments regarding how difficult it is for DSers to maintain optimal macro- and micronutrient levels need to be taken with a very large amount of salt (and calcium and protein). Out here in the long-term post-op real world, and on the various message boards where DSers congregate (if they are smart enough and lucky enough to find us), it is clear that the vast majority of DSers are getting TERRIBLE and INCORRECT diet and nutritional advice from even the best surgeons. A prime example was the publication of the Norwegian comparative study, where there were multiple objections made to the nutritional advice as between the RNY and DS (essentially the SAME diet and nutritional advice was given for both surgeries, which was wholly inadequate for the DSers).

    I submit that the inadequate and just plain WRONG nutritional advice given by DS surgeons to many if not most patients is behind the majority of the problems with maintenance of health post-op (as is the sale of crappy vitamins by surgeons - a pet peeve).

    - Water-miscible forms of fat soluble vitamins must be administered individually, as needed. High range values for D3 should be maintained (above 70 ng/mL) because it is very difficult to get D3 into normal range if it slips lower. "ADEKs" are essentially worthless, are not properly balanced, and are ridiculously expensive. As an example, I am 11.5 years out, and have never needed to supplement vitamin A, based on my labs, but I need to take 500,000 IU of D3/week, so if I was taking sufficient ADEKs, I'd probably be broke and toxic in vitamin A.

    - IV iron supplementation, at ferritin levels above 30 ng/mL, is critical for many of us, for quality of life - most iron supplements don't work, and really hurt our guts. And if it goes too low, it can be VERY difficult to get into normal range.

    - Calcium citrate supplementation is a constant source of confusion for post-ops. Almost everyone needs to be informed BY OTHER PATIENTS that a proper dose is TWO tablets, multiple times per day. Calcium carbonate is insufficient.

    - With respect to calcium absorption, vitamin K2 is very important, as is magnesium citrate, but few surgeons teach that.

    - With respect to post-op kidney stone formation, many surgeons don't seem to understand that in order to prevent the most frequent type of kidney stones, our diets need to be supplemented by both calcium and citrate , and if stones are forming, dietary calcium needs to be INCREASED to bind to oxalates in the diet in the GUT, so they are never absorbed. And vitamin C is converted to oxalate in the body, so consumption needs to be watched.

    - It is stunning how many DS surgeons (or their staff) tell their DS patients to follow a LOW fat diet, which is counterproductive after the first few weeks. Constipation is more of a problem in DSers than diarrhea.

    - Failure to inform patients about the benefits of high quality probiotics, taken daily, including S. boulardii to control C. diff, is one of the worst failures. Failing to offer reasonably accessible metronidizole as needed (after ensuring that dietary indiscretions are not the cause) to get relief from imbalances/overgrowth of problem bacteria, followed by intensive repopulation with probiotic organisms is a needless cause of uninformed DSers' discomfort and "complications" of odor and loose stools, which are almost always easily solved by identification and elimination/reduction of problem foods or other ingested substances (wheat, especially resistant starches which have been chilled after rehydration, lactose, sugar alcohols, raffinose, plants in the Solanaceae family [tomatoes, eggplant, peppers], as a few obvious examples).
  • In addition to the above, there is a great variability in the construction of the DS between surgeons. Size of sleeve and length of common channel, as well as the length of the alimentary tract (either in absolute lengths or as a percentage of the length of the small bowel, and how THAT is measured), vary all over the place, making comparisons difficult. On the one hand, there's nothing wrong with that in principle - each patient can and SHOULD have their DS personalized to their situation - gender, age, weight, comorbidities, diet history, body habitus (as opposed to BMI per se - what percent is fat vs muscle); on the other hand, giving the same procedure to everyone is just wrong, at least without a good reason such as having given fully informed consent to participation in a clinical trial comparing the effects of these parameters.
  • Finally, it IS important to distinguish between patients who would be better off not being given a DS because of inability to comply with the minimal requirements of eating adequate protein, managing moderate carb intake, taking all of the required supplements, getting proper routine lab work, and adjusting diet and supplement intake as required. We have seen people in our community who have refused to care for themselves, who have become substance abusers, who have committed suicide either literally or by abdication of their nutritional responsibilities. It is up to the surgeons and their mental health allies to determine whether a particular patients can manage or be managed adequately - with the understanding that not everyone is capable of handling the gift that the DS can be to someone who is morbidly obese. People die from being unable to manage ANY weight loss surgery - there is a frightening incidence of Wernicke's encephalopathy in the RNY community as a complication of alcohol abuse - but malnutrition (as opposed to desired malabsorption) can happen faster with a DS.
  • But shunning the DS - with its superior results in EWL and resolution/cure of comorbidities, durability of both, as well as quality of life - without understanding the responsibility of long term patient monitoring and PROPER nutritional education required to achieve these benefits, is doing a terrible disservice to the morbidly obese patients in your care. It is NOT that hard to manage a DS, but it is critical that it is done properly. That is where the problems come from, not because the DS per se inevitably causes complications.
And then Gagner chimed in
  • Well said. At the same time, it is incredible how vitamins/minerals are mismanaged with ROUX-en-Y gastric bypass. I hope participants at the last IFSO got to see one of the top 10 papers, a randomized study looking at supplementation postop (we need more of those for all different types of surgeries, moving from feelings to real science). Dr Aarts from Rijnstate Hospital in Arnhem (Netherlands) presented a double-blind randomized controlled study on the effectiveness of two multivitamin supplemental regimens after weight loss surgery (a standard and a fortified). A fortified multivitamin regimen with vitamin B12 14000 % RDA, iron 500 % RDA, and folic acid 300%RDA was found to decreased substantially deficiencies in mineral and vitamins. The standard regimens are currently insufficient in most bariatric patients, and higher levels are recommended to avoid such micronutrients deficiencies (Iron, Vitamin B 12 and folic acid). This will have an immediate impact on follow-up care of these patients worldwide.
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Thank you Diane....This is wonderful. I copied and pasted it onto the RMAP FB board and tagged the RMAP nurse in it - she then deleted it and kicked me off the board. LOL
 
marissamast said:
Thank you Diane....This is wonderful. I copied and pasted it onto the RMAP FB board and tagged the RMAP nurse in it - she then deleted it and kicked me off the board. LOL
Click to expand...
In the big scheme of things you haven't lost much there. I do feel sorry for the people who are still there. We are supposed to be able to rely on medical professionals for accurate advice but in real life that is often not the truth. And it's regrettable.

Some of these folks will figure it out. But only when they get in big trouble and they realize these people they depended on can't help them dig their way out. Sometimes, you have to get sick to get better.
 

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