Whocansay1
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New Revision here
- Thread starter Whocansay1
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Welcome, @Whocansay1
I'm not a "Hess Method" guru but it's hard to say if those are Hess numbers without knowing the total length. Honestly I suspect you will be just fine. Enjoy the ride.
I'm not a "Hess Method" guru but it's hard to say if those are Hess numbers without knowing the total length. Honestly I suspect you will be just fine. Enjoy the ride.
Clematis
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For a doctor who said a month ago he would never make a common channel less than 100, Esquerra has certainly changed his tune and recently has done shorter lengths. His reputed Hess method is still a little wonky.
But with his prior insistence on a longer common channel, I find it hard to believe he gave you a short 75 cm common channel on a total bowel length of 700cm (280 cm AL + CC and a 420 BL). At that total bowel length, your common channel would have been over 100 based on Hess. Is this surgical report incorrect? I suspect the first two numbers are correct but it is your total bowel length stated as 420cm and your biliopancreatic limb length is NOT shown.
BTW my original surgical report was incorrect as well. When I complained, I was sent an amended report.
But with his prior insistence on a longer common channel, I find it hard to believe he gave you a short 75 cm common channel on a total bowel length of 700cm (280 cm AL + CC and a 420 BL). At that total bowel length, your common channel would have been over 100 based on Hess. Is this surgical report incorrect? I suspect the first two numbers are correct but it is your total bowel length stated as 420cm and your biliopancreatic limb length is NOT shown.
BTW my original surgical report was incorrect as well. When I complained, I was sent an amended report.
harrietvane
Well-Known Member
I finally dug mine out to have a look! It's like the Lord of the Rings epic version of a report, including exactly which tools and sutures were used. (In Australia, they tend to be one or two pages with a lot of diagrams rather than words.)
'The ileocecal valve was identified and the small bowel was measured with an umbilical tape of 50 cm long, in a retrograde fashion, applying marking clips at 100 cm for the common channel. At 250 cm, the small bowel was transected with the Echelon 60, using a white cartridge. The duodeno-ileostoy anastomosis is an end to side ante colic, in 1 layer of 3-0 PDS, hand sewn. ... The distal anastomosis is a side-to-side ileo-ileostomy between the end of the biliopancreatic limb and the common channel at 100 cm.'
No Hess for me, but I had figured that much out from my initial reading of the report when I found this place post-op.
'The ileocecal valve was identified and the small bowel was measured with an umbilical tape of 50 cm long, in a retrograde fashion, applying marking clips at 100 cm for the common channel. At 250 cm, the small bowel was transected with the Echelon 60, using a white cartridge. The duodeno-ileostoy anastomosis is an end to side ante colic, in 1 layer of 3-0 PDS, hand sewn. ... The distal anastomosis is a side-to-side ileo-ileostomy between the end of the biliopancreatic limb and the common channel at 100 cm.'
No Hess for me, but I had figured that much out from my initial reading of the report when I found this place post-op.
DSRIGGS
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Those numbers do not add up. If the reported measurements are correct and not a mistake then you appear to have an Alimentary limb that is too short for that length of small bowel.
If you have 75 CC, 205 AL and 420 BPL that equals a 700 cm total small bowel.
Your CC is correct for that length of SB as it just a fraction over 10% (Hess say 10% CC & 40% AL = BPL (50%)).
Your AL should be roughly 280 CM (40% of 700).
According to your numbers you have an absorbing to non absorbing ratio of 40%:60% . A proper Hess would have had you at a 50/50 balance and the short fall, again assuming the report is correct, is your Alimentary Limb.
If you have 75 CC, 205 AL and 420 BPL that equals a 700 cm total small bowel.
Your CC is correct for that length of SB as it just a fraction over 10% (Hess say 10% CC & 40% AL = BPL (50%)).
Your AL should be roughly 280 CM (40% of 700).
According to your numbers you have an absorbing to non absorbing ratio of 40%:60% . A proper Hess would have had you at a 50/50 balance and the short fall, again assuming the report is correct, is your Alimentary Limb.
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DSRIGGS
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FYI - Dr Hess paper on the Hess method DS. Please note the areas I have marked in bold.
Duodenal Switch Hess Method Traditional DS
It is important to note that not all surgeons use Dr. Hess's method for performing the Duodenal Switch. The majority, if not all, of the long term data on BPD-DS is based on the Hess method of the procedure. There are studies out with 20 years data using the Hess method Duodenal Switch.
Correct parameters
The proper measurements when performing the Biliopancreatic Diversion with the Duodenal Switch are very important for good long term results. If the common channel is too long or the stomach is too large the patient may not have good sustained weight loss. If the alimentary limb is too short the patient may not be able to absorb adequate protein and may require a revision. The patient must be able to eat, the duodenal stoma should not be small, but wide open, so the patient can take in protein.
We have measured the total small bowel length in more than 1400 patients we have operated and there is a large difference from the shortest (12 feet) to the longest bowel (38 feet). You can see that one size does not fit all! In our experience a common channel of 10% is the best size. We use three sizes: 50 cm, 75 cm, and 100 cm whichever is the closest to the ten percent mark. This way we have three sizes of common channels and we can group them together to evaluate the lengths. The length of the common channel determines the degree of malabsorption of fat. You will, however, absorb enough fat for all the essential fatty acids needed for life.
The alimentary limb (the portion of small bowel which the food passes through) is formed nearest to 40% of the lower part of the small bowel, always in increments of 25 cm (10 inches) from 250 to 350 cm as shown below. The most common size used is 75 cm for the common channel and 275 cm for the alimentary limb. For example: the common channel length is 100 cm in only 7% of our cases, 75 cm in 67 %, and 50 cm in 23 %. From this you can see we feel that using a 100 cm common channel is not correct in most cases.
We believe measuring the total bowel is very important for good long term results (see our ten year graphs). If you don't count you don't know!
Volume of stomach 100 ml (+ or - 15 ml)
Common Channel 10% of total small bowel length, 50, 75, 100 cm
Alimentary limb 40% of total (SBL) 250, 275, 300, 325, 350 cm
Example (1): If you always use the 250 cm AL and 100 cm CC on all cases and the total bowel length is 500 cm the percent AL is 50%, this is too long for good weight loss. Also if you have a 100 cm CC there will be 16.7 %, too large an absorption of fat. This patient will not lose weight properly
Example (2): If you use the same parameters and the total small bowel length is 750 cm the AL is only 33.3 % and the CC is 16%; 33.3% alimentary limb is too short and the patient may have difficulty maintaining proper protein since the total alimentary limb is too short. Conversely the common channel is too long for the proper fat malabsorption.
Example (3): If the total small bowel length is 1000 cm as in the third example the common channel is proper, but the alimentary limb is very short and this patient will not be able to absorb adequate protein and will have difficulty. Most likely need to have a revision of the bowel lengths later.
Example (4): These parameters are all proper and will probably not have difficulty and should lose weight and keep it off for years.
HOME
The first Biliopancreatic Diversion with the Duodenal Switch (combination surgery for treatment of obesity) was performed on a patient who needed a re-operation procedure. At first we used this operation for only the patients who needed a re-operation for a failed restrictive procedure (Redo). Our results were so much better we begin to use this operation for all our patients. The above graph has the re-operation cases (blue) and the primary (first time surgeries) (red) listed for the first 15 years. You can see how the growth has been steady.
Duodenal Switch Hess Method Traditional DS
It is important to note that not all surgeons use Dr. Hess's method for performing the Duodenal Switch. The majority, if not all, of the long term data on BPD-DS is based on the Hess method of the procedure. There are studies out with 20 years data using the Hess method Duodenal Switch.
Correct parameters
The proper measurements when performing the Biliopancreatic Diversion with the Duodenal Switch are very important for good long term results. If the common channel is too long or the stomach is too large the patient may not have good sustained weight loss. If the alimentary limb is too short the patient may not be able to absorb adequate protein and may require a revision. The patient must be able to eat, the duodenal stoma should not be small, but wide open, so the patient can take in protein.
We have measured the total small bowel length in more than 1400 patients we have operated and there is a large difference from the shortest (12 feet) to the longest bowel (38 feet). You can see that one size does not fit all! In our experience a common channel of 10% is the best size. We use three sizes: 50 cm, 75 cm, and 100 cm whichever is the closest to the ten percent mark. This way we have three sizes of common channels and we can group them together to evaluate the lengths. The length of the common channel determines the degree of malabsorption of fat. You will, however, absorb enough fat for all the essential fatty acids needed for life.
The alimentary limb (the portion of small bowel which the food passes through) is formed nearest to 40% of the lower part of the small bowel, always in increments of 25 cm (10 inches) from 250 to 350 cm as shown below. The most common size used is 75 cm for the common channel and 275 cm for the alimentary limb. For example: the common channel length is 100 cm in only 7% of our cases, 75 cm in 67 %, and 50 cm in 23 %. From this you can see we feel that using a 100 cm common channel is not correct in most cases.
We believe measuring the total bowel is very important for good long term results (see our ten year graphs). If you don't count you don't know!
Volume of stomach 100 ml (+ or - 15 ml)
Common Channel 10% of total small bowel length, 50, 75, 100 cm
Alimentary limb 40% of total (SBL) 250, 275, 300, 325, 350 cm
Example (1): If you always use the 250 cm AL and 100 cm CC on all cases and the total bowel length is 500 cm the percent AL is 50%, this is too long for good weight loss. Also if you have a 100 cm CC there will be 16.7 %, too large an absorption of fat. This patient will not lose weight properly
Example (2): If you use the same parameters and the total small bowel length is 750 cm the AL is only 33.3 % and the CC is 16%; 33.3% alimentary limb is too short and the patient may have difficulty maintaining proper protein since the total alimentary limb is too short. Conversely the common channel is too long for the proper fat malabsorption.
Example (3): If the total small bowel length is 1000 cm as in the third example the common channel is proper, but the alimentary limb is very short and this patient will not be able to absorb adequate protein and will have difficulty. Most likely need to have a revision of the bowel lengths later.
Example (4): These parameters are all proper and will probably not have difficulty and should lose weight and keep it off for years.
HOME
The first Biliopancreatic Diversion with the Duodenal Switch (combination surgery for treatment of obesity) was performed on a patient who needed a re-operation procedure. At first we used this operation for only the patients who needed a re-operation for a failed restrictive procedure (Redo). Our results were so much better we begin to use this operation for all our patients. The above graph has the re-operation cases (blue) and the primary (first time surgeries) (red) listed for the first 15 years. You can see how the growth has been steady.
Hi and welcome @Whocansay1. Glad you are doing well following your revision. Safe travels back home! Looking forward to following your journey.
Congratulations! Don't stress too much about what has already been done. Many of us don't know the exact configuration and lengths, so I have just been winging it. If knowing it helps you, hopefully, it will be motivation to be very careful with adequate protein and daily vitamins forever, which you need to do regardless of the lengths. As long as you have someone you trust following you and your blood levels, just enjoy yourself (and bacon!)
Whocansay1
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Straight to the meat, I like it lol
Whocansay1
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So did you not feel your surgery was successful Clemantis? Are you having issues?
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Munchkin
Full of Fairy Dust
Welcome!
DSRIGGS
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75 CM is what the Hess Method would call for on a 700 CM Total SBL. 10% x 700 = 70 CM and they go to the closest increment of 50, 75 or 100 CM for the CC based on where 10% of SBL puts you.
The issue I take with Esquerra on these numbers that he is saying are Hess numbers is the AL (Exactly the problem I had). Because Lisa was a revision from VSG is the only reason I can see him varying from Hess numbers unless there was something else he saw that caused this action, but 205/700 is only 35% of Total SBL so I don't know why he chose that number.
Lisa and I talked yesterday and hopefully things will be okay. Like all of us, she will just need to follow her labs closely and if she sees thing dropping there are options.....unless she sees that there is an issue I see no reason to worry.
SmilinsShrinking
Well-Known Member
Quick question, is there any chance that Dr. Esquerra makes the length shorter because it is a revision and it has already been shown that the patient need extra malabsorption for losses and best hopes for keeping it off?
( I assure you it was not meant as a criticism... I am a pre-op revision patient and I'm hoping for the best success possible)
( I assure you it was not meant as a criticism... I am a pre-op revision patient and I'm hoping for the best success possible)
DSRIGGS
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No criticism in your comments hon.
He may have done as you have suggested but I would argue that it has not been shown that a VSG to DS revision needs extra malabsorption. Many believe that weight loss is slower with a revision as compared to a virgin DS but I have seen no data (could exist but I haven't seen it) that demonstrates that VSG to DS patients lose less than virgin DS patients. Frankly there have been very few studies of any kind with the DS so it would surprise me if this specific study has been completed.
My thoughts and they are just my opinions is that the switch component of the DS is what keeps the weight off long term and that the sleeve is just a kick starter.
That being said this could very well have been his logic for making the AL shorter. Personally I would have given a few percentage points less of malabsorpiton if any.....Maybe like make the balance 47% absorbing/53% non absorbing and not 41%/59%.
In any case let's hope it all works out just fine.
