New to SADI

[throughthickandthin]

You need to understand that most DS patients don't have these horrible side effects like constant diarrhea and if they do it is usually because of a less than perfect job by the suegeon. You also need to know that bile reflux is a very real possibility from the SADI. No surgery is without risk and it is your decision but please don't make your decisions for the reasons you stated because those are rare side effects & not common.

Best of luck to you with whatever path you choose.

Thanks for your response. I must be missing something here. There is another thread on the board right now talking about constipation and diarrhea issues. I've the years I have seen countless threads on boards about post ops dealing with these issues. There is another thread right now about a non compliant DSer who has multiple spine fractures and other issues. We have to be honest with ourselves and each other. The full DS has the best long term weight maintenance but also requires the most diligence with supplementation and can have severe bowel issues at times. If that weren't true, there would not be so many threads devoted to these issues and there would be no reason for docs to continue trying to refine these surgeries. A surgeon who can do a SADI can almost surely do a DS as well. The hardest part is disecting the duodenum, from there it's a lot like constructing a long limbed RNY. The reason why experienced DS surgeons like Gagner, Roslin, Smith etc. are offering the SADI is not to mislead people or make it easier on themselves, it is to hopefully find in time the procedure which offers good weight control and morbidity resolution with an acceptable profile of side effects. It may turn out that for or some people RNY is too little, DS is too much, but SADI is just right. Or maybe not, only time will tell. But you can't say it's a bad procedure, as the limited data available has been favorable.

 

[DianaCox]

"it also has less severe bowel issues and likely require less supplementation"

I have not seen any proof of this statement in the literature. However, I am QUITE sure it allows less fat consumption (fat being very satiating as well as delicious), and will be less effective in the long run.

There is not a SINGLE paper comparing the outcomes of SADI vs. DS - I wonder why?
http://www.ncbi.nlm.nih.gov/pubmed/?term="single+anastomosis"+duodenal

Yet there is a clinical trial that was initiated in 2009 - for which not a single result has been reported:
https://clinicaltrials.gov/ct2/show/NCT01685177
"Single Anastomosis Duodeno-Ileal Bypass vs Standard Duodenal Switch as a Second Step After Sleeve Gastrectomy in the Super-Morbid Obese Patient (SADI vs CD)"
"Hypothesis of the study is that Single-Anastomosis Duodeno-Ileal bypass behaves at least equally to standard duodenal switch as a second step after sleeve gastrectomy in the super-morbid patient. Secondary aims are to demonstrate that single-anastomosis duodeno-ileal bypass is simpler to perform, quicker and has less postoperative short, mid and long-term complications."


Gee, I wonder why no results reported?

There is, however, a position statement currently being worked on by the ASMBS - it is not publicly available; however, just the first page of the draft in progress can be seen here (http://www.sciencedirect.com/scienc...0d9b9a8aab4a1413f4e1c&ie=/excerpt.pdf target=). I think you can tell what they are going to say from the part of the last paragraph that IS available:

"There are currently 4 published studies on single-anastomosis DS procedures (prospective or retrospective case series) with 222 total patients (including second-stage patients) with follow-up from 18 months to 5 years [3–6]. Three of the 4 studies are from a single institution representing a single ongoing consecutive series on the SADI-S that is included in the Clinicaltrials.gov Protocol Registration System. The fourth study compared the LDS modification with a matched gastric bypass cohort. Both sites involved surgeons already experienced with performing standard laparoscopic DS procedures. Given the lack of any randomized or prospective comparative data and the limited data regarding long-term nutritional effects, however, there is insufficient evidence to draw any definitive ..."

I would not want to be anyone's guinea pig.

Here's another point of view: http://www.dsfacts.com/pdf/bariatric-surgery-book-chapter-published-1467041305.pdf

SADI- SIPS
Single Anastomosis Duodeno-Ileostomy (SADI) and Stomach Intestinal Pylorus-Sparing (SIPS) surgeries are NOT the same as the Duodenal Switch (DS) operations. Any suggestions that the SADI or the SIPS procedures are the same as DS is misleading and inaccurate. SADI and SIPS procedures have evolved recently primarily in response to the high failure rate of all other weight loss surgical procedures. An easier alternative to DS was sought and SIPS-SADI was born; now this procedure has been misrepresented to be the same as the DS. The only similarity anatomically is the presence of the pyloric valve as a functional part of the post-surgical anatomy. The small bowel portion of the SIPS-SADI is unlike that of the DS. In DS operations, the absorption of the fat is primarily limited to the common channel, which is usually 10% of the total length (if the surgeon performing the duodenal switch bases the common and alimentary limb lengths as a percentage of the total length). This number is much closer to 40-50% in the SIPS-SADI procedure. Additionally, bile reflux, internal hernia, inadequate weight loss and even weight regain, are all possible complications much more likely than that with DS. The revision of the SADI-SIPS is possible, but not as simple as some suggest. The length of the small bowel, location of the anastomosis in relation to the colonic mesentery, length of the duodenal, are all factors in dictating how easy or difficult the revision of the SADI-SIPS to DS will be [17,18].

It is critical that patients are very well informed (informed consent) as to the exact operation that is being performed on them. As stated above, Duodenal Switch operation is not the same as SADI or SIPS. The notion that they can be interchangeable is anatomically, and medically inaccurate.

 

[Ridgerunner]

Ridgerunner, just want to let you know you're not alone. I will be having revision in 4 days and have 99 percent decided on SADI over the full DS. I have talked with multiple surgeons and not one tried to mislead me. Dr.Gagner, Dr. Smith and Dr Pernaute were all very clear about the difference between the DS and the SADI. Dr. Smith who will be doing my surgery made it very clear that he prefers the classic DS, and that the SADI is still experimental. I chose the SADI because I know it will likely not be as effective as the DS in allowing liberal fat consumption and may not be as effective in total weight loss but it also has less severe bowel issues and likely require less supplementation. The DS is certainly the more effective procedure with proven results as each of these surgeons agreed, but it also comes with some drastic side effects that some of us would rather avoid if possible. Whether that is a good trade off and we get what we're hoping for only time will tell, but we are making fully informed decisions based upon the information out there. From what I have seen all of the skilled DS surgeons are very clear about the differences. If you look at Gagner's website, he very clearly illustrates the differences. If anything, they push for the DS and do not necessarily illustrate how challenging the bowel issues and adequate supplementation can be for some patients.

Lord above! Thank you!
I have expressed again and again that I am not going into this decision blindly, that I have researched extensively each of my options and I am not using a bait and switch surgeon but for some reason this does not get through. I really appreciate you sticking your neck out to let me know that I am not alone. I hope to see you in one of the FB pages that Southernlady mentioned because I am making one last post and then leaving this forum.

 

[throughthickandthin]

Diana-

Thank you for the additional info. I would like to know, if you believe that the SADI will provide less fat malabsorption, why would you not believe that there would greater absorption of fat soluble vitamins and fewer bowel issues as less fat is being eliminated.

This is a tough decision but it is very clear that living with the DS requires an obsessive dedication to supplementation and other health issues. For many it seems totally worth it, but I have seen others lose their jobs and their health to some of these factors. It may be their own fault for not supplementing or eating correctly but it is still the end result for them. For me, ridgerunner, and many others it seems very drastic. Especially, as you still have to be strict with carbs. Let's face it, if we could all control our carb intake most of us would not have a weight issue.

That being said, maybe the right answer is just to keep the sleeve and be done with it. I know the DS will give good results but the cost in terms of quality of life are very hard to justify. As we agree, the SADI will be less effective, so maybe it's not worth it either. Maybe just nerves but I'm starting to think that maybe no surgery is the right surgery.

 

[Clematis]

@throughthickandthin I was terrified of having the foul gas and poop emergencies that it seemed everyone had, and posted here to ask people how they managed. If that was the case, I wasn;t sure it was worth it to me to have the surgery. I think it was @Munchkin who said she had no bowel issues at all. I was incredulous because you are right, it seemed that everyone on these boards and FB was talking about deadly gas and pooping their pants and other horrific things. A few more like munchkin said they too had no issues so I decided to go ahead.

Before surgery I bought a paycheck worth of Poopouri spray, Devrom internal deodorizer tablets, bottles of various probiotics, as well as Imodium and Miralax. I have used NONE of them - a lost a bundle of money. Like, munchkin, I have ZERO foul gas, ZERO disgusting poopers and never a poop accident. I occasionally have "floater" poopers when I eat too much fat, but I have never created oil slicks in the toilet. (But I don't eat that much fat.) I had one instance of constipation that may have torn a small fissure -- don;t know why it happened, but it happened only once. I've had countless episodes of constipation pre-DS but only one day of it in nearly 9 months post-DS. I have had a couple episodes of diarrhea too, but no more than pre-DS.

Keep this in mind: people who have never have bowel trouble with their DS have little reason to seek out and post on online forums. The presence of the small minority who have bowel issues seems large on the forums compared to the majority of people who do not have issues and therefore do not post.

As for the supplementation, yes, one does need to consciously manage that but it is hardly difficult to get labs drawn twice a year and if necessary adjust one's vitamins. I do not take as many vitamins as some do because my lab results don't dictate that I need to. (And I take vitamins only twice a day.) Many people who post here about taking more-than-usual supplements do so because they are having troubles, for whatever reason. Again, you may see more posts/questions about supplements from the minority of people who are having problems, not from the majority of those who don't.

 

[DSRIGGS]

Diana-

Thank you for the additional info. I would like to know, if you believe that the SADI will provide less fat malabsorption, why would you not believe that there would greater absorption of fat soluble vitamins and fewer bowel issues as less fat is being eliminated.

This is a tough decision but it is very clear that living with the DS requires an obsessive dedication to supplementation and other health issues. For many it seems totally worth it, but I have seen others lose their jobs and their health to some of these factors. It may be their own fault for not supplementing or eating correctly but it is still the end result for them. For me, ridgerunner, and many others it seems very drastic. Especially, as you still have to be strict with carbs. Let's face it, if we could all control our carb intake most of us would not have a weight issue.

That being said, maybe the right answer is just to keep the sleeve and be done with it. I know the DS will give good results but the cost in terms of quality of life are very hard to justify. As we agree, the SADI will be less effective, so maybe it's not worth it either. Maybe just nerves but I'm starting to think that maybe no surgery is the right surgery.

If you can't do something as simple as taking vitamins daily you should have neither procedure. The SADI is a malabsorptive procedure as well and it will also require vitamins for life.

You talk about constipation. Women in general have more issues with constipation than men. My wife has constipation from time to time and she is a normie with no weight control issues other than 15 pounds gained over the last 20 years putting her at a whopping 140 lbs. The thread on the board that you mentioned is from Pam who had a hip replacement recently and was taking narcotics. She has had the DS for at least 3 years now I believe and says right in her post that she has never had constipation issues until now. Mark is trying to optimize his vitamin regimen for best results and it is likely the 3,000 mg of calcium he is taking that is causing him some issues.

Diarrhea. Eating a bunch of junk food causes diarrhea but the vast majority of DS patients who eat properly have no diarrhea issues.

You mention non compliance. If you are non compliant with EITHER the DS or SADI you will have big problems.

Compliance is not difficult and it takes three simple steps. First, vitamins must be taken daily and follow up labs are requird. These are non negotable for the real DS or the SADI.

Second, one must stay hydrated drinking at least 64 oz a day.

Third, one needs to eat a protein focused diet.

Those three things are simple things to do but if you can't do them you should not have either procedure and stay with your sleeve. That being said your sleeve is obviously not working for you if you are investigating ds or SADI so best of luck with your decision. You just need to know that a non compliant SADI person will have serious issues just a ds patient.

 

[Jbandmmomma]

I think you're missing that most DSers do not have bowel issues, therefore there are none to lessen.

 

[Spiky Bugger]

I asked for others that had the SADI-S to respond. Please be respectful of my request.

Oh, gooodie! DO pop in and introduce yourself and then tell us all how to behave.

 

[DianaCox]

With the SADI, you will STILL be taking a lot of special vitamins, due to the absence of the distal duodenum and most if not all of the jejunum in the alimentary tract, and at risk if you don't do the exact same monitoring and supplementation - you just might be able to get away with a few less pills/week. Maybe. There is such great variation among even those of us with the same surgery by the same surgeon, you can't reliably predict HOW you're going to end up, and whether it will change over time. I need more supplementation at 13 years out than I needed at 6 or 10.

With the SADI, you still have short bowel - perhaps a tad longer - and will still be at the same or similar risk of bowel issues due to changes in the gut microbiome as well as some undigested/unabsorbed food getting into the colon - but I'll be the difference is NOT one-to-one with the extra absorption you WILL get.

Also, there is a BIG difference between micronutrient malabsorption - which tends to be permanent - and macronutrient malabsorption (calories, protein in particular), which tends to increase over time. Which is why RNYers are so screwed after a few years - they still have micronutrient deficiencies, but have substantial weight regain because the macronutrient malabsorption fails after a while.

And with SADI vs. DS you get as a bonus the added risk of bile reflux, upstream filling of the afferent limb, issues caused by the tighter sleeve the SADIsts are giving patients to compensate for more absorption (which will eventually stretch out anyway, so only a temporary "solution" which can cause a lot of misery in the short run), and - weight regain, due to inadequate malabsorption and reliance on a tight sleeve that doesn't stay tight.

AND - no long term results published, despite the fact that it has been done since at least 2009.

If the SADI replaces the RNY, I'm fine with that. But until it is a tried and true tested procedure, it's risks known, the diet and supplementation needs tested and determined, on an individual basis, I will still continue to caution against it. If you want to be a guinea pig, be my guest. SOMEONE has to do it to make these determinations. But I wouldn't want to be one, nor would I let someone I cared about be one without making sure they know ALL of the warnings, including the ones I give here, free of charge, to people I don't know from Adam's off aunt. I'm just generous that way.

And I don't give a rat's ass whether you like the "tone" I use in communicating this information, because it's THAT important. If it doesn't resonate with you, or you don't appreciate it, I really don't care - because this is a public message board, and the next person who comes along and uses the search function for SADI or reads this board will find my message to you, and may very will be more receptive and concerned about their health and safety and the other issues we raised than you seem to be.

 

[Spiky Bugger]

Well then I am glad that you and others now have a place where you can go. I truely am. I too am trying to find a place where I can go and not feel like I have to defend my intellect, my mettle or my personal choices everytime I want to ask a question. I need to find somewhere that I can give and receive help without a lecture. I need to find a place where I am not the "red headed step child".

It's "truly." So you can add spelling to the list of things to defend.

 

[DianaCox]

Diana-

Thank you for the additional info. I would like to know, if you believe that the SADI will provide less fat malabsorption, why would you not believe that there would greater absorption of fat soluble vitamins and fewer bowel issues as less fat is being eliminated. There may be more absorption, but frankly, what's the difference between having to do annual labs for ALL THE SAME THINGS, and taking 15 pills/week instead of 15-25 (because you are still going to malabsorb the same mincronutrients that are absorbed in the duodenum and jejunum)? And I have seen NO proof of either that, or that SADIst have fewer bowel issues - not that most of us have "issues" in the devastatingly difficult sense that you suggest. But we sure do enjoy eating high fat foods with little or no guilt. (I had an anal fissure long before I had the DS, and had a lateral sphincterotomy, and I've STILL never shit myself in public - although I will admit to getting careless at home and waiting too long and having an accident or two - my non-DS husband has had the same thing happen - we're old, shit happens.)

This is a tough decision but it is very clear that living with the DS requires an obsessive dedication to supplementation and other health issues. That is an outrageous and groteque exaggeration. I'm almost 13 years out: I take my supplements twice a day - after breakfast and before bed. I have my labs drawn once a year, and sometimes redo them if I have made an adjustment, to see if things are improved. I'm in the process of getting this year's results back, which I'm posting in a separate thread - please feel free to have a look - my skinny-minnie PCP is envious of my labs. Oh, and tomorrow is my biannual (every other year) DEXA scan - since my D3 was over 90 and my PTH was under 40, I'm expecting a good result too, for someone my age and sex.

I eat a relatively normal, but high protein and moderately high fat diet, with "attention" paid to carbs, but mostly just to the ones that bother me, and even those I will eat if I want them occasionally, when the consequences (if any) will occur when I'm home. For example, my diet today:

• I had an eggy piece of sourdough (which doesn't bother me as much as white bread does) French toast (cooked in a lot of butter) for breakfast, with regular syrup, and three greasy sausages.
• I had fresh fruit salad (cherries, grapes, watermelon, banana and blueberries) with poppy seed dressing for a snack.
• I had a bowl of very meaty chili and cornbread (cornbread isn't as much of a problem as white bread) SOAKED in butter and salted to hell and back.
• I had some salty pretzles as a snack.
• For dinner, I grilled steak kabobs with multicolored bell peppers and red onions (there are leftovers for tomorrow) and grilled fresh corn (removed the silk, filled the inside with butter and Tajin seasoning, wrapped the husks around the ears and wrapped in aluminum foil) and I added MORE butter and salt before eating it.
• I had flan from the restaurant across the street for dessert.
• And then I ate a zillion sunflower seeds with diet soda until my lips and tongue hurt from the salt.
• And I may yet have a ramen soup or more fruit salad before bed - I usually need something on my stomach right before going to sleep.

I do not feel like I am obsessed. Oh and all that salt? My blood pressure runs low since my DS (90/60), so my doctor said to eat lots of salt - which I clearly do.

For many it seems totally worth it, but I have seen others lose their jobs and their health to some of these factors. I'm sure you have - if you troll the DS boards, you will find plenty of (1) people who got shitty surgeries from shitty surgeons; (2) people who refuse to follow the relatively simple rules of test, supplement and adjust; (3) people who already had a LOT of health problems before they got their DS; (4) people who not only had shitty surgeons, but surgeons who gave them IMPROPER nutritional guidance (which is MOST of the surgeons), believed in them like they were deities, and who didn't take control of their own health; and (5) people with eating disorders who refuse to control the CRAP they throw into their maws.

It may be their own fault for not supplementing or eating correctly but it is still the end result for them. Yup, if you can't follow the simple rules, this surgery is NOT for you.

For me, ridgerunner, and many others it seems very drastic. Especially, as you still have to be strict with carbs. Does it look like I'm strict with carbs?? Let's face it, if we could all control our carb intake most of us would not have a weight issue. That's utter bullshit - (1) if you have a metabolic disorder, it wouldn't matter; and (2) you have to be SMART about carbs, notsomuch strict. I've lost 15 lbs in the last few months eating like this.

That being said, maybe the right answer is just to keep the sleeve and be done with it. If by "be done with it" you mean diet, get discouraged when that doesn't work long-term, give up and regain, well, have fun with that.

I know the DS will give good results but the cost in terms of quality of life are very hard to justify. My only regret 13 years later was not being able to have done it 40 years ago. I am healthier at 63 than I was at 36. Look at my labs, and my blood pressure - oh, and I weigh 175, which is quite comfortable for me, especially since at least 10 lbs is excess skin.

As we agree, the SADI will be less effective, so maybe it's not worth it either. For you, that may be true. Maybe just nerves but I'm starting to think that maybe no surgery is the right surgery. Again, for you, that may be true. The DS requires a commitment to expend a very modest amount of effort to maintain your health, and you don't sound ready for it.

 

[hilary1617]

@throughthickandthin

The DS is one of the best decisions I ever made and has substantially *improved* my quality of life. The only downsides for me are (1) that when I eat a low carb diet, I lose more than I'd like and then my skin looks to big for the rest of me out and I'm not up for plastic surgery, so I eat a fairly carb-heavy diet to stay a size L vs a size M, (2) I previously didn't menstruate often and after surgery it now comes monthly, (3) I became lactose intolerant so I have to take lactaid or avoid skim milk. I can pretty much eat anything except for milk without any reaction.

After recovery, the only time I have any material bowel issues, same as pre-DS, is when I have to take painkillers, which constipate me terribly and lead to horrible things. I've had hemorrhoids since my first pregnancy, well before DS and recently had a painkiller-related anal fissure. I have a fairly voluminous bowel movement every morning when I wake and it doesn't smell like a cinnamon bun and that's about it.

(Disclosure: I temporarily had bile salt diarrhea with removal of gall bladder and also when I had to go on CREON following an unrelated cancer surgery.)

In terms of supplementation, I take some pills with my meals and get tested once a year. It's an easy routine.

P.S. I also have survived Pancreatic Neuroendocrine Tumor diagnosis post DS and lost half my pancreas and liver (which has grown back). I doubt my outcome would have been nearly as good had I been SMO at the time of that operation.