CC length

Discussion in 'Duodenal Switch' started by emmy, Aug 19, 2018.

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    DianaCox

    DianaCox Bad Cop

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    I'm not sure you caught the fact that the first link was to Dr. Keshishian's blog on the subject, which contained an embedded link to an earlier post. Keshishian is one of the most experienced DS surgeons on the planet. And he subscribes to the Hess method.

    "Others do “standard length common channel” rather than a Hess method Duodenal Switch. I have always performed a traditional Hess method Duodenal Switch. The Hess method Duodenal Switch has held the largest and longest excess weight loss maintenance for 28 years, going into 29 years. Here is a past blog regarding small bowel length."​

    This is the past blog: https://www.dssurgery.com/length-small-bowel/ " In our practice, we measure the total length and the common channel and the alimentary lengths are based on the patient BMI, comorbidities, age, sex, and activity level."

    Here is the link to the Hess method: http://www.dshess.com/Parameters.htm He has a chart which shows the result on percentages of using fixed alimentary limb and CC lengths, depending on the length of the entire small bowel.

    The blog cites the 2003 Hess editorial, which is behind a paywall. https://sci-hub.tw/10.1381/096089203322618885

    Obesity Surgery, 13, 966
    Correspondence
    Limb Measurements in Duodenal Switch
    To the Editor:

    In the past 15 years the duodenal switch (DS) procedure has gained a great deal of acceptance throughout the bariatric surgery world. In June 2002 at a conference of several surgeons who perform DS, by adding all of these procedures by that group, there had been 10,000 cases performed at that time. Many surgeons are performing this operation, which is a modification of the biliopancreatic diversion (BPD). Many different methods and measurements are used to calculate the limb-lengths. We have performed 1,350 BPD-DS cases in the past 15 years. We measured the entire small bowel on the antimesenteric border at full stretch in all cases and found that the small bowel will be from 11.5 feet (345 cm) to 38 feet (1140 cm) in length. There is a considerable difference in small bowel length from one patient to another. Some surgeons will not regularly measure the entire small bowel. We feel strongly that it is important to measure the small bowel to calculate the proper limb-lengths.

    Our results have been very successful. We now have a study of 120 patients ³10 years postoperatively. At the 10-year point, 93% of them were counted with an average excess weight loss of 76%. We have <3% revisions of the distal Roux-en-Y for hypoproteinemia or excess weight loss. If the surgeon measures the small bowel and performs these operations by a percentage base for the limb-lengths, there will be little difficulty with low protein or excess weight loss and still be a good long-term weight loss.

    It is important to have the common channel as short as needed so that there is adequate malabsorption of fat, and to keep the total length of the alimentary limb as long as possible and still not reduce the weight loss. For that reason, we use 10% of the total length for the length of the small bowel for the common channel. We make it either 50 cm, 75 cm or 100 cm, whichever comes nearer to the 10%. We use 40% of the total small bowel length for the length of the total alimentary limb, from the stomach to the cecum. These may vary from 8% to 12% for the common channel and from 38% to 42% for the alimentary limb, but always increments of 25 cm so that there are groups that can be compared. Our percentage variation takes into account whether the patient is male or female and whether they are very large or just barely 100 lb (45 kg) overweight. Short obese women lose more slowly than tall obese men. If one follows these guidelines, there will be good long-term results with minimal hypoproteinemia.

    There are some surgeons who make all their common channels 100 cm long. If they have a short obese female about 5 feet (150 cm) tall with a short bowel, this patient will not lose adequate weight or may not lose any weight at all. Some surgeons will add 150 cm to the 100 cm common channel to make a total alimentary limb of 250 cm. If this happens to be a tall man, the common channel of 100 cm may be satisfactory. However, the total length of 250 cm on a patient who has roughly 800 cm of total bowel, gives about a 30% total bowel that carries food and absorption. This patient is going to have trouble maintaining protein, and will have excess weight loss and multiple difficulties. One needs to use a combination of the proper lengths. How can one keep the common channel the same size and increase the alimentary limb to maybe 300 or 325 cm? It is not easy!

    The patient has to have a relatively small stomach, about 100 to 120 cc volume, and one must be careful how the duodeno-ileal anastomosis is handled. I have been informed about several cases where the anastomosis was formed with a 21-EEA. This is too small. The patient may become partially obstructed, and if this patient cannot eat, he or she will be unable to take in adequate protein, and will develop hypoproteinemia. Because of the stasis above the stomal stricture, the patient may begin to develop ulceration around the anastomosis, which then becomes more strictured, requiring treatment. It is important to hand-suture either end-to-side or end-to-end in such a method that there is a wide open anastomosis between the duodenum and ileum. We prefer the Valtrac® anastomosis, which is an absorbable mechanical ring which after 3 weeks begins to dissolve and passes. We have over 900 cases with no stricture after using this instrument. We did have a few strictures when we hand-sutured, and two required re-operation. There have been strictures with the EEA anastomosis performed by other surgeons using the 21-mm EEA.

    Regarding the patient with the 100-cm common channel and a 250-cm total alimentary limb: think about how you are going to correct this. It is not easy to make the common channel smaller or the total limb longer with this situation. When performing the BPD-DS, the surgeon should measure the bowel totally; measure all of the limbs, measure the volume of the stomach and give attention to the method of the anastomosis. If the surgeon does not do these things, there will be failure to lose weight, or loss of too much weight and protein loss, and the surgeon will not know why this is happening. Measuring is very important, especially the length of the small bowel and the volume of the stomach in all these cases. Even if one does not use the measurements for limb size above, the surgeon should measure and record the results. If you don’t measure, you don’t know!

    Douglas S. Hess, MD, FACS
    Bowling Green, OH, USA
    E-mail: doughess@wcnet.org
     
  2.  
    RainCity

    RainCity Well-Known Member

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    You asked a yes/no question.

    You had your surgery already but seem very argumentative about what the amazing veterans on this site post about the DS. Are you concerned you didn’t receive a standard of care DS, or you had a cookie cutter DS? Have you read your op report yet to find out exactly what was performed?
     
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    southernlady

    southernlady Administrator Staff Member

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    I KNOW I got a cookie cutter of a sort. Because my BMI was so close to not evening being able to have surgery, my surgeon wanted me to be between 175 and 200 on my common channel. I got him to agree with 175 in the preop day of surgery. I do have my alimentary limb but without hauling out the paperwork....

    My surgeon has gone to a larger sleeve and 100 common channel for almost every single DSer since 2012/13.
     
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    Remingtonh

    Remingtonh Well-Known Member

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    Seriously, I'm just asking questions, not trying to be argumentative. I hear constantly the praises of Dr. Hess and the amazing "Hess method" but I haven't seen any challenge to that. I understand there are very knowledgable veterans here, but even Einstein and Hawking have to prove their theories...

    Anyway, it makes sense to me that measuring bowel and basing limb lengths on the particular patient would seem to be better. I just wonder why Hess's measurements are considered the best? Most of the supporting evidence submitted is Hess's own works, and though I'm sure he's an ethical and honest gentlemen, I just wonder how biased they are? I haven't read all the links yet but I'll get on it. Thanks Diana for posting them.

    I got a cookie-cutter DS. 150cm alimentary limb and 100cm common channel (or thereabouts, I mean, who knows really - hopefully within a few inches at least...) From what I was reading from Diana's text, it would seem that a 100cm CC, for me, a not-short man, is probably just fine. Lets just hope the rest of the cookie-cutter DS lengths happen to work well for me.

    Really, I'm just glad I got a DS and not an RNY with no pylorus valve and 400cm CC or whatever - Hess method or not...
     
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    DianaCox

    DianaCox Bad Cop

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    My DS was a Rabkin cookie cutter - 100 cm common channel, 250 cm total alimentary tract. My guts were measured at 670 cm.
    100/670 = 15%
    250/670 = 37%

    So my numbers are not that far off of “ideal.”
     
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    southernlady

    southernlady Administrator Staff Member

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    AND if you put surgeons who do a Hess method side by side, no two would come up with the same exact measurement on even the same patient. The small intestine is slippery and acts like a slinky (the children's toy). Each person who pulls a slinky out to measure will pull slightly different.
     
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