Choosing Sleeve

[kevin86]

Instead of being so negative maybe you guys should show me that this is not the right direction to go. All I've heard is how bad of an idea it is but not a single person has taken the time to show me that it's a bad idea. Is there evidence that it won't work for someone my size? Because all I've found is people who have had success with it. I'm not trying to be rude but I also believe that if you're not being helpful then you're being negative. Thank you for those that have been supportive. As for others I'm asking you to show me that it's a bad idea not just tell me.

 

[k9ophile]

I've read all the previous replies and found several reasons why the sleeve may not be the best way to go. As for showing you, I'm not sure what you want to see. I have a friend who got the sleeve. She knows I have a DS and thought she couldn't comply with all the supplementation and vitamins. I'm glad she didn't. It would have been better for her, yet she knows her tolerance for following the necessary aftercare the DS requires. Seeing as how she doesn't follow sleeve *rules*, I'm glad she didn't get the DS. She's gained good portion of her weight back. If she had a DS and was non-compliant, she'd be a total train wreck.

I don't think anyone was being negative. (It's hard to determine tone sometimes in writing.) Some are blunter and others choose their words in another way; it's all good.

One more thought: it seems to be a trend that insurance companies will only pay for ONE surgery. You can change your insurance and the new one can refuse to do a second. With your BMI, I'd recommend a surgery with some malabsorption. While I, of course, favor the DS, it's your choice. Just make sure you have thoroughly done your research of scientific and anecdotal information.

 

[Clematis]

Everyone must come to their own decision and I respect yours.

My local doctor only does sleeves. I studied up (I am all about the data) and learned there is no research to show the long term effectiveness of a VSG, and what little medium term research there is shows significant weight regain and return of co-morbidities. (The doctor freely admitted this.) It seemed like a short term solution for me.

I was very disappointed. I had been researching and mentally preparing for WLS and felt I had run into a wall. (Not helping was having my husband switch jobs with an insurance plan that prohibited bariatric coverage, so I was suddenly self-pay.)

Then I read up on the DS. Unlike VSG alone, the research DOES exist to show the long term effectiveness of the DS. The constriction of the sleeve helps take the weight off; the malabsorption of the switch helps KEEP it off. Once I decided that made sense for me, I had to find an out-of-town surgeon because I was not happy with the DS-inexperienced surgeons here who only do 2-3 DS a year. (I wanted someone who did a DS every DAY.) My surgery is in 10 days.

Again, you need to choose what is best for you. For me, the data supported the DS.

 

[robs477]

I just went back and read all these posts again and I see nothing anywhere that is even remotely being negative or rude. As far as “showing you” or proving to you that the statistics and the numbers regarding DS success vs. other WLS support the DS, especially with someone starting off with your BMI, really exists, I will leave that research up to you.

Personally, not to be rude, but, I don’t care enough about it to spend the time to spoon feed anyone information that is readily available everywhere on the net regarding the DS success rates etc. Choose whatever surgery YOU think is best for you and I sincerely wish you the best success with your WL and your decision.

 

[kevin86]

I just went back and read all these posts again and I see nothing anywhere that is even remotely being negative or rude. As far as “showing you” or proving to you that the statistics and the numbers regarding DS success vs. other WLS support the DS, especially with someone starting off with your BMI, really exists, I will leave that research up to you.

Personally, not to be rude, but, I don’t care enough about it to spend the time to spoon feed anyone information that is readily available everywhere on the net regarding the DS success rates etc. Choose whatever surgery YOU think is best for you and I sincerely wish you the best success with your WL and your decision.

Spoon feed....... Let's be glad you're hopefully not leading any support groups. Did you miss the part about the fact the research I've done shows that it would be successful. I've asked people to show evidence to the contrary to help me if I'm going the wrong direction. There's a difference between spoon feeding and helping others. You appear to only be in this group to meet your own selfish needs and to not contribute when someone asks for help. As a doctor once put to me just as you must be given compassion you must also give compassion. I came to this group for help not to be accused of wanting to be spoon fed. Until you've walked a mile in my shoes I suggest you not try to make judgments.

 

[DianaCox]

http://www.ncbi.nlm.nih.gov/pubmed/21890430

RESULTS:
The preoperative median body mass index was 45.8 kg/m(2) (range 35.8-63.7), and 9 patients (45%) were superobese (body mass index ≥ 50 kg/m(2)). For LSG as a definitive bariatric procedure, 8-9-year follow-up data were available for 13 patients. Of the remainder, 4 patients underwent revision surgery and 3 were lost to follow-up after 2 years. For the entire cohort, the median excess weight loss (EWL) was 73% (range 13-105%) at 1 year, 78% (range 22-98%) at 2 years, 73% (range 28-90%) at 3 years, and 68% (range 18-85%) at 8 or 9 years (P = .074). Of the 13 LSG-only patients with 8-9 years of follow-up, 11 (55% of the starting cohort) had >50% EWL at 8 or 9 years. No significant difference was found in the initial body mass index between the LSG-only patients with >50% EWL and others (45.9 kg/m(2), range 35.8-59.4 versus 45.7 kg/m(2), range 38.9-63.7, respectively; P = .70). The LSG-only patients with >50% EWL had a marginally significantly greater EWL at 1 year compared with the others (76%, range 48-103% versus 45%, range 13-99%, respectively; P = .058).

CONCLUSION:
At 8-9 years of follow-up, 55% of patients had >50% EWL from LSG as a definitive bariatric procedure.

The rest of the patients - 45% - (which I would bet included ALL of the superobese ones) therefore had unsuccessful outcomes - and keep in mind, they EXCLUDED the 4 patients who had revisions (presumably for inadequate WL) or the 3 who were lost to follow up (likely because it didn't work, so they stopped following up). The range at 8 or 9 years of 18-85% was not broken out by starting BMI in the Abstract - the article is behind a paywall, so i can't prove it, but the odds are that the SMOs were at the low end of barely any long-term WL.
​

http://www.ncbi.nlm.nih.gov/pubmed/23677267

RESULTS:
The mean total weight loss (TWL) among the super morbid obese group (41.31 +/- 21.23 kg) was statistically significantly greater compared to the obese group (24.31 +/- 13.00 kg, p=0.009) and morbidly obese group (26.81 +/- 15.56 kg, p=0.001). The mean percentage excess weight loss (EWL) was clinically significant among obese (57.8%), morbidly obese (42.5%), and super morbid obese patients (45.7%), however, it was not statistically significant between the groups (F[2,105]=2.132, p=0.124).

This is only after 30 months - already, the SMO patients are on average a failure (less than 50% EWL), and the long term results of course would have shown more and more rebound regain.
​

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662747/ (this is the whole article, which is publicly available)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662747/table/T2/
(Table 2 results) - %EWL for SMO = 56%

And this is after only 22 months - longer term results of course would have shown more and more rebound regain.

"Despite a high satisfaction rate overall, it appears that it may be difficult for the super obese population to reach a BMI <30 kg/m2 with LSG alone. Chopra et al25 found similar results 24 months after surgery, with a greater %EWL in the cohort of patients with a BMI <50 kg/m2 compared with those with BMI >50 kg/m2, although their results were not statistically significant."​

http://www.ncbi.nlm.nih.gov/pubmed/24839191

Obes Surg. 2014 Nov;24(11):1843-9. doi: 10.1007/s11695-014-1284-0.
Biliopancreatic diversion-duodenal switch: independent contributions of sleeve resection and duodenalexclusion.
Marceau P1, Biron S, Marceau S, Hould FS, Lebel S, Lescelleur O, Biertho L, Kral JG.
Author information

Abstract
BACKGROUND:
The choice of first-stage operation in bilio-pancreatic diversion with duodenal switch (BPD-DS) is controversial. There are no published long-term comparisons of one- and two-stage BPD-DS outcomes.

METHODS:
During 2001-2009, among 1,762 patients scheduled for BPD-DS 48 had duodenal switch (DS) and 53 sleeve gastrectomy (SG) as first-stage procedures. We compared prospectively updated outcomes of 42 DS (100 % open) and 49 SG (88 % laparoscopic), 13 of whom completed their second stage, to a control group of 91 patients with open one-stage BPD-DS.

RESULTS:
One-year mean percent excess weight loss (%EWL) was greater after SG than DS (47 ± 19 vs. 39 ± 13 SD; p = 0.01) with earlier nadir (16 ± 10 vs. 45 ± 30 months; p < 0.0001) but more rapid significant weight regain. After 5 years, %EWL was 12 ± 35 for 9 SG, 45 ± 19 for 30 DS (p < 0.0006), and 70 ± 18 for the first-stage BPD-DS (p < 0.0001). Weight loss was less after two- than one-stage procedures (p < 0.02). Comorbidities improved progressively between SG, DS and BPD-DS (p < 0.001 for trend). HbA1C decreased by 10, 19, and 31 %, respectively (p < 0.0001). Dyslipidemia was cured in 41, 82, and 100 %, respectively. Systolic and diastolic blood pressure decreased only after DS (12 %; p < 0.0002). Patient satisfaction was similar for SG and DS but greater after BPD-DS overall (p = 0.04).

CONCLUSIONS:
SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.​

Look at those numbers very very carefully: After 5 years, %EWL was
12 ± 35 for 9 SG,
45 ± 19 for 30 DS
70 ± 18 for the first-stage BPD-DS

And attached is another paper that I got from Dr. Marceau himself recently. I also want to post our conversation, because it helps with the nomenclature.

Dear Dr. Marceau,


I would like to request a copy of your new paper “Long-Term Metabolic Outcomes 5 to 20 Years After Biliopancreatic Diversion” to use in the pro bono insurance appeals I help people prosecute in order to overcome denials of the duodenal switch.

By the way, if I may be a bit of a critic, I would strongly urge you to standardize the reference to duodenal switch and NOT call it a BPD when it isn’t – the abstract of this paper is very misleading:

· In the title, you call it “Biliopancreatic Diversion”
· In the Background, you state:

o “Biliopancreatic diversion (BPD) is a complex bariatric operation requiring meticulous surveillance which has impeded its broad adoption. Improvements in surgical care and technique, better teaching programs, and stringent norms for follow-up have contributed to increased safety of BPD for patients with BMI <50, achieving better long-term results than other bariatric operations. Here we report 20-year outcomes of 2615 consecutive patients (median 8) having open BPD withduodenal switch(DS) between 1992 and 2010.”
o This is CONFUSING.​

· In the Conclusions, you again confuse the nomenclature:

o “BPD deserves more consideration as a primary procedure for eligible patients in experienced centers with sufficient resources for delivering high-quality care and long-term follow-up.”​

Most insurance companies in the US make a CLEAR distinction between BPD (not approved) and DS (sometimes approved), and almost all of them cite reports of nutritional deficiencies with the BPD as reasons for refusing to cover the DS.

Thank you in advance for your assistance with BOTH issues.​

His response:

Dear Diana,

Of course I am happy to send you our last "Long term metabolic Outcomes 5 to 20 years after BPD" and I encourage you to use it is the most valuable document in favor of DS or BPD.

Basically we believe BPD is the most valuable part of this operation. To us it is not confusing it is reinforcing that on an Academic and physiologic point of view the great advantage of both BPD & duodenal switch is the BPD part. Whatever the name used by some insurance company.
​

My reply:

Dear Dr. Marceau,

Thank you so much for sharing this document.

I was very interested in your answer to my concerns about the nomenclature, and really do want to understand this. The term BPD refers to the intestinal portion of the surgery, irrespective of what is done to the stomach – is that right? Yet it is my understanding that BPD is used internationally for the entire procedure of that intestinal configuration PLUS a distal gastric resection, including REMOVAL of the distal portion of the stomach, pyloric valve and proximal duodenum. The term “duodenal switch,” on the other hand, is used to refer to the entire procedure of that intestinal configuration PLUS a vertical sleeve gastrectomy (BPD/VSG or BPD/DS). How is the term BPD different from DS, in your view?

The issue is, when the term “BPD” is used, the BPD/Distal gastric resection is presumed, and when the term “DS” is used, the BPD/VSG is presumed. Thus, insurance companies have been using poor results from BPD/Distal gastric resection publications and tainting the BPD/VSG surgery with those results.​

And his response:

DS has been proven to give less secondary effect and the lengthening of the common channel less protein malabsorption but both BPD & DS are the most efficient bariatric procedures. Our report concerns only DS. Our intention is to insist on the fact that the Intestinal bypass is the active element of this operation. We present ourselves against the unjustified discrimination presented by insurance companies against any BPD.​

So, there you go.

 

[southernlady]

Did you miss the part about the fact the research I've done shows that it would be successful. I've asked people to show evidence to the contrary to help me if I'm going the wrong direction.

If your research shows the DS to be successful, my query would be why you want the sleeve alone?

Our first surgeon told my husband that he would lose weight with the sleeve but never get below 200. At 5'8", he would have still been obese. And he wouldn't even let me consider the DS...told me I would lose too much. (my starting BMI was 35.2). We fired that doc and found new ones. My husband got his DS almost 5 years ago now. His lowest was 147 (a 22.3 BMI but looked too skinny). Now he has settled in around 180. Yes he is overweight but NOT OBESE. I got to 121 for 10 seconds. Now I am 147 which is just a touch overweight (a 25.2).

Now if you know yourself well enough to know that vitamins are not gonna happen faithfully, then yes, the sleeve is a better option but honestly the synergy of having a virgin DS makes it easier to lose weight than being a 2 stepper. We do have two steppers who were given no option as their BMI was extremely high (as in over 90).

Another thing to keep in mind is something already mentioned. Many insurance companies are limiting individuals to one surgery per lifetime and it does NOT MATTER who paid for the first one. You could have been a self pay for the first one and still be denied the revision because of that limit.

http://www.dssurgery.com/procedures/compare-surgical-procedures.php?subnav=2
Outcomes Comparison Chart. That is where the 66 % comes from for the VSG.

Yes, people of any BMI CAN be successful with the sleeve but the key is LONG term...not the first year or the second but 5, 10, 15 20 years down the road. So find out how far out people are. Our VSG'ers will be the first to admit it's HARD work long term. @Jo777 is a long term VSG'er. @star0210 and @DuodenalSwitchaRoo are two steppers.

 

[Munchkin]

Kevin, I'll take a stab at it. And no one here wants to be rude to you! We just know the sleeve will not do what you need it to do. One of our basic beliefs is think twice, cut once. Here's the facts as I see them. You are a high BMI male and you are interested in the sleeve because you feel it is necessary to do something now.

Here is a rhetorical question for you. I am not expecting an answer, just something to think about. Why are you heavy? Do you know? Do you eat 4 or 5 times what a 'normal' person eats? If the answer is no, you are probably a superabsorber. Your body is efficient, it wastes nothing and you absorb more calories from the food you eat. A 'normal' person poops out calories. They don't absorb all of what they eat. Has your metabolism been broken and busted by the many diets you have tried over the years? Has it gotten harder and harder to drop 100lbs and keep them off? Is it now almost impossible?

If your answer is yes, you have a metabolic condition that needs a surgery that will correct, or reset your metabolism. The only surgery that will do what you need long term is the DS. Period. I keep hoping they will come up with something better but this is what's available today.

For you, the sleeve is like putting a bandaid on a broken leg. The sleeve is simply restriction, a diet. Most successful sleevers live long term on 800 to 1200 calories a day. Think low calorie, low fat. How has that worked for you in the past? I know they tout the metabolic advantages of the sleeve but they are minimal. You still absorb everything the same way you did before. Long term, the sleeve stretches and you can eat, and absorb, more. There is no doubt you will lose some weight. And it's likely you will reach a point where you start gaining again because the sleeve did not address your metabolic issues. You will have your honeymoon period with the sleeve and drop some weight.

For contrast let's talk about your standard, proximal RNY. It doesn't bypass much. The body adapts and people start re-gaining at about the 2 year mark. Then they are still fat and stuck with that pesky pouch. Hooray for you for opting for something that leaves you with a fully functioning stomach.

Finally the DS. So much is bypassed that your body can't adapt. It in effect resets your metabolism and gets rid of type 2 diabetes immediately about 90% of the time. And a few more percentage point lose their diabetes in the first 6 months or so. Now there's dramatic proof of the metabolic effects of the DS. And you have yet another advantage, the male factor. This is just my observation but men are ideally suited to this surgery. They lose more, faster. I have been around fat world for decades and I know of only 2 EXTREME cases where men failed to get where they need to be. And 1 of those patients failed due to mental/psychological issues the DS can't fix.

I think you know what you need and the driving force behind your decision is the need to do something now. This desire is so strong you are willing to settle. I sincerely hope you are not subscribing to the mentality that you need to suffer and work hard to be deserving of losing weight. Contrary to what most of the world believes, obesity is a disease, not a character flaw. Remember the bandaid and the broken leg.

Best of luck! No matter what you decide to do.

 

[robs477]

Theres an old saying…”You can lead a horse to water, but you can’t make him drink it”…You don’t know anything about me you #%$^#@... and I am NOT on here trying to meet my own “Selfish needs” as you put it! My needs have already been met, Ive lost 100% PLUS of my expected WL, so there would be NO REASON for me to stick around here except to try to help people, some even in spite of themselves!

My point IS/WAS unless you change your mindset and become more open to the points some of these VETS are trying to help you with, then what’s the point??? Why should we waste our valuable time trying to persuade or convince you? It sounds like you already know everything anyway and have your mind made up, so I re-iterate, who really cares if you don’t? Not me.

BTW....You're real name wouldn't happen to be Dennis, would it?

 

[Kiekerdepiekske]

To add my two cents: I had the VSG in 2010 and experienced regain after a couple of years. Wasn't able to loose any of the regained weight so decided to complete the DS. Granted, my starting BMI wasn't als high as yours but still quite high (starting BMI at time of sleeve was 56). According to my surgeon (dr. Himpens in Belgium) chances you will need the complete DS as a heavyweight are about fifty/fifty. I do understand that the reason behind you choosing the sleeve is mainly financial. The good news is that you can always add the switch later (although you will loose more slowly). However, the DS is always done in two phases here in the Netherlands and Belgium and I do believe that it is a safer procedure that way, especially in super obese patients.

 

[kevin86]

Thank you everyone. Outside of a coupe certain comments this has been really helpful. This is probably the most difficult decision I've ever made. It's left me in tears multiple times. I understand that DS is better weight loss. I know this is the case. I also know what's feasible though. Maybe it's fear of waiting to be able to do the DS. All that keeps going through my mind is what if I die while saving up my money. As a 29 year old I've given up my young life because my weight and my fear of my weight killing me. So yeah maybe this decision is largely based on emotions and not facts. Deep in my heart I want to know that I can start living my life. I understand numbers and stats say that I should get the DS but numbers and stats also say I will die if I can't get some procedure soon. Comments that say that I need to change my mindset have no idea how much I truly listen to what's posted here. I read every comment and suggestion multiple times. I'm tired of hoping and praying I wake up in the morning. I hope this all makes sense. I'm kinda emotional today so it affects my typing at times.

 

[newanatomy]

We understand having to make a life changing decision. Every single one of us had already made the decision and then acted on it. It was emotional for all of us and scary. Still, we live with the consequences of our choices.

 

[southernlady]

As a 29 year old I've given up my young life because my weight and my fear of my weight killing me. So yeah maybe this decision is largely based on emotions and not facts. Deep in my heart I want to know that I can start living my life. I understand numbers and stats say that I should get the DS but numbers and stats also say I will die if I can't get some procedure soon.

At least you are starting EARLY in life. I was 56 when I had the DS. I was an insulin pump dependent type 2 diabetic. I am in that very small percentage that doesn't totally resolve the diabetes. My a1c still runs a 6.0-6.2 which AT MY AGE is fine with my PCP.

Consider Munchkins remarks even if you don't answer them here would do much toward your decision.

Here is a rhetorical question for you. I am not expecting an answer, just something to think about. Why are you heavy? Do you know? Do you eat 4 or 5 times what a 'normal' person eats? If the answer is no, you are probably a superabsorber. Your body is efficient, it wastes nothing and you absorb more calories from the food you eat. A 'normal' person poops out calories. They don't absorb all of what they eat. Has your metabolism been broken and busted by the many diets you have tried over the years? Has it gotten harder and harder to drop 100lbs and keep them off? Is it now almost impossible?

If your answer is yes, you have a metabolic condition that needs a surgery that will correct, or reset your metabolism. The only surgery that will do what you need long term is the DS. Period. I keep hoping they will come up with something better but this is what's available today.

Granted a sleeve would have been easier for me but I knew I had been on every diet possible and the ONLY one that I could live with long term was the low carb/high fat, lots of protein of the DS because it's what I had been doing as a diabetic. It's also why my a1c never got above a 7 in the 14 years (AFTER my initial diagnosis) before my DS. But weight just never budged. The FEW times I successfully lost weight in my life meant truly being rigorous in what I ate/didn't eat, exercise like you wouldn't believe. I wanted a NORMAL life and the DS gave me that chance. I could lose weight pre-DS, I just could not KEEP it off. And keeping it off was critical. Now I've lost weight and other than being active, exercise is not part of my vocabulary (except maybe walking the dogs)

One thing about this group...we are, AS a group, more focused toward the DS than any other forum out there. But we also know not everyone needs a DS. Many are not ready. But we do want people to be very sure of their reasons for getting a different surgery. IS the DS for everyone, HELL NO! It takes determination and a willingness to adhere to vitamins, lab work, standing up for yourself in the face of the medical profession.

You said:

Instead of being so negative maybe you guys should show me that this is not the right direction to go. All I've heard is how bad of an idea it is but not a single person has taken the time to show me that it's a bad idea. Is there evidence that it won't work for someone my size? Because all I've found is people who have had success with it. I'm not trying to be rude but I also believe that if you're not being helpful then you're being negative. Thank you for those that have been supportive. As for others I'm asking you to show me that it's a bad idea not just tell me.

We can not show you why it's a bad idea for you. It might not be but for the general group, it is a bad idea to have two surgeries, not one. Two surgeries means going under anesthesia TWICE, hospital bills TWICE, recovery TWICE. Why not think twice but only cut ONCE?

We can give you all the research but you will have to finally decide for yourself where you might fit in those figures. As to the people who have had the VSG at a higher BMI...how far out are they? If less than 5 years, they aren't yet successful. LONG term success as in lifetime is what we are talking here.

 

[DianaCox]

You have insurance. There is no FRIGGIN' DOUBT that a single step DS would be best for you. You said this: "In order to do DS I would have to go to a surgeon 15 hours away. This in turn would require extensive travel, extensive cost and extensive time. Therefore it would require many more funds be saved up likely in the thousands." Why do you think that?

15 hours away? Have you not heard of planes? Arrangements can be made to seat you on a plane, in spite of your size - you just have to pick a flight time where the plane isn't full, even if it is early in the morning or late at night.

If there is no qualified DS surgeon in-network in your area (and I guaran-damn-tee you there isn't a DS surgeon in NM), then I'm pretty sure Aetna has to pay for at least a portion of your travel expenses, and possibly those for a traveling companion. This is from a sample EoB in California, and the statement refers specifically to transplant procedures, but I believe they should have something comparable when it is necessary to travel for medically necessary treatment:

Travel and lodging expenses incurred by the Member receiving the Transplant, the organ donor and Traveling Companion for travel between the Member’s home and the IOE facility, when the IOE facility is 100 miles or more from the Member’s home. Round trip coach class air, train, or bus trave are covered. Travel and lodging expenses are subject to any maximums set forth in the Schedule of Benefits.
​

You should at least check this out.

 

[Larra]

Kevin, I had not planned on posting on this thread again, having said my peace, but I'm back for 2 reasons:

first, it has become clear from your responses that you do know how much better the DS would be in your situation than the VSG, but you are opting for VSG anyway for speed and logistic reasons. These are not good reasons IMHO. When you are drowning and someone tosses you a rope, you don't ask whether or not that rope is going to hold, you grab onto it and hope for the best. Desperate people make desperate decisions, not always good decisions. That is where your mind is at this point. I won't belabor the differences between the operations and their different results because you already know this stuff. You are just making a decision out of desperation. Many of us can relate. We have all been in that dark place at one time or another. I can only advise you to step back, get out of that dark place, and figure out a way to get the operation you really need.

Second, I was appalled at your response to @robs477 . I've had the pleasure of meeting him and his lovely family, and also have read so many of his posts here. He has shown nothing but kindness and compassion to so many others. His surgery is long over but, unlike lots of other people, he hasn't disappeared, but instead has stayed here to help and support other people who are coming along now. You owe him an apology.