Dr Daniel Cottam, BMI of Utah.

[DianaCox]

A bit more about diabetes and SADI:

http://www.soard.org/article/S1550-7289(15)00029-5/fulltext (this article has not yet been published, or is not available without a subscription - this is the abstract):

Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients
Correspondence

• Correspondence: Andrés Sánchez-Pernaute, M.D., Ph.D., Chief, Esophago-gastric, obesity and metabolic surgery, Hospital Clínico San Carlos, c/Martín Lago s/n, 28040 – Madrid, Spain

Received: October 25, 2014; Accepted: January 29, 2015; Published Online: February 05, 2015

Abstract
Background
Bariatric operations achieve a high remission rate of type 2 diabetes in patients with morbid obesity. Malabsorptive operations usually are followed by a higher rate of metabolic improvement, though complications and secondary effects of these operations are usually higher.

Objectives
Analyze the results of a simplified duodenal switch, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) on patients with obesity and type 2 diabetes mellitus (T2 DM).

Setting
University Hospital, Madrid, Spain.

Methods
Ninety-seven T2 DM patients with a mean body mass index (BMI) of 44.3 kg/m2 were included. Mean preoperative glycated hemoglobin was 7.6%, and mean duration of the disease was 8.5 years. Forty patients were under insulin treatment. SADI-S was completed with a sleeve gastrectomy performed over a 54French bougie and a 200 cm common limb in 28 cases and 250 cm in 69.

Results
Follow up was possible for 86 patients (95.5%) in the first postoperative year, 74 (92.5%) in the second, 66 (91.6%) in the third, 46 (86.7%) in the fourth and 25 out of 32 (78%) in the fifht postoperative year. Mean glycemia and glycated hemoglobin decreased immediately. Control of the disease, with HbA1 c below 6%, was obtained in 70 to 84% in the long term, depending on the initial antidiabetic therapy. Most patients abandoned antidiabetic therapy after the operation. Absolute remission rate was higher for patients under oral therapy than for those under initial insulin therapy, 92.5% versus 47% in the first postoperative year, 96.4% versus 56% in the third and 75% versus 38.4% in the fifth. A short diabetes history and no need for insulin were related to a higher remission rate. Three patients had to be reoperated for recurrent hypoproteinemia.

Conclusion
SADI-S is an effective therapeutic option for obese patients with diabetes mellitus.

So, with the DS (as reported in the Frenken paper quoted in my earlier post:

3.3. Influence of Preoperative Duration of Insulin Therapy on
Postoperative Outcome. According to their need for insulin,
patients in group 3 were divided into 4 groups: 15 patients
were treated with oral antidiabetic medication, 25 used
insulin for less than 5 years, 23 used insulin for 5–10 years,
and 11 used insulin for more than 10 years. At discharge
from hospital, all patients in groups I and II were free of
insulin. Thirty-three percent of patients in group III, still
needed insulin at the time of discharge, but all of them were
free of insulin 12 months after the operation. In group IV,
73% needed insulin at the time of discharge, 23% still needed
small amounts of insulin 12 months after the operation
(Figure 4). HbA1c levels also decreased continuously in all
groups. Mean levels below 6% were reached 3 month after
surgery in groups I and II, 6 month after surgery in group III
and 2 years after surgery in group IV (Figure 5).

SO:
- With DS, at 12 months out, 77% of people who had been insulin dependent for >10 years were no longer insulin dependent.
- With SADI at 12 months out, only 47% were in remission (and this study lumped together ALL of the people who were insulin dependent, not even distinguishing for how long!! - this includes people who only recently went on insulin!!) AND WORSE - the remission rate steadily decreased over time post-op with the SADI - by 5 years out, ONLY 38.4% were still in remission!! And that statistic may not even include ANY people with insulin dependent diabetes >10 years!

And the Pernaute SADIs have 200-250 cm alimentary tracts - you'll be getting a 300 cm one.

As Frenken says:

As seen in bariatric surgery for morbid obesity, there will
not probably be only a single “anti-diabetic” operation but
several options, depending on the patients’ comorbidities,
weight, and, most likely, also duration and therapy of the
patients’ diabetes.

I would really really reconsider if I were you. You need to have the BEST chance of putting your diabetes in remission NOW.

And I'd demand an explanation of why Cottam thinks a SADI/SIPS/LDS is your BEST chance, based on the published data.

 

[Charris]

I was brittle diabetic in 1997. I took 8 insulin shots a day. With the ERNY I was in remission for 13 years. I became diabetic again and was going to be revised to a sleeve. Ms. Batt on OH sent me a message saying I needed a DS. I knew nothing about a DS. I tell you this because I thank goodness this SIPS or LDS was not really being discussed at that time. I'm not a person who is very knowledgeable about medical stuff. I could have ended up with something that wouldn't have worked to resolve my diabetes again. For that reason I strongly agree with Diana that if doctors do this new surgery then DO NOT call it anything that implies that it is a DS because it's not! Also in my mind they must feel that the DS is a great surgery or why would you keep referring to it as a DS like surgery. I just feel like someone who is not well versed or knowledgeable regarding medical stuff could be mislead and end up with something other than what they really need. I wonder how the LDS OR SIPS is going to work for those who are SMO? Will they be able to loose as well or enough as if they has a full DS?That is just one of the issues. There is no long term information to indicate long term results for anyone. I understand every procedure initially is experimental but I would not want to risk my health to provide that data.

 

[hilary1617]

@southernlady , Could the acronym LDS be appended to the SADI/Loop/SIPS forum title? Hard to believe there is yet *another* name for this procedure...

 

[Jo Lynne]

I am seeing conclusions being made that are not in line with what I am saying...
sometimes I struggle with communication. Doesn't stop me from trying. I am off work today and will have time on my laptop to look at everything you all shared. And I appreciate it. I may be squeamish around sharp peircing objects but I am not intimidated by discussion and looking at all sides.

First, the reason I said the traditional DS surgery is longer from Loop DS was from my own research- not from what Dr Cottam "told me." I watched a video on the Loop DS first on Dr Cottam's page because I was referred there by my PCP. Dr. Cottams team had done a recent presentation at my doctors office and they were impressed with the whole approach to care, saying they are addressing many treatment/support gaps they see post bariatric surgery. Before I could get an appointment, Dr Cottam's team had me look at their page to learn about the surgeries they offered and to fill out intake paperwork.

I was immediately impressed with the Loop DS surgery video on the website- excited to learn there was something new that looked like a much better surgery than the RNY. I Googled for more info. That's how I found about the original DS... which was not even an option through my insurance the last time I looked at WLS. Everything I saw the Loop DS was a newer less complicated. Online the old DS reads as a more complicated longer surgery. Like I said I was scared off from the RNY several years ago the original DS doesn't sound like an easier surgery than an RNY. It reads as a more complicated surgery online. I can't argue with you that there are results to support it is to date known for the best outcomes for long term diabetics.

From personal experience... My husband had both his knees replaced last year TKR. His doctor does a new procedure where the measurements are taken and the replacement is machined to fit. The surgery is robotic and takes 30/minutes. The doctor does 9 surgeries one day a week and all his patients go to PT together for the 2/days they are in the hospital and then have a regimented follow up at home. OMG has this been an amazing experience and he is getting around better now than he did in the previous 10 years. I am not pushing him in a wheel chair!!!

So I will contrast him to my cousin who is a beautiful healthy weight woman in her late 50s who got her TKR a month before my husband who is over weight. She lives in a more remote area and their hospital does not have access to the new surgery techniques. Her surgery was over 3 hours long. She is still significantly less mobile than my husband... and she says she feels she was better off pre surgery. I posted pictures of a one mile walk my husband and I took with our dogs last week. Family was cheering him on through FB... She posted a picture with a cane saying it is her first walk in the sun because her pain and healing have been slow. She is one of those addicted nature hikers so it is difficult to see this has been such a struggle for her compared to my husband's success.

Apples to oranges? Maybe. Not if I am pointing out that new approaches are not always bad. Again I will look at what you are sharing with me. But I can't express enough how happy I was to discover the Loop DS and that the RNY was not my only option!!

 

[star0210]

@DianaCox i may have asked this before I can't remember but could you explain in layman's terms what you mean by "selective" fat malabsorption?
Selective vs what? Non-selective?

 

[DianaCox]

If your ONLY choices were RNY vs. SADI/LDS/SIPS, that's a no-brainer, and I hope the RNY is abandoned in favor of the SADI for those who cannot manage the relatively simple but utterly necessary requirements of the DS, and who don't "need" the superior benefits of the DS.

But that is not your situation - I suggest that you NEED the superior benefits of the DS, and I URGE you to get a second opinion from a surgeon whose whole practice is not invested in his experimental protocol that REMOVES the DS as an option. I suggest you contact Keshishian, for example.

Moreover, you need to look at the SADI as a LESSER surgery, with SOME of the benefits of the DS - it is not an IMPROVEMENT on the DS, like your husband's knee surgery, it is a compromise between the RNY and the DS, trying to find something "good enough" that doesn't put the patient at risk from their own non-compliance, stupidity or (and this is probably the biggest issue) CRAP nutritional advice and lack of proper support from their surgeon. It is a compromise that purports to relieve the surgeon from the responsibility for the patient's failure to educate their patients properly and over time.

You want "good enough," where that may well mean not resolving your severe T2D, as well as the risk of needing further surgery a few years from now, which will be even less likely to work because of the delay? Go for it, so long as you understand the risk you are taking.

Personally, I would want the best result, not merely what my surgeon thinks (in keeping with his experimental protocol, in which you are likely to be the outlier for whom it doesn't work, and who proves the statistical significance of the less-ill patients, because of the length of time you've been insulin-dependent) is "good enough."

 

[Jo Lynne]

Diane I have to admit being impressed with your passion and being well versed in this.

 

[DianaCox]

Selective fat malabsorption:

• The DS prevents the pancreatic enzymes (including enzymes that break down fats (lipases), proteins (proteases) and complex carbs (amylases)) and bile (which dissolves fat into a form which is water miscible, and thus into the form that the lipases can break down) from contacting your food until the last 100 cm of the small intestine (ileum), AKA the common channel.
• Without bile, fat CANNOT be digested.
• However, the intestines secrete SOME proteases and amylases, plus the acid in the stomach also can break down proteins and carbs, so there is a significant amount of digestion of protein and carbs BEFORE the common channel - but NO digestion of fat.
• Therefore, with the DS, about 50% of the protein and complex carbs are absorbed, but only about 20% of the fat.

This is why the DS provides SELECTIVE fat malabsorption - it selectively causes more fat malabsorption than other sources of energy.

With the SADI, instead of 100 cm of common channel, there are 300 cm - THREE TIMES as long to absorb fat, as well as protein and carbs. So, compared to the DS, there will be FAR more absorption of all sources of energy, FAR more calories absorbed, and NO selectivity for malabsorption of fat.

SADIsts cannot eat like DSers. They will have to eat like RNYers with a medial bypass - watching calories and fat for the rest of their lives.

And this is yet another reason I HATE that the surgeons are calling this hybrid procedure by a name that implies is it "just like the DS, only safer." It isn't.

 

[southernlady]

@southernlady , Could the acronym LDS be appended to the SADI/Loop/SIPS forum title? Hard to believe there is yet *another* name for this procedure...

Yes, I can but right now, not at home and when we do, we are in the midst of fixing another (inside the house) failed water pipe!

 

[Lilyofthevalley]

It is also important to know that after surgery you will be placed on a strict 1000 a day calorie diet. You could probably do that now for yourself.

 

[Elizabeth N.]

As long as you thoroughly understand what procedure you're getting, that's fine. I will continue to object to the nomenclature and the obvious attempts to make it sound like the DS stats and experience apply to the newer procedure. It will hopefully stand on its own in a few years, but the differences are not trivial and should not be glossed over.

 

[JackieOnLine]

My husband had both his knees replaced last year TKR. His doctor does a new procedure where the measurements are taken and the replacement is machined to fit.

She lives in a more remote area and their hospital does not have access to the new surgery techniques. Her surgery was over 3 hours long.

when I lived in Sidney, Nebraska (remote!!!) we had both of these versions done and the difference was incredible. we were used to getting someone out of bed on the day after their knee replacement and putting them through a fair amount of pain to get it moving and them walking. then, a surgeon started flying in from Laramie, Wyoming to do the knees where they measure ahead of time and the parts are made to fit you, instead of the other way around.

what a difference! you couldn't FIND your knee patient because by the time we came to do therapy with them they were walking around everywhere, it was incredible. you find them the same day of surgery and they had 90 degrees of flexion, wow!

the surgeon told us he could afford to do it at our hospital because we had funds from the federal government due to being a "rural access" hospital. not even sure if that is still a thing but it was then.

rural hospitals SHOULD be subsidized to be kept open, you have a wreck on the freeway out in the middle of nowhere you need to have a local ER to stabilize you before then fly you somewhere bigger.

my two cents!

 

[Elizabeth N.]

Those rural hospitals should be subsidized for the good of the locals, too :-D. You know, those folks that feed the world....

 

[JackieOnLine]

Those rural hospitals should be subsidized for the good of the locals, too :-D. You know, those folks that feed the world....

absolutely, I was one of those locals.

 

[marissamast]

Do you understand that there are no long term studies or results for that procedure? Do you understand that the "Loop DS" does not have selective fat malabsorption?

I wouldn't mind if the "Loop DS" replaced the RNY, because I'm SURE it will be better than the RNY, at least in terms of patient comfort (no dumping, no reactive hypoglycemia, more likely to be a higher rate of resolution of diabetes). BUT IT NEEDS IT'S OWN SEPARATE NAME THAT DOES NOT USE "DS" - IT IS NOT A DS!! The hallmark of the DS is selective fat malabsorption, and these single anastomosis variants DO NOT HAVE THIS BENEFIT! And it will be too confusing to people.

People who have this variant surgery should NOT be looking at the DSers for dietary advice - we can and should eat more fat and protein than they can, and far more calories - there simply is no comparison. But I'll bet people with these variant procedures end up with some of the same vitamin and mineral malnutrition issues, because the surgeons and nutritionists DON'T GET IT, and are giving crappy advice to everyone.

What is the "attachment" they are putting below the pyloric valve? Is that like a lap band? I am so thankful that BMI utah's support staff were so inefficient in getting back to me with an appointment that I went to RMAP. I figured if they couldn't even get scheduling an appointment right, there wasn't much chance of anything else going right!