Dr. Roslin brings DS to Saudi Arabia

[Elizabeth N.]

Ahhhh okay. Thanks Joanne, and Dr. Roslin, for clarifying!

I'd like to know how the Loop Non-DS was explained to the patients.

 

[Joanne]

'

Loop Non-DS .

THAT name makes me laugh

 

[Elizabeth N.]

'


THAT name makes me laugh

Well, I am no anatomy expert, but how is the duodenum switched in this procedure? The name seems misleading to me. Can anybody clarify that point?

 

[newanatomy]

Thanks @Larra and @Joanne

 

[Larra]

Thanks Joanne! Now we know, and we also know more about his role there.

To EN, I think the loop-DS really still is a DS, just without the RNY configuration. It still has the sleeve gastrectomy, and still has bypassing of a lot of the small intestine, the difference is only in how the bypassing is done. Is it as good as the tried and true DS? Better? Worse? I have no idea. for myself, I'm glad I had the same DS that the longterm studies by Hess and others documented as so effective. On the other hand, at some point someone took a good look at the old Scopinaro procedure and realized that it could be improved upon, or we wouldn't have our present day DS. If we only do the same thing over and over, medicine will never advance. I do think it's important, though, for patients to understand what they are having done and why. I think this is more of a problem with ERNY, with surgeons telling patients that it's "just like the DS" or words to that effect. It isn't. As long as there is honesty and informed discussion, I think surgeons are on safe ground.

 

[DianaCox]

I'm going to disagree with Larra here. To me (NOTE: with no MD after my name), one of the hallmarks of the DS is SELECTIVE fat malabsorption, and the SADI doesn't have that.

In a regular DS, there is ~150 cm of ileum attached to the proximal duodenum in which SOME complex carb and protein digestion takes place, even in the absence of pancreatic proteases and peptidases (they break down proteins to amino acids) and carbohydrases (they break down complex carbs to sugars), because the intestine produces some of these as well, plus the digestion of carbs and proteins is started by acid hydrolysis in the stomach. Fats require pancreatic lipases and bile to digest at all (with the exception of some smaller triglycerides). Which is why, as a rough approximation, we absorb about half of the complex carbs and proteins, but only ~20% of the fat we eat. This is SELECTIVE fat malabsorption.

In contrast, with the SADI, there will be complete digetstion for the entire 250 cm of the part of the small intestine from the duodenal-ileal anastomosis. All three - protein, carbs and fat - will likely be quite well absorbed, well over 60% of all of them, and probably more as the alimentary tract adapts to the short bowel. Yes, there will be less fat soluble vitamin malabsorption, but SADI patients will not get nearly the "fat is your friend" benefits that we do. Just as proximal RNYers eventually lose almost all caloric malabsorption, I would bet SADIers (and they will be very saddy) will have to diet to maintain weight loss after a few years.

Those are my predictions.

 

[Elizabeth N.]

Thanks Joanne! Now we know, and we also know more about his role there.

To EN, I think the loop-DS really still is a DS, just without the RNY configuration. It still has the sleeve gastrectomy, and still has bypassing of a lot of the small intestine, the difference is only in how the bypassing is done. Is it as good as the tried and true DS? Better? Worse? I have no idea. for myself, I'm glad I had the same DS that the longterm studies by Hess and others documented as so effective. On the other hand, at some point someone took a good look at the old Scopinaro procedure and realized that it could be improved upon, or we wouldn't have our present day DS. If we only do the same thing over and over, medicine will never advance. I do think it's important, though, for patients to understand what they are having done and why. I think this is more of a problem with ERNY, with surgeons telling patients that it's "just like the DS" or words to that effect. It isn't. As long as there is honesty and informed discussion, I think surgeons are on safe ground.

Can you go into the reasoning behind why it's called a duodenal "switch" then? (In both configurations I mean?) Maybe I'm overthinking that term. Does it just mean that almost the entire duodenum is removed from contact with food, or is there more to it than that?

 

[Elizabeth N.]

In contrast, with the SADI, there will be complete digetstion for the entire 250 cm of the part of the small intestine from the duodenal-ileal anastomosis. All three - protein, carbs and fat - will likely be quite well absorbed, well over 60% of all of them, and probably more as the alimentary tract adapts to the short bowel. Yes, there will be less fat soluble vitamin malabsorption, but SADI patients will not get nearly the "fat is your friend" benefits that we do. Just as proximal RNYers eventually lose almost all caloric malabsorption, I would bet SADIers (and they will be very saddy) will have to diet to maintain weight loss after a few years.

Those are my predictions.

Ahhhhh, so THAT'S why there's the concern about bile reflux. Now I recall how somebody medical explained it a while back: Bile enters the alimentary limb way far away from the pylorus in the DS as we have it. Yes?

 

[DianaCox]

The switch part of the term, I believe, refers to the fact that the connection of the duodenum to the rest of the gut is "switched" to another location. In that context, the SADI has a switch.

And yes, the traditional DS eliminates the potential for bile reflux, while the SADI has bile flowing past the pylorus.

 

[Larra]

I agree with Diana about the meaning of the "switch" and that both the classic DS and the loop DS will have the switch, but disagree about the bile reflux part. While bile reflux is a potentially very serious problem with the loop gastric bypass (also known as mini gastric bypass), with the loop or SADI DS, the connection of duodenum and small intestine is still of the distal side of the pyloric valve, which is supposed to be a one way valve. Thus the stomach should be largely protected from bile reflux, and the esophagus even more so, since bile would have to reflux through the pyloric valve and all the way up the sleeve to get to the esophagus. With loop gastric bypass, the bile can reflux freely through the stoma connecting the small intestine to the tiny pouch, with the stoma not having any kind of valve, and from there it's almost no distance to the esophagus.
So, which bile reflux is definitely not an issue with the DS, I would think it would not be a big risk with the SADI either. Now, the points about how well various nutrients will be absorbed with SADI compared to DS is the part where I think the results are not known. Diana makes good points about how this may work in theory, but there are, at this point, no studies documenting how the patients actually fare. This is why, again informed consent is so very important.

 

[Elizabeth N.]

I love learning new stuff .