Had an interesting email from Dr. Esquerra's assistant, Nina

[Clematis]

But Scott, you are very tall and malabsorption issues are more a possibility. We women are not. To achieve normal weight without dieting the rest of our lives (duh, why we had this friggin' surgery) our limb lengths are very important, especially the absorbing limbs of AL+CC. I'm left with absorbing limbs of 60% vs the 40% BP limb. In my case where I should have had a 50cm common channel and ended up with a 100cm (double the length), that is nearly TWO FEET more bowel he left to absorb nutrients. That is significant.

But it is more than that. It is a question of medical honesty and trust. If a surgeon repeatedly swears he does Hess Method before surgery, then comes in to one's room and says YES HE DID THE HESS METHOD and then one discovers he LIED, is this not at the very least unethical if not malpractice? (But can;t sue Mexican surgeon. It's near impossible to do internationally anyway, but we all had to sign a waiver the morning of the surgery.)

 

[southernlady]

Another consideration is HOW they measure. Do they just lay the intestine out and measure or do they stretch it some? It's like measuring a slinky...It comes in a very small box but stretched out can reach many feet.

 

[DSRIGGS]

But Scott, you are very tall and malabsorption issues are more a possibility. We women are not. To achieve normal weight without dieting the rest of our lives (duh, why we had this friggin' surgery) our limb lengths are very important, especially the absorbing limbs of AL+CC. I'm left with absorbing limbs of 60% vs the 40% BP limb. In my case where I should have had a 50cm common channel and ended up with a 100cm (double the length), that is nearly TWO FEET more bowel he left to absorb nutrients. That is significant.

But it is more than that. It is a question of medical honesty and trust. If a surgeon repeatedly swears he does Hess Method before surgery, then comes in to one's room and says YES HE DID THE HESS METHOD and then one discovers he LIED, is this not at the very least unethical if not malpractice? (But can;t sue Mexican surgeon. It's near impossible to do internationally anyway, but we all had to sign a waiver the morning of the surgery.)

Clematis. You have every right to be be upset that he has your absorbing to non absorbing tracts ratio out of proportion. Whether he followed a Hess Type method can be debated but if he says he measured your SBL and individual limbs he gave you a Hess DS, BUT HE DIDN'T STAY WITHIN APPROPRIATE GUIDELINES. I get that anger and you have every right to be, but I have to make two comments that are very related:

• It isn't that your CC is too long, it is that your CC AND, I REPEAT AND, your AL are too long relative to your SBL. Had he simply done the Marshall cookie cutter on you then you would have had by luck ended up with a perfect balance of 100 CC + 150 AL = 250 BPL. We can argue about whether he should have made up that 50 cm by:
  • shortening your CC to 50 cm and left the AL at 200. I say no that this would be too short (JMO and what I am hearing from many surgeons)
  • taking 25 cm from CC and 25 from AL giving you a 75 cm CC and 175 cm AL - I think that might have been a good balance that you would have liked
  • shortening you AL to 150 for the 100 CC + 150 AL. IMO that would have done you the best. That is what Jim has and also Marshall's standard CC & AL configuration and most of his patients do well that I know because they had shorter SBL (assumption but they are shorter than me).

• You say that I am taller so malabsorption issues are more of a possibility. That is jut not true. A person's height is irrelevant, when as you are so rightfully arguing, the HESS Method is PROPERLY EMPLOYED. It is done for precisely the reason you are alluding to, and that is too compensated for varying small bowel lengths so as to prevent too much or too little absorption. So it is not height that is important, but bowel length and although there is a correlation it isn't perfect -
  • Jim at 5'10 has the same SBL as somebody else who said they are 5'1 - so there is variance of SBL within a given height.
  • I had severe absorption issues BECAUSE AND ONLY BECAUSE my AL was way too short 200 cm rather than the 275 cm that it should have been. One can argue that I have a short SBL for my height if you look at the chart from the SBL lenght to height study that I posted.
• The Hess equation of CC 10% + AL 40% = BPL 50% is ONLY A GUIDELINE
  • PLEASE NOTE: My CC WAS ACTUALLY LONGER than Hess suggested 10%. Hess guideline says 10% but mine was actually 17.2%. 10% would have been 72.5 cm and I was given 125 cm. I will argue that the CC length was correct. That would have been just fine had Marshall measured my SBL and made my AL at 250 cm or he could have shortened the CC to 100 CM to give "Anthone suggested balance of 50/50 irregardless of individual CC & AL lengths". Either way would have worked.
  • If you notice CC length seems to be in 25 cm increments such as 75, 100 or 125 in most DS'rs. They rarely equal 10% exactly so the difference to achieve the 50/50 absorbing to non absorbing balance is typically made up with the length of the AL
  • Again, look at Jim his numbers of 100 CC + 150 AL = 250 BPL are rations of 20% CC & 30% AL and he is doing just fine.

By the way Marshall measured 100 and 150, Dr K measured 125 and 200 - this is the measuring variation between Docs that Liz brought up. In reality before my revision my Hess Proportions were CC 17.% + AL 27.8% = BPL 55% so my absorption as measured by Dr K was roughly 45% of SBL absorbing.

I know that is a lot of stuff but I am trying to get the point across that the CC is only one part of the equation and that the HESS is only a guideline and not etched in stone at 10% CC and 40% AL. Those who are going for surgery in the future do not need to tell the Dr what the CC length should be, they need to make the Surgeon promise that he will give them that 50/50 absorbing to non absorbing tract issue. That is the important part.

Finally, I agree 100% that he screwed your procedure up and that 60/40 ratio for you is too much. He should have shortened your AL to 150 like Jim's. You have every right to be upset just like I had every reason to be upset with Marshall. Both Dr's screwed up our ratios. Marshall just doesn't care about the ratio, but Esquerra says he does but for whatever reason brain cramped and made your AL too long.

Best of luck going forward. You are almost at a 25 BMI which is probably where I will end up eventually if things work out. Hopefully you can maintain around that level without dieting. I agree, we had this surgery to live and eating is part of that, so you shouldn't have to diet.

 

[BebeZed]

I read through all of this and I have to say while my CC is 100 with a total length of 540, I'm doing just fine in the weight loss department with nearly 70% EWL at 7 months... and I eat probably more carbs than I should, don't particularly exercise (although I'm doing a LOT of walking lately and way more active), and generally go about my business and enjoy life So.... I think 100cm for me was a wise choice. It's working for me. I'd rather be a few pounds over than malnourished for sure. So as always, YMMV but... I still have confidence in Esquerra.

 

[DSRIGGS]

I read through all of this and I have to say while my CC is 100 with a total length of 540, I'm doing just fine in the weight loss department with nearly 70% EWL at 7 months... and I eat probably more carbs than I should, don't particularly exercise (although I'm doing a LOT of walking lately and way more active), and generally go about my business and enjoy life So.... I think 100cm for me was a wise choice. It's working for me. I'd rather be a few pounds over than malnourished for sure. So as always, YMMV but... I still have confidence in Esquerra.

do you know your AL length? That is very important. If it is 100 it is too short. If it is 300 it is too long, if that makes sense. I know I am a broken record but CC length is only one element of the DS and the AL length is JUST AS important because it absorbs as well.

Glad you are doing so well. You seem happy.

 

[BebeZed]

do you know your AL length? That is very important. If it is 100 it is too short. If it is 300 it is too long, if that makes sense. I know I am a broken record but CC length is only one element of the DS and the AL length is JUST AS important because it absorbs as well.


Glad you are doing so well. You seem happy.

I totally get what you're saying. My AL is 200, so AL and CC combined is still a bit longer than the pure Hess method. I'm comfortable with it but yes, I would totally discuss expectations with him just as I did. Like I sai, I'm very happy thus far although my weight loss has been slower than a lot of people but I also believe it would be much faster if I was a bit more strict with diet and exercise.

Long story short, if it's a concern then talk it out and if you can't get resolution is time to look at going to another surgeon. It's a very personal journey and you have to do what you feel is best.

 

[DSRIGGS]

I totally get what you're saying. My AL is 200, so AL and CC combined is still a bit longer than the pure Hess method. I'm comfortable with it but yes, I would totally discuss expectations with him just as I did. Like I sai, I'm very happy thus far although my weight loss has been slower than a lot of people but I also believe it would be much faster if I was a bit more strict with diet and exercise.

Long story short, if it's a concern then talk it out and if you can't get resolution is time to look at going to another surgeon. It's a very personal journey and you have to do what you feel is best.

79 pounds in 7 months is nothing to sneeze at. Great job.

Yeah I don't know why he didn't give both of you ladies shorter AL's but you are doing well so far and as you say, happy. That is all we can ask for in life, IMO, to be happy and healthy.

 

[Susan in Tennessee]

I read through all of this and I have to say while my CC is 100 with a total length of 540, I'm doing just fine in the weight loss department with nearly 70% EWL at 7 months... and I eat probably more carbs than I should, don't particularly exercise (although I'm doing a LOT of walking lately and way more active), and generally go about my business and enjoy life So.... I think 100cm for me was a wise choice. It's working for me. I'd rather be a few pounds over than malnourished for sure. So as always, YMMV but... I still have confidence in Esquerra.

Yes, it really sounds like you're doing extremely well! I'd be happy too if I were you. (all that Walking and ahem, other stuff is really doing the trick).

 

[Munchkin]

Don't disregard the 'man factor'. Can I prove it, no. But since the first diet ever, men have always lost better, faster, more, than their female counterparts. I don't think this is urban legend people have repeated till it is accepted as true. I think it's quite real. It is a basic difference between men and women that I would surmise, goes back to cave-man days. Women needed more body fat to attract a male, nurture a fetus, and continue the species. Men were leaner and stronger to function better as hunters/gatherers. We may not like it but it is undeniably logical.

The limb lengths can/do make a difference but I think it's still all about how resistant to weight loss you are. How hard your body is going to fight to get back to it's happy place, fat. Plenty of people with bowel lengths that are too long make it to goal. And plenty of people with bowel lengths that are too short still struggle and they are still fat. And those people with the numbers that are too short should be loaded with serious deficiencies. But many are not. And the long bowel people should have fewer deficiencies but in reality that's not always true either.

@DianaCox reminds me every now and then the results of the DS have always been a bell curve. That means if you achieve that perfect BMI, someone else has to fail. The bell curve is no big secret, all the docs know about it. There is no simple combo of magic numbers. If there was, they would all be doing it. The numbers matter but they don't tell the whole story. There is still a bucket of unknowns. And remember what the docs consider to be a 'success' can still leave you fat. Many of us, the patients, will only consider themselves successful if they end up with a normal or overweight BMI. We start out wanting more than the docs think we will get!

Don't get too wrapped up in the numbers.

 

[CarbJunkie73]

I swear, after reading all these posts, I'm going to ask the doc to let me do my own surgery so I'll know exactly what I'm getting!! I got this!!

So, I went and googled 'cm to feet' and while it doesnt sound (to me at least) like a HUGE diff in cm,it IS converted to feet!!! Holy cow!! 3.2ft vs 2.5ft vs 1.6ft!

I have full confidence in Esquerra's capabilities... it's knowing MY BODY and how it has held on to every pound that I have NO CONFIDENCE IN, WHATSOEVER... and if me having this surgery is going to be the end of my marriage, like its looking so far, I REALLY NEED THIS SHIT TO BE DONE RIGHT!!!!!!!!!!

So, to make sure I have this straight, I need to ask the doc to shorten my AL (if he insists on using the 'Esquerra Method' of a 100cm CC) so that my total CC+AL equals as close as possible to my TBL?

The other shitty part is I have to go and pay them the $10,500 balance TONIGHT and I havent heard a peep from Nina/Karla on ANY of my emails!!! Go friggin' figure!!!

 

[Susan in Tennessee]

@Munchkin I remember when I made my very first introduction post here several months ago, you welcomed me and pointed out that I was "quite short" and that short women often had trouble reaching normal BMIs. At that time I was still deciding on type of surgery and your remarks really registered with me and my past struggles and I've always remembered it.

 

[Susan in Tennessee]

I swear, after reading all these posts, I'm going to ask the doc to let me do my own surgery so I'll know exactly what I'm getting!! I got this!!

So, I went and googled 'cm to feet' and while it doesnt sound (to me at least) like a HUGE diff in cm,it IS converted to feet!!! Holy cow!! 3.2ft vs 2.5ft vs 1.6ft!

I have full confidence in Esquerra's capabilities... it's knowing MY BODY and how it has held on to every pound that I have NO CONFIDENCE IN, WHATSOEVER... and if me having this surgery is going to be the end of my marriage, like its looking so far, I REALLY NEED THIS SHIT TO BE DONE RIGHT!!!!!!!!!!

So, to make sure I have this straight, I need to ask the doc to shorten my AL (if he insists on using the 'Esquerra Method' of a 100cm CC) so that my total CC+AL equals as close as possible to my TBL?

The other shitty part is I have to go and pay them the $10,500 balance TONIGHT and I havent heard a peep from Nina/Karla on ANY of my emails!!! Go friggin' figure!!!

no, equal to BPL, right Scott?

 

[CarbJunkie73]

no, equal to BPL, right Scott?

Well crap!! I need an acronym lesson I'm going by the dsHess.com lingo....

Actually, now I'm all screwed up and need to go back to the pics for a while to study!! SHHHHHIIIIIIIIIIIIIIT!!!!!!!!!!!!!

 

[Susan in Tennessee]

Well crap!! I need an acronym lesson I'm going by the dsHess.com lingo....

CC + AL (both absorbing limbs) = BPL (non absorbing limb) Add them ALL up and it should be the total bowel length (if I've got this wrong Scott is going to rap my knuckles with a rolled up magazine) but I'm holding my breath because I seem to not be able to retain anything I am taught these days!

 

[CarbJunkie73]