hello from the newbie!

[hilary1617]

@DSRIGGS,

First, Scott, I totally respect you, your experience and your point of view. (Given we've know each other for a while, I hope that goes without saying, really, but saying it anyway!!!!) You've definitely been through the wringer.

I'm just thinking back to the day of my pre-op appointments when I asked my then prospective surgeon about limb lengths. He said that he had tried a variety over many years and that in his experience 100 cm had yielded the best results in his patients. So, his emphasis was on his own clinical data.

Thankfully, I've only heard of a very limited number of patients who have had the degree of challenges you experienced and fewer still where the malnutrition has been directly tied to limb length (versus poor supplementation/diet). The complications rate overall for DS is pretty low and there is a high success rate. My thought is that the number of cookie cutter surgeons is likely higher than Hess surgeons. So, for most patients, I'm inferring tha the cookie cutter approach yields successful long term weight loss without material problems. That doesn't mean that I think cookie cutter is optimal. I believe you, Dr. K, and many respected vets that Hess is a superior method. We don't disagree on this point.

I just don't know that it is sheer laziness that keeps the cookie cutters from becoming Hessers.

I'm lazy myself and haven't looked for such, but I'd guess that the best way to convince a cookie cutter to be a Hesser is to show him or her significantly differentiated long term outcomes of valid, reasonably large side-by-side studies. If you've got a link to something along those lines, I'm happy to pass it on to the local team to try to drive for change!

 

[DSRIGGS]

@DSRIGGS,

First, Scott, I totally respect you, your experience and your point of view. (Given we've know each other for a while, I hope that goes without saying, really, but saying it anyway!!!!) You've definitely been through the wringer.

I'm just thinking back to the day of my pre-op appointments when I asked my then prospective surgeon about limb lengths. He said that he had tried a variety over many years and that in his experience 100 cm had yielded the best results in his patients. So, his emphasis was on his own clinical data.

Thankfully, I've only heard of a very limited number of patients who have had the degree of challenges you experienced and fewer still where the malnutrition has been directly tied to limb length (versus poor supplementation/diet). The complications rate overall for DS is pretty low and there is a high success rate. My thought is that the number of cookie cutter surgeons is likely higher than Hess surgeons. So, for most patients, I'm inferring tha the cookie cutter approach yields successful long term weight loss without material problems. That doesn't mean that I think cookie cutter is optimal. I believe you, Dr. K, and many respected vets that Hess is a superior method. We don't disagree on this point.

I just don't know that it is sheer laziness that keeps the cookie cutters from becoming Hessers.

I'm lazy myself and haven't looked for such, but I'd guess that the best way to convince a cookie cutter to be a Hesser is to show him or her significantly differentiated long term outcomes of valid, reasonably large side-by-side studies. If you've got a link to something along those lines, I'm happy to pass it on to the local team to try to drive for change!

Hilary,

Thanks for the reply and you know I completely respect you and value your perspective and advice on this forum....especially thank you for the Welchol recommendation when I was on CREON. It definitely helped the burning gut and butt syndrome as I like to call it.

Regarding the efficacy of the Hess vs Cookie Cutter the only data/study that I have is for the Hess Method and it is a study Dr K presented to the ASMBS in 2003 I believe.

http://www.dssurgery.com/about/publications/albumin-abstract.pdf

I am not aware of any studies on the cookie cutter side so I can't offer anything there. That doesn't mean they don't exist, I just haven't seen any....if anyone else has seen nutritional studies by a non Hess DS surgeon please post them.

Regarding your surgeon doing the DS based on a 100cm CC only (which BTW wouldn't be too far out of line with the Hess in many cases), what does he do for the AL length? For the life of me I don't understand why in the DS community so many people only talk about the CC. It isn't just the CC that matters for the performance of the DS. In my mind what is crucial with the Hess method and the DS in general, is that ALcm + CCcm = BPLcm.

So in a Cookie Cutter Scenario - Assume a 600cm total SBL and 100cm CC:

• If a 200cm AL was given then that would be perfect yielding absorption of 50% of inches available
  • CC 100cm + AL 200cm = 300cm BPL. 50% absorbing inches
• If a 150cm AL was given then that person would only have 42% absorbing inches. That could be enough to create issues with nutrition.
  • CC 100cm + AL 150cm = 250cm; 250CM absorbing tract/600cm Total SBL = 42%
• If a 250cm AL was given that would yield absorption of 58% available inches:
  • CC 100cm + AL 250cm = 350cm absorbing inches; 350cm absorbing tract/600cm Total SBL = 58%. Likely to not lose sufficient weight.

Now go to a person like me who is 6'2 and has 725cm Total SBL and do the same thing as your Dr, which BTW my Dr did. I had a 100cm CC per Dr Marshall and Dr K actually measured it at 125cm and my supposed 150cm AL at 200cm. So I had 325cm/725cm = 45% absorption from Dr K's measurements and from Dr Marshall's reported AL + CC of 250cm was 250/725 = 35%. In any case I had bad malnutrition.

When you add in all the variability of differing small bowel lengths (study shows a correlation with height) , how can you possibly get it right for everybody if you used the same AL & CC length on everyone? The answer to me is that obviously you can't. I respect the opinion of others but to me the data shows the Hess Method works 100% of the time in Dr K's study of 373 patients. (Mot one failed and seven went on CREON temporarily but did not need revised). I had issues with malnutrition with the cookie cutter. I am not statistically significant but it is clear to me what the science says.

​

Regarding my comments about some surgeons being intellectually lazy on DS research, I guess I am describing Marshal and my experience with him. It isn't fair to ascribe his behavior to others. Marshall is Director of Trauma for Level 1 Trauma center at a very large hospital (700 beds I believe) so he spends a great deal of time with Trauma patients and consequently only a small amount of time with Bariatrics (and he still does a lot RnY GBP). He is a GREAT CUTTER, he just doesn't understand the DS and the impact of limb lengths well enough and was frankly negligent with me in that regard. He was intellectually lazy when it came to the DS as he told me there is no science behind how much to add to the CC if one has malnutrition and didn't even consider adding to the AL....both positions are absolutely incorrect. Maybe it isn't fair to ascribe his behavior to others, but i haven't seen data on the "cookie cutter" and malnutrition so I don't know.

Summary: I respect your opinion and I know I strongly advocate for the DS and don't speak well of the cookie cutter as an ASMBS approved standard of care for the DS. Please don't take that as me saying anything bad about those patients who had successful cookie cutter DS's. I certainly try to be cognizant of my comments that I know are stated strongly but I do try not to offend. Yes the cookie cutter works for many but for those of us on the tails of the normal distribution curve, we were failed. I simply think the cookie cutter shouldn't be performed when it only takes 15 more minutes to measure the Total SBL and optimize channels for optimal patient outcomes. As a good friend and board member has said, the tough part surgically when it come to the DS is dividing the duodenum, so that part is done and the measuring to get correct channel lengths is a piece of cake relative to the duodenum division.

Anyway I love your posts, your style and I know I would find you very charming if we ever met. ....thanks for your reply and sorry I am such a windbag.

 

[hilary1617]

Scott,

Thanks for the follow-up and for raising the issue of limb lengths for us all to ponder. I'm sure if we were to meet in person it would be all smiles (and for once, my end of the conversation would actually be typo-free)!

Memory fails me this far out as to what my other limb lengths might be, though at some point will dig out my old surgical report. You've also piqued my curiosity as to how those lengths are determined by my surgeon - will ask him the next time I'm in his office: is another limb always also at a fixed length (AL?), with the variation always in the remaining limb (BPL?); or does he cut down the middle for the balance above 100 to create a 50%/50 split; or something else altogether.

Have a great weekend!

 

[Larra]

Hi there! sorry I didn't greet you sooner, I was out of town for a few days and didn't see your post. Welcome!

By now you have probably met with "your" surgeon, but as others have said, he is very unlikely to recommend an operation he doesn't do, and as we discussed elsewhere, there is no one in San Diego doing the DS. Dr. Keshishian is very highly regarded, and even if you are not sure about the DS, you have nothing to lose by having a consultation with him, which would be an opportunity for you to hear a positive point of view about the DS from a surgeon with extensive experience with it who actually follows up his patients far more than most. And a consultation doesn't commit you to any course of action, if you learn all about the DS and don't think it's for you, do something else and you will be making a better informed decision.
My own opinion is that you do have a couple serious metabolic issues that the DS would benefit, meaning the prediabetes (which won't be pre forever) and the PCOS and metabolic syndrome. The DS has a very high cure rate, yes cure, for type 2 diabetes, and while a cure can't be guaranteed for PCOS it's your best shot at a cure. The metabolic benefits of the DS are far greater than those with gastric bypass, and without the miserable side effects of dumping, limited diet, no NSAIDs for the rest of your life and such. And while sleeve does help some people, it does not have any of the metabolic changes you need for the problems you have mentioned.

As far as your band is concerned, I hope by now you realize that it's the band that failed and not you. Of course your fills didn't work, your band was broken. The fill just leaked out and you were left with nothing. Whatever you do, don't blame yourself, and don't let any doctor blame you either.

 

[DSRIGGS]

Scott,

Thanks for the follow-up and for raising the issue of limb lengths for us all to ponder. I'm sure if we were to meet in person it would be all smiles (and for once, my end of the conversation would actually be typo-free)!

Memory fails me this far out as to what my other limb lengths might be, though at some point will dig out my old surgical report. You've also piqued my curiosity as to how those lengths are determined by my surgeon - will ask him the next time I'm in his office: is another limb always also at a fixed length (AL?), with the variation always in the remaining limb (BPL?); or does he cut down the middle for the balance above 100 to create a 50%/50 split; or something else altogether.

Have a great weekend!

Thanks and have a great weekend yourself Hil!

and lol on the memory. I had my revisions just in August and I still have to go back and look at Dr K's op report to remember exactly how long my SBL was. I am not even 50 yet (June) and I already have the memory of a 80 year old.

 

[Munchkin]

That surgeon already failed you once with that crap band. Why would you go back for more? You didn't fail. The band doesn't work.

Welcome! Be strong, be assertive. Don't let them sell you another clunker.