Pay for the DS... Walk out with something else.

[Larra]

@Up2Me3 , 200 patients being followed over 7 years of experience doesn't mean that all 200 have been followed for 7 years. The first few yes, but some just for 6, and a lot more for 5 or less. And it's just one study. So the bulk of these patients are still what I would consider short term. Given that morbid obesity is a chornic, lifelong medical problem once you have it, that's a drop in the bucket.

For me, back when I had my DS in 2006, it was very well established and standard of care. The Hess study, involving almost 1000 patients followed for 10 years, had been published. It was very influential in my decision to have bariatric surgery. I had already decided against gastric bypass because I had seen so many people, both online and in a local support group, get it, do great initially, and then hit a wall where no matter how hard they tried they could not lose any more weight and there were nowhere near normal weight, AND they began struggling not to regain.

I understand about takiing that leap. I felt the same way, and what got me to leap was that I knew what my future held if I didn't. I think you feel the same way, you just aren't sure where to leap. If you really want to be a trailblazer and go for something that might turn out to be promising, that's your decision. And I understand that having a surgeon whom you like and trust prefer the SADI has to be a big influence. But to me, given how much weight you need to lose, I would think the tried and true would be the way to go.

 

[Up2Me3]

@Spiky Bugger and @DianaCox I'm going to copy and paste the email replies that I received from Dr. Sanchez-Pernaute - with his permission. Please let me know your thoughts - he has addressed some of my concerns (I highlighted those). I do realize and hear you both on the LONG TERM prognosis not being proven.....still a concern for me.


Thank you for your confidence in writing me to seek for advice.
The first thing I've got to tell you is that you are in very good hands, as your surgeon undoubtedly has the greatest experience on SADI-S in the States.
I will try to explain you what you are asking for.
After SADI-S there should not be more bile across the pylorus than before surgery, unless your pylorus is not working well. The operation does not disturb the pyloric muscle; the union of the duodenum with the small intestine is done 2 - 4 cm away from the pylorus, and this muscle is avoiding bile from entering the stomach, as in non-operated people.
The elimination of one intestinal suture (anastomosis) reduces risks, as there is going to be less probability of postoperative leaks ("intestinal perforation through the sutures"). The elimination of the so-called Roux-en-Y eliminates the opening and closing of the mesentery, which is the fat and vascular leaf that holds the intestine; its opening in other kind of operations makes easier to suffer from postoperative herniations and intestinal obstruction.
In this way SADI-S simplifies the traditional DS. When I started it I anticipated results should be similar to those of the duodenal switch. Now, more than 7 years later, with almost 200 patients operated, which I have been following personally initially every month, and then every three months, I can affirm that this is true.
The operation is basically the same, but with the passing of time I've seen it has some more advantages over the traditional switch.
- There is a longer common channel, where your food is finally absorbed, so there is less steatorrhea, which is the elimination of fat in the stools
- This longer limb intensifies the metabolic effect of the operation, as there is more surface of contact of your bile with the intestinal cells
- If there is a problem in the future with a reduced absorption, which happens in about 5% of the patients, the operation is easily revised to a less aggressive one, as there is only one intestinal suture.
In summary, SADI-S is the modern type of DS, and currently there is no reason, except for the preoperative presence of a pyloric insufficiency, to perform the old operation.
I hope I've answered your questions.
If you want to see a video of the operation, follow this link:
https://www.youtube.com/watch?v=ksbP0BiD09U
If there is anything else you want, please write me again.
Sincerely,
Andrés Sánchez-Pernaute, MD, PhD

And here is his second email in response to my follow-up question(s) - I hope I'm not irritating him as well with all my questions LOL! I am also asking these of my surgeon - I'm just wanting different opinions.

I met you doctor in Montreal, at the last World Meeting of bariatric surgery held in September. I had the opportunity to perform alive a SADI-S as a second step after a previous sleeve, and he did a similar case in the same afternoon. Then I saw him at a SADI-S symposium in which he commented his experience which is, as far as I know, the third largest series in the world, after mine and one from Chile. He knows perfectly the physiological basis of the operation and has a great experience as a laparoscopic surgeon.
Speaking about reflux, you have acid reflux from the stomach into the esophagus, but no bile reflux, or alkaline reflux, from the duodenum into the stomach. Those are quite different issues that in case they work together could be dangerous, but this seems not to be the case.
The metabolic function of bile acids or bile salts when interacting with the intestinal surface has nothing to do with gastric or esophageal reflux. Don't worry about that.
It is true that the sleeve gastrectomy, a part of SADI-S but also of the traditional Duodenal Switch, is related to an increase in gastroesophageal reflux. However, the sleeve gastrectomy as a part of the duodenal switch is being performed in the world of bariatrics since 1988, when Douglass Hess introduced it as a part of the DS. If the sleeve is correctly performed, there should not be a significant increase in gastroesophageal reflux symptoms.
Malabsorption is expected to be the same than after DS, and, of course, greater than after gastric bypass, and because of this it offers better results.
And finally, long-term data are the following:
Long-term excess weight loss 90 to 95% (7.5 years)
Normalization of glycated hemoglobin (HbA1c) for diabetics, 80 - 90%, depending upon the history of the disease, duration, need for preoperative insulin....
Failure to reach a 50% excess weight loss: 5 - 6%
Malnutrition needing revision: 2 - 3%
Long-term excess weight loss for gastric bypass is 60 - 65%, normalization of HbA1c 70 to 80%, failure to reach a 50% excess weight loss is 30 to 40% and malnutrition needing revision below 1%.
The mean number of bowel movements is 2.5 per day, and it is directly related to the amount of fat ingested.
It is usually necessary to take calcium and vitamin D3, and many patients also need iron. Other supplements are not systematically prescribed.
I'm sure this is a very important step for you, but I' sure you are going to do very well.
Sincerely,
Andrés Sánchez-Pernaute

Hope this is also helping the gal that went in for a DS and came out with a Loop unknowingly. I can't seem to find her - there are a couple of people on here with the same avatar is seems. I would be mad as HELL to have been given a surgery I did not agree to - HOWEVER - for her...as it's already a "done deal"...I think things look promising and hoping that this is giving her some comfort!

 

[Spiky Bugger]

@Spiky Bugger and @DianaCox I'm going to copy and paste the email replies that I received from Dr. Sanchez-Pernaute - with his permission. Please let me know your thoughts - he has addressed some of my concerns (I highlighted those). I do realize and hear you both on the LONG TERM prognosis not being proven.....still a concern for me.

Hi Stephanie,
Thank you for your confidence in writing me to seek for advice.
The first thing I've got to tell you is that you are in very good hands, as Dr. Cottam undoubtedly has the greatest experience on SADI-S in the States.
I will try to explain you what you are asking for.
After SADI-S there should not be more bile across the pylorus than before surgery, unless your pylorus is not working well. The operation does not disturb the pyloric muscle; the union of the duodenum with the small intestine is done 2 - 4 cm away from the pylorus, and this muscle is avoiding bile from entering the stomach, as in non-operated people.
The elimination of one intestinal suture (anastomosis) reduces risks, as there is going to be less probability of postoperative leaks ("intestinal perforation through the sutures"). The elimination of the so-called Roux-en-Y eliminates the opening and closing of the mesentery, which is the fat and vascular leaf that holds the intestine; its opening in other kind of operations makes easier to suffer from postoperative herniations and intestinal obstruction.
In this way SADI-S simplifies the traditional DS. When I started it I anticipated results should be similar to those of the duodenal switch. Now, more than 7 years later, with almost 200 patients operated, which I have been following personally initially every month, and then every three months, I can affirm that this is true.
The operation is basically the same, but with the passing of time I've seen it has some more advantages over the traditional switch.
- There is a longer common channel, where your food is finally absorbed, so there is less steatorrhea, which is the elimination of fat in the stools
- This longer limb intensifies the metabolic effect of the operation, as there is more surface of contact of your bile with the intestinal cells
- If there is a problem in the future with a reduced absorption, which happens in about 5% of the patients, the operation is easily revised to a less aggressive one, as there is only one intestinal suture.
In summary, SADI-S is the modern type of DS, and currently there is no reason, except for the preoperative presence of a pyloric insufficiency, to perform the old operation.
I hope I've answered your questions.
If you want to see a video of the operation, follow this link:
https://www.youtube.com/watch?v=ksbP0BiD09U
If there is anything else you want, please write me again.
Sincerely,
Andrés Sánchez-Pernaute, MD, PhD

And here is his second email in response to my follow-up question(s) - I hope I'm not irritating him as well with all my questions LOL! I am also asking these of my surgeon - I'm just wanting different opinions.

Hi again Stephanie,
I met Dr. Cottam in Montreal, at the last World Meeting of bariatric surgery held in September. I had the opportunity to perform alive a SADI-S as a second step after a previous sleeve, and he did a similar case in the same afternoon. Then I saw him at a SADI-S symposium in which he commented his experience which is, as far as I know, the third largest series in the world, after mine and one from Chile. He knows perfectly the physiological basis of the operation and has a great experience as a laparoscopic surgeon.
Speaking about reflux, you have acid reflux from the stomach into the esophagus, but no bile reflux, or alkaline reflux, from the duodenum into the stomach. Those are quite different issues that in case they work together could be dangerous, but this seems not to be the case.
The metabolic function of bile acids or bile salts when interacting with the intestinal surface has nothing to do with gastric or esophageal reflux. Don't worry about that.
It is true that the sleeve gastrectomy, a part of SADI-S but also of the traditional Duodenal Switch, is related to an increase in gastroesophageal reflux. However, the sleeve gastrectomy as a part of the duodenal switch is being performed in the world of bariatrics since 1988, when Douglass Hess introduced it as a part of the DS. If the sleeve is correctly performed, there should not be a significant increase in gastroesophageal reflux symptoms.
Malabsorption is expected to be the same than after DS, and, of course, greater than after gastric bypass, and because of this it offers better results.
And finally, long-term data are the following:
Long-term excess weight loss 90 to 95% (7.5 years)
Normalization of glycated hemoglobin (HbA1c) for diabetics, 80 - 90%, depending upon the history of the disease, duration, need for preoperative insulin....
Failure to reach a 50% excess weight loss: 5 - 6%
Malnutrition needing revision: 2 - 3%
Long-term excess weight loss for gastric bypass is 60 - 65%, normalization of HbA1c 70 to 80%, failure to reach a 50% excess weight loss is 30 to 40% and malnutrition needing revision below 1%.
The mean number of bowel movements is 2.5 per day, and it is directly related to the amount of fat ingested.
It is usually necessary to take calcium and vitamin D3, and many patients also need iron. Other supplements are not systematically prescribed.
I'm sure this is a very important step for you, but I' sure you are going to do very well.
Sincerely,
Andrés Sánchez-Pernaute

Hope this is also helping the gal that went in for a DS and came out with a Loop unknowingly. I can't seem to find her - there are a couple of people on here with the same avatar is seems. I would be mad as HELL to have been given a surgery I did not agree to - HOWEVER - for her...as it's already a "done deal"...I think things look promising and hoping that this is giving her some comfort!

My thoughts: Sánchez-Pernaute could be absolutely correct. But as of this moment, he is the chief cheerleader for this procedure...the first name on the only SADI publication at PubMed and that article covered 50 patients over a maximum of three years.

Not enough for me.

But that doesn't mean that other people wouldn't want to go for it. And it doesn't mean that after Sánchez-Pernaute has peer reviewed results over actual long term and after the ASMBS endorses the procedure as an acceptable bariatric surgery and after insurance companies decide to cover it (they'd be among the first, because it's a simplier aka probably cheaper) procedure than the DS...after all that I would take another look.

But until then, SADI patients are guinea pigs...and I don't covet that job.

 

[DianaCox]

So far as from what I have seen, weight regain starts between years 3-5 for most bariatric surgeries (though for the DS is it usually a little later, due to better malabsorption). There are VERY few SADIs that far out. I also haven't seen how the diet differs - I suspect there are dietary restrictions about limiting fat. Long term, diets are hard to maintain.

The ONLY "good" thing I can think of about the SADI is that, when it fails, revision to a proper DS will look like this:

• (Assuming 300 cm "alimentary" tract created with SADI): Cut the intestine just upstream from the duodenal-(distal)jejunal anastomosis to create separate biliopancreatic and alimentary limbs, and leaving a longer-than-average alimentary tract (DS usually has a duodenal-(proximal)ileal anastomosis, further down the small intestine)
• Seal the open intestine upstream of the anastomosis
• Anastomose the distal end of the biliopancreatic limb to the normal DS site placement on the alimentary limb, about 100 cm from the ileocecal valve

Whether doing so would have any effect on failed weight loss, I don't know, because that's the problem with failed surgeries - every time you do a bariatric surgery, you further damage the metabolism and make it more efficient - making a DS out of a SADI might help maintain weight loss, but probably won't induce much if any FURTHER weight loss, without a concomitant (and far more dangerous) resleeving. Because that's just the way things seem to work with revisional bariatric surgeries.

As for how I found out about it - I was bitching on OH that after doing my due diligence on weight loss surgeries - i.e., lapband and RNY - that I had come to the conclusion that I could not do it - they didn't work, people were miserable, and there was lots of puking involved, and I don't DO puking. And I couldn't live on a diet anyway, so fuck it. Someone PMed me the link to duodenalswitch.com (yes, there was NOTHING on OH at the time about the DS), and suddenly, the skies cleared, the sun came out, and angels sang. THIS surgery made medical and biochemical SENSE! And people were HAPPY with it! And not puking or dieting!

So the owner of duodenalswitch.com had the ORIGINAL DS surgeons list. In my area (SF Bay) there were two choices: PacLap (both Rabkins were doing the DS at at the time) and LapSF (Jossart, Cirangle and Feng, though I don't think Feng was doing the DS). Both of them were on the list, though the Rabkins were clearly preferred. I interviewed both of them on the same day, and by the time I walked out of LapSF (the second appointment), my mind was made up - and Jossart could suck my hind titty - he said the RNY was good enough for me, since my BMI was "only" 49 and Aetna didn't cover the DS. Fuck you very much.

Since I had one of the best within 51 miles of my house (important that it was 51 and not 49 for insurance purposes!), I didn't feel it was necessary to look any further. In the six months between interview and surgery, I only became more confident of my choice.

There were already several long term publications at the time, most notably the Hess publication, as well as the Rabkins' stats.

 

[DianaCox]

OK, I wrote the above over several hours and didn't notice your posts from Dr. P inbetween.

I have no idea what this means: "This longer limb intensifies the metabolic effect of the operation, as there is more surface of contact of your bile with the intestinal cells"

To my knowledge, bile being in contact with intestinal cells is irrelevant to any "metabolic effect" of which I am aware. Bile is necessary to dissolve fats, which is a precondition for lipases breaking fat down so it can be absorbed. Instead of bile being in contact with the fat in your food for 100 cm as it is with the DS, in the SADI it is in contact for 300 cm (if I understand how his SADI is constructed). What that means, is that there is going to be at least double if not close to triple, the fat absorption in a SADI - that's the only "metabolic effect" I know of, and thus LESS of the favorable metabolic effect of a DS. Perhaps you can ask him what he means by that statement.

And I still wish the SADIsts would stop calling it a DS - one of the hallmarks of the DS is selective fat malabsorption - this is not what you are getting when your entire alimentary tracts is a common channel - all you have is effectively a short gut.

 

[Larra]

Diana, I have long known that you were special, but was unaware that you had a hind titty. Just one? On the right or the left, or perhaps centrally located?? When you have your mammograms, do they include the hind titty? I wouldn't want you to ever need a hind titty mastectomy.

I bet that thing was uncomfortable when you were breast feeding your children.

 

[DianaCox]

In retrospect, i think I mixed metaphors "Sucking hind titty" means, I believe, getting the dregs, the worst position, like the runt of the litter gets. What I think I really meant is he could suck my DICK, thought that presents still other anatomical issues, so I substituted a more female derogatory term.

Speaking of that turn of phrase, however, my daughter's ex-sister-in-law is a a delightful mouthy tart of a girl, Her parents are old-school, genteel-appearing, Hispanic immigrants - but with deliciously dirty minds. One day, the SIL - who was about 16 and feeling her oats and pissed off at her mother, decided to launch the worst cussing she could think of at her - "Momma, SUCK MY DICK!" - to which her momma answered with a smile and in the sweetest tone of voice - (with the Spanish accent of course) - "Oh Tanya, you talk just like your daddy!" At which the 16 year old ran screaming from the room with her fingers in her ears .....

 

[Munchkin]

Less steatorrhea..... Translation....more fat is absorbed than with the DS. Me personally, I need all the steatorrhea I can get!

Here's my best guess based on the sparse knowledge I have of 2 patients. One lost the weight and is now starting to rail against the regain train. She is less than 2 years out. And the other is about 6 months out and has had only a very paltry loss. I am thinking it's a viable easier OP for the surgeon and probably better than the RNY or band. But the longterm results are going to show it is less effective than the whole DS.

In 10 years or so we will know the answer.

If I was starting out today I would at least consider this but with 20/20 hindsight I'm still wishing I had had a more drastic DS!

 

[Larra]

I liked the mixed metaphors and this thread needed a little comic relief.

 

[Sheanie]

Yes, @DianaCox, the hind tit is inferior in mammals. Less fatty hindmilk production, thus less brain growth. But I also like your dick sentiment.

This statement in particular bothers me:

In summary, SADI-S is the modern type of DS, and currently there is no reason, except for the preoperative presence of a pyloric insufficiency, to perform the old operation.
With no long-term proof, this statement is a lie. I predict the SADI will be proven to be what I have suspected it to be all along: a lazy procedure for the surgeon.

 

[Up2Me3]

Less steatorrhea..... Translation....more fat is absorbed than with the DS. Me personally, I need all the steatorrhea I can get!

Here's my best guess based on the sparse knowledge I have of 2 patients. One lost the weight and is now starting to rail against the regain train. She is less than 2 years out. And the other is about 6 months out and has had only a very paltry loss. I am thinking it's a viable easier OP for the surgeon and probably better than the RNY or band. But the longterm results are going to show it is less effective than the whole DS.

In 10 years or so we will know the answer.

If I was starting out today I would at least consider this but with 20/20 hindsight I'm still wishing I had had a more drastic DS!

@Munchkin I thought you did have the DS....what do you mean you wish you'd had a more drastic DS? Would you mind sharing your numbers....tell me to jump if you'd like....I hold VERY tightly to my number

I have a 3rd follow up with Cottam today and I'm trying desparately to get into Simper for a 2nd and possible surgeon switch. I'll keep you posted. Thanks for all the feedback.

 

[southernlady]

@Munchkin I thought you did have the DS....what do you mean you wish you'd had a more drastic DS? Would you mind sharing your numbers....tell me to jump if you'd like....I hold VERY tightly to my number

I have a 3rd follow up with Cottam today and I'm trying desparately to get into Simper for a 2nd and possible surgeon switch. I'll keep you posted. Thanks for all the feedback.

I know I had the DS but if I had had my druthers, I would have also been a bit more drastic...my common channel is 175 (lowest I could get Boyce to do on ME). I would have much preferred a shorter common channel.

 

[Jbandmmomma]

THIS. A smaller sleeve and a shorter common channel. (Not that I am wishing for it at 5 months out, but in a few years I very well might be.)

 

[southernlady]

THIS. A smaller sleeve and a shorter common channel. (Not that I am wishing for it at 5 months out, but in a few years I very well might be.)

My sleeve is still rather small. So I'm okay there. Just means I have to eat OFTEN!

 

[Larra]

@Up2Me3, there has been so much back and forth here, and I know this has to be a really tough decision for you. So I just wanted to say that no matter what you decide, we will be here for you, and we will be hoping for you to be fantasticly successful and healthy and happy. We want you to lose all that weight and have huge flaps of skin hanging down to the ground around your otherwise perfect body.
It's a very personal decision whether to have bariatric surgery at all - most MO people never do. And these days there are more choices about what type of surgery, which is good in a way because this isn't a "one size fits all" thing any more than panty hose ever was, but it does make the thought process more difficult and stressful. So get your consults, do what you believe is best for you, and thenn commit to it and make the most of it that you possibly can. And we will support you in your efforts whatever your decision.