Self pay, deciding between DS vs SADIS due to complication concerns -

[TheRealist]

I'm in the process of setting up surgery as self-pay because my workplace plan has a weight loss surgery exclusion (all types, for any reason). I've found what I think is a well qualified surgeon who is also affordable for self-pay patients: Paul Enochs with Bariatric Specialists of NC. I've been surprised by how low the cost is, but the surgeon seems to be well-credentialed (FACS, ASMBS) and has been practicing for a long period of time. The cost for a full DS are $14k and the cost for the SADIS are $12k. That includes a 1 day hospital stay and 5 years of follow-up care.

I'm leaning toward the full DS for all the reasons that everyone here already knows:

(1) Since I'm paying out of pocket, I want the most effective tool to get to a normal BMI and stay that way. The full DS is the only option proven to be capable of doing that over the long-term for most patients.

(2) Although the full DS has a higher complication rate, people with my health profile are in the category least likely to experience any major complications (BMI 43, 32 years old, no co-morbidities).

(3) The preliminary research on SADIS looks good, but there still isn't enough data to know about long-term outcomes. 10 years ago everyone thought the lap-band was going to be the best new weight loss surgery, but look how that turned out. I don't think SADIS will necessarily go the same way. But for now, there isn't much long-term research to know whether SADIS will have comparable weight loss effects.

If this were covered by insurance, I would opt for the full DS without issue. However, my insurance has very scary language about how they will not cover complications from uncovered procedures. Complications from any weight loss surgery are expensive, but the more complex the surgey is the more likely it is to result in complications. The full DS is one of the most complex procedures, SADIS is much simpler. I think my health profile means my chances of complications are low, but they would probably be even lower with SADIS.

Honesty, I'm fearful of having the full DS and then having bankruptcy-level complications (wouldn't take much - just about any hospital stay would do it). Also, with a full DS, I'd only be able to stay in the hospital for 1 day. That seems unusual - most people seem to have a few days (or more) hospital stays.

So what to do? Go with the SADIS because its less likely to lead to complications and work out well under a self-pay circumstance (only 1 day hospital stay, etc.)? Or take the risk with the full DS?

 

[DianaCox]

It’s open enrollment for most people - can you change to a better insurance plan?

Since you’re self-pay, can you buy a supplemental insurance plan for surgical complications?

Check for how long your insurance company can legally refuse your routine follow up care under the ACA mandate against restrictions based on pre-existing conditions.

 

[hilary1617]

@TheRealist,

My perspective is there isn't much risk difference between procedures - the risk is having either without a safety net if something goes wrong. Possibilities of standard surgical complications are out there for either procedure and 1 day in hospital seems short to me for either. What if there ertr an infection or leak? Would additional days be covered under the original fee if medically necessary? Would that be covered in the 5 year follow-up care?

My take is that the SADI isn't much simpler from a surgical standpoint. The only difference is that there is one less anastomosis. In exchange for one less anastomosis, the SADI poses a complication risk that the DS does not - that of risk of bile reflux. If you are considering this on a long term nutritional risk basis, long term results aren't out yet for SADI, but for DS that is usually prevented with adherence to testing and supplementation.

Probably would be a good idea for you to discuss with Dr. Enochs. I'm curious about his office's actual comparative experience or any statistical studies of which he might be aware...

I echo Diana's thoughts about switching plans if possible.

All the best!

 

[southernlady]

One thing to verify if you go with him for the DS is how long a common channel. There is one group in NC doing the DS with 300 cm common channels but which group escapes me at the moment. I know it isn’t Sudan and his partners at Duke but can’t remember who it is.

 

[TheRealist]

Thanks for the quick responses!

Unfortunately, switching insurance plans isn't an option. I only have a full PPO plan and HDHP plan through work, and both of them have surgery exclusions. I thought about getting a plan through the ACA, but that seems to be almost as expensive. Most of the plans on my state's exchange are $450/month premiums and $7,000 out of pocket maximums. I get no subsidies because my workplace has a plan I'd be opting out of. All the ACA plans also come with 12 month "medically supervised weight management" requirements before they will approve surgery. So by the time I've paid for 1 year of $450/month premiums, and hit the OOP maximum on the plan for the surgery year, I'm looking at roughly equivalent costs.

I've been jumping through the pre-surgery testing requirements and am going to ask about the 1 day hospital thing at my scheduling visit. I think additional hospital days come out of my pocket - probably $2k-$3k a day. I could probably do 1 extra day, but at that rate I'd want to avoid it. As I understand it, the follow-up care for this practice includes 5 years of check-in visits with the surgeon. At first a few weeks post-op, then every 6 months, then toward the end of the period yearly. It does not cover lab work, but I think I can get my insurance to cover labs with the right coding (the office seems to be happy to avoid coding things with "morbid obesity" as the code).

I've been looking into getting insurance for surgical complications, but can't really find much. I would think I am a good risk-profile for this, but maybe not? As time passes after the surgery, I think I could use the "you can't deny a pre-existing condition" argument to get things covered. But I am most worried about the first ~90 days, st that seems to be when most of the major complications can occur. After that, things seem to be mostly be related to nutrition deficiencies.

The common channel is normally 300cm for this practice, but they seem to be very amenable to changing it. I was going to ask for 150cm. I'm a 6"2 male, so my understanding is that going below that might induce a bit more risk. Dr. Enochs is actively doing peer-reviewed research on SADIS, and he has published some things that are very much in favor of the procedure. But I don't feel that I'm being pushed into SADIS. In my initial consult he seemed to think a SADIS would be best for my health profile, but also thought a traditional DS would be fine.

 

[Clematis]

A 300cm common channel is simply not worth the expense or risk. There is no data to support how something that incredibly long will benefit.

Consider a proper DS with Dr. Esquerra (or Dr. Wilhelmy) at Mexicali Bariatric Center. They keep you in the hospital for 4 nights so if you should have a complication, it should happen then and be attended to. (But I've never heard of a MBC patient having a major complication.) The hospital is wonderful -- far cleaner than any in the US!! It's $11k (and sometimes less as they have "specials"). You're transported to and from San Diego airport and spend the first night pre-surg in a lovely hotel. Many of us went there and were thrilled with the results.

 

[TheRealist]

I've thought about Mexico as an option but my main concern is follow-up. Assuming all goes well there won't really need to be much, I know. But I like the fact that I can call the surgeon and see him in person if anything arises without traveling internationally (at no additional cost - for the next 5 years). Irrational? Certainly. But that bit of irrational peace of mind means a lot to me.

I don't plan to get either surgery with a 300cm common channel. The length of the common channel seems to be a key piece to keeping the weight off long-term. With either SADIS or DS, I would be asking for a 150cm channel.

 

[southernlady]

I've thought about Mexico as an option but my main concern is follow-up. Assuming all goes well there won't really need to be much, I know. But I like the fact that I can call the surgeon and see him in person if anything arises without traveling internationally (at no additional cost - for the next 5 years). Irrational? Certainly. But that bit of irrational peace of mind means a lot to me.

I don't plan to get either surgery with a 300cm common channel. The length of the common channel seems to be a key piece to keeping the weight off long-term. With either SADIS or DS, I would be asking for a 150cm channel.

Then get the DS and have him agree to it IN writing on your consent form. And have it witnessed by someone other than one of his office staff...like one of YOUR family members.

 

[TheRealist]

I didn't think about doing that - but I certainly will! I guess it never occurred to me that they would agree to doing 1 length and end up doing 300cm. Does that happen? Will definitely make sure its on the consent form to hopefully avoid that. I even thought about asking for 100cm, but I worry that the chance of having lose stool/flatulence issues goes up the more you get lower than 150cm.

Now if I could just figure out which surgery (DS vs SIPS) and how to deal with the issues of complications/more than 1 night in the hospital/etc.

 

[Munchkin]

Realistically speaking, once you are cut and healed, there is no reason to see your surgeon ever again. They are cutters... Period. The followup care available in most practices is worth exactly nothing and I believe you said he doesn't pay for lab work too so what's the value in that 5 year thing?

There is not enough difference in the rate of postop complications to make one surgery a safer bet than the other. It all boils down to what you want! Hope you are getting rid of your GB too!

 

[Clematis]

Can you get him to do a common channel based on the Hess Method? That is your best bet for anyone, especially for a tall man as yourself. Total bowel length is usually -- but not always -- a function of one's height.

 

[Clematis]

I second @Munchkin Surgeons and their nutritionists give abysmal advice. I know it sounds crazy to take nutritional advice from the internet but please suspend disbelief and do exactly that. They are not trained in the care and feeding of DS patients

 

[Clematis]

As my attorney husband says, he would be appalled if a client came to him for years seeking investment advice on the settlement he litigated for them. Docs do not receive nutritional training in med school.

 

[southernlady]

I didn't think about doing that - but I certainly will! I guess it never occurred to me that they would agree to doing 1 length and end up doing 300cm. Does that happen? Will definitely make sure its on the consent form to hopefully avoid that. I even thought about asking for 100cm, but I worry that the chance of having lose stool/flatulence issues goes up the more you get lower than 150cm.

Now if I could just figure out which surgery (DS vs SIPS) and how to deal with the issues of complications/more than 1 night in the hospital/etc.

Every surgery carries the risk of complications up to and including death but a reputable surgeon will do their best to limit complications.

The more than one night is problematic as both require almost the exact same amount of cuts/incisions. The exception is the second anastomoses of the DS.

 

[Larra]

So many good comments already!
As @hilary1617 said, the only possible less surgical risk with SADI is one less anastomosis, and it's the easy anastomosis at that, which rarely (you can never say never, but really rarely) causes any complications anyway. And the SADI always has a long common channel. That's how it's designed. You would have to use almost the entire small intestine in the loop part of the SADI to get a 150 cm common channel. Not how it's done.
I second the recommendation of Dr. Esquerra. You would have a few days in a hospital, where everyone who goes there says the care is excellent and the place is the cleanest hospital they've ever seen. Yes, it's less convenient, but it's just a one time thing, and they make it as easy as they can for you. Your pcp can order your follow-up labs, which is what most of us do anyway, and you are clearly a very intelligent person who can check your labs yourself and adjust your supplements as needed.
But, if you do stay local, get everything in writing before the day of surgery. BTW, I was throwing up the day after surgery in a hospital right here in the USA with a very experienced DS surgeon and a complication free surgery. There was no way I could have gone home after just one day. I guess if I had been self-pay that would have been 2K more to pay.