Surgeon wants VSG vs Roux-en-Y

[Clematis]

Hello all.

I'm in need of good counsel about WSL options. I have BMI of 40, pre-diabetes, cholesterol levels of 300+, hypertension and I am no spring chicken. After years of research, I decided on roux-en-y because it had both restrictive and malabsorption features, and the agony of dumping would be an immediate reinforcement. I also have had life-long reactive hypoglycemia but that is very well managed as long as I don't eat pancake syrup in the morning.

I had my surgeon consult yesterday for roux-en-y but when he found out I had had a tiny kidney stone a year ago, he was adamant that I have a VSG with a 3/4c capacity instead because of fear I'd have dehydration and suffer repeated kidney stones. (I don't know if RH was also a concern for him; he did say there was no data regarding whether people with preexisting RH are more likely to have the type of RH that can happen in RNY.) This switcheroo to VSG blindsided me and I didn't have appropriate data for a lucid rebuttal. I'm crafting a written response to be waiting in his In Box on Tuesday morning.

My take is that there simply is not enough long term data on the VSG to warrant the risk (and expense -- I'm self pay) of having most of my stomach excised. What little data there is shows disappointing 5-10 year results in achieving and maintaining significant reduction of weight, diabetes, hyperlipidemia and hypertension. (Most WLS looks "good" a year out -- hell I have even dieted off 80-100 lbs on my own many many times. But after a year... or after 5 years... Meh. I am too old and too cash-strapped to have conversion surgery 5-10 years out.) Anecdotal info I have gleaned from several WLS forums does not make the VSG look like a good long term choice. There's almost no VSGers still posting 5 years out. Just as the once lauded gastric band has been abandoned, I wonder if the restrictive-only VSG will fall in to disuse as well.

And so what do you all know about the dehydration issue, specifically dehydration in RNY vs VSG? I see quite a few VSG people posting that they are dehydrated, too.

Those who have had VSG 5+ years ago: how difficult is it to maintain your weight loss?

I was so very excited yesterday to start this process, and so disappointed as I left the surgeon as I fear the VSG would be a long term failure for me.

Thanks so much for any of your input.

PS: I've read that many of you have the bubbling red hots for DS and that was definitely on my dance card when I went in yesterday. But the surgeon told me that this hospital does not do it and that the other 2 hospital systems in town only do it for the SMO, not someone with BMI of 40.

 

[weaura]

That made me laugh because you're right we are "bubbling red hots for DS".
I don't have answers for any of your questions. Sorry.
If you are already a self pay, would you be willing to find an experienced and excellent surgeon with experience in DS?
There are people here who will give you some great suggestions and advice on your questions.
I'm glad you're here. You came to the right place.

 

[Larra]

Welcome!
I think it's great that you're doing your own research, and you are right about a lot of things and maybe not so right about some other very important things.
First, you don't way how old you are, but I don't think that should be a factor in your decision.
Next, re: VSG - you have clearly done a good job with your research. Long term results are starting to come in and they don't look great. My personal belief is that there will be some successes, but it will require great diligence, a low fat, low carb, low calorie diet for life, and exercise. And we are seeing more and more people who really did try their best and are now seeking revisions.
Next, re: lap band - I wish you were right about it being abandoned, but we aren't there yet. Again, a high failure rate and lots of people seeking revisions. but there is a manufacturer still pushing this flawed product and some surgeons making $$$ for relatively quick and easy surgery and more $$$ for fills and unfills. So not abandoned yet, but perhaps headed in that direction.

Next - gastric bypass. While it does have better long term results that VSG for both weight loss and resolution of type 2 diabetes, the results aren't really all that great. the failure rate, meaning losing less than 50% of excess weight, is at least 30%. So that means "success" is defined as losing just 50% of your excess weight. I personally would not have felt successsful

 

[Larra]

continuing - sorry! the website is not functioning well and I didn't want to lose what I had already written.

I would not have felt successful with just 50% to 60% weight loss, which is where a lot of people with gastric bypass end up.

More importantly, you have a big misconception about dumping. It is NOT a weight loss tool or aid. It is a very nasty and potentially dangerous side effect that some - not all - people with gastric bypass have. No one can tell you ahead of time whether or not you will dump, or whether you will dump on sugars or fats or both or neither. Many people who do dump learn which foods will cause a problem (remember, dumping is a problem) and just eat something else instead, or learn exactly how much will cause a problem and eat up to that limit. But lots of people who dump never get even close to a normal weight, or experience significant regain. Dumping is a bad thing, not a good thing.

As far as your cholesterol and blood pressure go, your chances of resolving these issues would be better with DS. Same for diabetes. Best weight loss and best maintenance of that weight loss, and yes, I'm one of the "bubbling red hots for DS" people. If you can't get a DS locally (I don't know where you are) I would recommend that you travel. Get an operation that is going to work long term, that won't make you dump, that WILL allow you to take NSAIDs (did you forget that if you get that RNY you can never take NSAIDs safely again ever?) and that won't make you dump.

Let us know where you are. We know the resources. We can help direct you to a respected DS surgeon. Before you know it you'll be bubbling red hot for the DS too.

 

[DianaCox]

If you are self-pay anyway, go to a surgeon who will give you a proper DS, customized to your medical needs.

 

[Munchkin]

Anything but the crap band beats the rny. Honest. The standard proximal rny bypasses so little that regain starts at around the 2 year mark when the body adapts to the bypass. Let's talk stomach. The VSG leaves you a smaller but still complete stomach and you have a pyloric valve. The stomach does stretch a bit to the point where most can eventually eat a small normal meal. The rny pouch is the abomination here. It's not right or anything even close to a real functioning stomach. That's why they call it a pouch.

Dumping is not a good thing. It is never good to suffer like that. Why do so many think we need to suffer to be deserving of losing weight? Obesity is a disease, not a character flaw. You didn't fail, the medical community failed you. You have a metabolic disease and you need a surgery that addresses your metabolic issues.

Just a little story for you. And I've told it before. I had to wait 2 years for my surgery date to roll around. I worked in an office full of fat women and 10 of us had surgery around this time. 8 had the rny, 1 crapband, and 1 DS, me. The crapband lost nothing. And some of the rny folks did well in the beginning. But today, 13+ years later, every single one of them weighs as much if not more than they did preop. And they are still puking and dumping. I am the only one who looks relatively normal. And I am still heavy. I never reached a normal BMI. If I had it to do over again, I wouldn't have waited 2 years. I would have gone elsewhere and had the DS on my schedule. During those 2 years, I can't tell you how many times they told me to just have the rny and be done with it. I'm glad to the moon and back I didn't give in! And BTW, all their co-morbs came back when they re-gained the weight!

Let's talk about your doctor. He/she is in business to make money. Always follow the money. He/she doesn't want you to give your money to someone else. They WILL sell you the surgery they do. Just like the Toyota dealer is NOT going to tell you about the new Nissan. Same difference. It's business. But it's YOUR life. So be careful and don't buy a lemon! Pick your surgery...then find a doc. Do what's right for you. If you give in and just do whatever is convenient and close to home, you will end up with the VSG or rny. There is a surgery mill on every corner.

Almost everyone who has WLS has to work to keep the weight off long term. The folks who have restrictive only surgeries have less to work with. The DSers usually get a get out of jail free card for several years and even when they have to start watching their weight, the DS gives them enough malabsorbtion to be able to fight back. There's a reason why we are bubbling red hot for the DS. It's the only surgery that addresses the metabolic issues that made us fat in the first place, life postop is pretty normal, and it's better at keeping the weight off than anything else out there. Someday there will be something better but today there is nothing out there that beats the DS.

Small kidney stone? You said you are not young. One small kidney stone in your whole life is honestly not that big of an issue and it's something that just happened. Now if you had a huge history of kidney stones that might be a different story. For most, hydration is not a big deal after you get through those tough times immediately after surgery. You just need to be aware and make a concentrated effort to get in enough fluids. Go back and read the paragraph about your doc again. He/she will find reasons why you should have the surgery they do! People I know who are truly kidney stone sufferers get them several times a year for decades. That's a real history of kidney stones. And none of the people I know with these issues have had any WLS. 1 small kidney stone in X years is an anomaly. 3 kidney stones a year for 3 years is a history. Get the difference? Be aware but don't let this one thing dictate your surgery choice. Addressing comorbidities like cholesterol, diabetes, and hypertension would be bigger concerns for me.

If I had to choose between the 2 surgeries you are contemplating, I would pick the VSG so I could at least have a real stomach, not a pouch. The malabsorbtion from the rny is gone by about the 2 year mark and in my mind it's just a cruel trick. I also don't want a blind stomach that can't be scoped that could cause me big problems in the future. If you are going to have to live on 800 to 1000 calories a day for the rest of your life, you might as well have to do it from the beginning. And why do you have to do this when others can eat normally? Because you have a metabolic disease these surgeries do not adequately address.

Too many people pick the doc first and that's a huge mistake. No matter what surgery you have, here's what everyone needs to do! To be a successful patient you have to be assertive and your own best self advocate. You can't afford to do this backasswards. Think twice(or even 10 times) and cut once!

1) Research. Read and learn. Talk to people who have had surgery and find out the best and worst of every procedure that interests you. Talk to as many people as you can who are 10 years or more postop. Every procedure has a honeymoon period. You want to talk to people who are way past that! NOTE: never believe the glossy brochures and promotional materials you might find in a doctor's office. Or online. Be a critical thinker! They want to sell you something. Each and every one of them!

2) Pick the surgery that's best for you. Be honest with yourself and know why you are fat. Is dumping for the rest of your life OK? Are you willing to do the work? Have your labs done and take supplements? Will the surgery work with your lifestyle? What changes will you have to make?

3) Find an experienced doc who does the surgery you want. Research the doc to make sure you are comfortable with their qualifications.

4) See the doc and discuss the surgery. Then make up your mind if you want to proceed.

Best of luck to you! The happiest patients are always the ones who ask all the hard questions before they are sliced and diced!

 

[southernlady]

For the record, I am a lightweight, my pre-op BMI was 35.2...was 56 (now 61) when I had the DS. Knew I needed NSAIDS the rest of my life. Had reactive hypoglycemia before WLS and dumping (early or late) is miserable...read the studies I have linked here: http://bariatricfacts.org/threads/reactive-hypoglycemia-and-wls.3411/

Yeah, we have the red hots for the DS! And welcome, @Clematis

 

[newanatomy]

Hello and welcome. You have done some great research and already received some fantastic advice from the posters above. They are vets that really know their stuff.

I thought you might appreciate a newer post-ops opinion and experience. I had my DS about 20 months ago. When I started the approval process for surgery, I was barley over the 40 BMI mark. I was approved but postponed my surgery for seven months due to my son's wedding. By the time my surgery date rolled around I was almost a 44 BMI. I am now, well on Monday will be, 49 years old. I chose the DS because of all the normal reasons, highest EWL and maintenance. I wanted to have the best chance at success. I also need to be able to take NSaids.

For me, the DS has been amazing! I feel so much better without the extra weight. Life is so much easier. I eat things I love to eat, watch my carbs and enjoy! I take my supplements and watch my labs, easy!

I am sorry that you have to self-pay. However, it opens the door to choices of surgeons for you. Not all bad.

 

[Clematis]

You guys are AWESOME. Thanks for all the swift replies. I’ve been looking at three WLS sites for a while now. Today when I decided to post this thread I chose BF as I have learned you all have strong opinions and aren’t afraid to share them. I would never want to get on the wrong side of some of you. You know who you are.

Kidney stone history: I had one last fall after 9 months on Adderrall for ADHD (I had lost weight and I was also dehydrated to the point I was getting leg cramps.) I also had two small kidney stones, three years apart 37 years ago. (I’m 62 now.) I don;t think once every 37 years qualifies as a significant history. (But I don;t want to discount a kidney stone — egads I’d rather be in labor than suffer a stone.) Is there less chance of dehydration with a DS?

There are 3 major hospital systems in Cleveland who do WLS. I researched the WL surgeons of all three, focusing on who does exclusive or near exclusive WLS vs someone who is the "I’ll cut any organ, any size" Earl Schieb of general surgeons, and for how many years they have performed WLS. With that criteria, all 3 systems had at least one or two suitable surgeons.

1. The teaching hospital system had a slick online marketing video (really, if the video was the only determining factor, I’d have chosen them). Too bad that every time I called I heard a bored voice saying “Center for Bariatrics. Hold” and then they never came back on the line. Ever. After 3 days of calling back multiple times and never getting beyond “Hold”, screw ‘em. (It was in this video that the surgeon very clearly states that dumping is a BENEFIT to surgery as it is a form of aversion therapy.)

2. The Big Brand hospital system who is leading a national PR charge for WLS and pushing it on their own vast network of employees, seemed to have unskilled counselors using the hospital’s intranet to search for answers to questions. To speak with anyone with any knowledge, one was required to watch their dreary online “seminar” and answer highly personal questions in an online form that took 45 minutes to complete. I found entering this info for who-knows-who to see quite off-putting and a risk for HIPPA violations, but it fits with this hospital’s major flaw of celebrating technology over human interactions. I spoke on the phone with three “counselors” as well as the head of WLS finance/accounting and all four people were frosty and/or unpleasant. Do I really want to wrangle a very sensitive problem and have major surgery with this culture? (My PCP is in this system.)

3. The last hospital (where I saw surgeon yesterday) pioneered WLS here decades ago — their experience exceeds all others. Other than their bariatric center, though, I would never consider doctors in this inner-city, charity hospital system and had never before set foot in the place or known anyone who had. But pulling my (fat) snobby nose out of the air, absolutely everyone who works at this center is warm and fuzzy and as nice as can be. (Oh dear. That makes it sound like I chose the Miss Congeniality of the bariatric pageant. But I had already vetted the surgeons at all the hospital systems; I was just choosing the nicest of the bunch.)

Another thing that got my knickers in a bind was when they put down a GW for me that would still have an overweight BMI of 28. WTF? The explanation he gave is that people who are SMO don’t often ever reach a normal BMI, but are so excited to lose 100 lbs or so. But what does this have to do with me, I asked? I’m BMI 40, not SMO. I am confident I can get to my REAL GW with BMI of 21 (I just need surgical help to STAY there). He said GW can be adjusted down the road. (I don’t understand that rationale. So when someone reaches the GW set by the MD, they say “Oh, just kidding” and tell them their new GW is 100 lbs lower?)

Ok after typing all this... Running an errand... Thinking... Coming back... Rereading. The VSG is just not right for me and I don;t think the RNY is either. I think I have to recontact the Big Brand hospital on Tuesday and have a consultation with a surgeon there who does DS even though so far they aren’t particularly nice.

Another bump in the road. Oh well.

DAMN. JUST WENT TO BIG BRAND SITE AND THEY DO NOT LIST DS AS OPTION... BUT I SWEAR SOMEONE ON ONE OF THESE WLS FORUMS SAYS THEY HAD DS THERE.

WHERE ARE THE SURGEONS WHO DO THIS?

 

[southernlady]

Another thing that got my knickers in a bind was when they put down a GW for me that would still have an overweight BMI of 28. WTF? The explanation he gave is that people who are SMO don’t often ever reach a normal BMI, but are so excited to lose 100 lbs or so. But what does this have to do with me, I asked? I’m BMI 40, not SMO. I am confident I can get to my REAL GW with BMI of 21 (I just need surgical help to STAY there). He said GW can be adjusted down the road. (I don’t understand that rationale. So when someone reaches the GW set by the MD, they say “Oh, just kidding” and tell them their new GW is 100 lbs lower?)

I wasn't even GIVEN a goal weight by my surgeon. I chose my own based on what *I* wanted.
Okay, I started at 203, BMI was 35.2
My first goal was to be smaller than my wedding weight in 1996 of 185. Very doable with the DS.
Second goal was to get to what my PCP's and Endo's over the years had told me to aim for, 160. Did that.
Third goal was to get to the weight I was when I left the Army, 155. Got there.
Fourth goal was to reach my lowest ADULT weight of 147 when I went into the Army (and yes I was overweight but my body fat back then saved me). Got there.
Fifth goal was to reach NORMAL BMI of 145. I did that at 7 months out (remember I am a lightweight). Notice my fourth and fifth goals were ONLY 2 lbs apart, LOL.
Final goal was to go as low as I could...to account for the inevitable bounce back down the road. I kissed 121 for 10 seconds at 15 months out after a STALL of 5 months.

Now in maintenance, I TRY to stay between 135 and 140 (altho right now I am just above that but still below 145).

I look horrid at 121...way too scrawny! A higher weight actually looks better for me. That's why the 135-140 range.

So what is normal BMI for you? How much would you need to lose to crack 24.99 BMI? Honestly after that it is all gravy!

 

[Jo777]

I think I'm one of the few VSGers that are active on this site.. I had mine in April 2011, got to a normal BMI at 12mo out.. and over the last couple years I very slowly gained about 20-25lbs.. into overweight-land, but a very normal size 12-14. I'm also 42, and have a significant pannus, among other areas of extra skin from being over 300lbs for a good portion of my life. I gained by very, very poor eating/drinking behaviors over an extended period of time, not a failure of my surgery.. Since getting things more settled in my life with my aging parent and my stress-levels, my eating has been much improved (not living on carbs constantly) and my weight so far as I can tell by my pants, is leveling out again.

I find it fairly easy to maintain, provided I do what the vast majority of WLS patients, including DSers need to do: eat high fat, moderate protein, and low carb. I only find I get the hungries/cravings or gain if I start allowing simple carbs (sugar, flour, alcohol) into my daily routine. I do not believe it's healthy for anyone (nor sustainable) to eat a low fat diet.. I also don't do low-cal, I did to take it off during the window when motivation was highest- but now I maintain somewhere in the 1600-1800 cal range, sometimes up to 2000, probably some days are down near 1200- just depends on my hunger level, more fat=better in my experience. I tend to eat 3-4x a day, fat forward, and have veggies as a side.. Chicken thigh with the skin, or ribeye with butter, and buttered veggies or cream-sauced veggies. A few oz of fatty meat, and about 1/4-1/3C veggies is what I can comfortably eat to this day, hasn't changed much since about 12 mo post-op.

I have very good restriction to this date, and very rarely ever bother to track calories anymore- however I did track all macros up until I was several months post-goal. I never suffered from dehydration..

If you are self-pay, as I was (and I considered the DS, but ruled it out).. IF you think the DS is the best for you, get it! I would NOT under any circumstance bother with the RNY.. It is at best, no better than the VSG, and often can be worse for many reasons. If you want malabsorption, the DS is it.. if you believe restriction is the best fit- the VSG. IMO, those are it.

Edited to add- just saw you have ruled out the VSG & RNY- so disregard the post above, and good luck with the DS. This is a fantastic site, with much information. I stay here for the wealth of it- even if some of it doesn't directly apply to me due to my surgery choice.

 

[newanatomy]

Here are a few surgeons near you. Maybe people will pipe up with some others too.


David Greenbaum MD, FACS
Address:401 Young Avenue, Moorestown, NJ 8057 United States

Phone: (856) 291-8920

Mitchell Roslin MD, FACS
Address:186 E 76th st, NY, NY 10504 United States

Phone: (212) 434-3285

Michael Hill MD, FACS, FASMBS
Address:309 County Route 47 suite 4, Saranac Lake, NY 12983 United States

Phone: (518) 891-1610


Fernando Bonanni MD, FACS, FASMBS
Address:225 Newtown Rd. 2nd Floor, Warminster, PA 18974 United States

Phone: (215) 441-6800

 

[southernlady]

Here are a few surgeons near you. Maybe people will pipe up with some others too.


David Greenbaum MD, FACS
Address:401 Young Avenue, Moorestown, NJ 8057 United States

Phone: (856) 291-8920

Mitchell Roslin MD, FACS
Address:186 E 76th st, NY, NY 10504 United States

Phone: (212) 434-3285

Michael Hill MD, FACS, FASMBS
Address:309 County Route 47 suite 4, Saranac Lake, NY 12983 United States

Phone: (518) 891-1610


Fernando Bonanni MD, FACS, FASMBS
Address:225 Newtown Rd. 2nd Floor, Warminster, PA 18974 United States

Phone: (215) 441-6800

Roslin is deep into doing SIPS now.
Bonanni may or may not consider doing the DS on a lightweight as his normal criteria is 50 or above, unless a diabetic. Not sure if pre-diabetes counts in his book.

Greenbaum has the best SELF pay US price.

 

[Clematis]

new anatomy & southernlady> Thanks for the list. I just found the member I knew I had seen on O.H. who had DS at the Big Brand hospital here so I know I can have it done locally. That's good news.

southernlady> they asked me for three weights, Ideal, Tolerable and Intolerable. I said 120, 130 and 140. They nodded and smiled. And wrote down 157.
5'4" CW 233. Lowest adult weight 111 for a nano-second 24 years ago (scarecrow thin). 125 eighteen years ago. 145 ten and seven years ago. I think I was down to about 180 last fall for an eyeblink. Never held any of these weights more than a few months before rocketing back up.

jo777> i'm a firm believer in the high protein/fat low carb diet and any weight lost in the past two decades has been because of it. but i guess you do have to work it, huh. always. forever. i'm one hell of a sprinter but not much of a marathoner.

 

[debbiebobebbie]

My WLS history is in my signature. I just encourage you to measure twice and cut once. As an owner of both the RNY and the DS, the DS lifestyle is so much more compatible with normal life. Dumping SUCKS!!!! and isn't shown to help induce weight loss, or aid in maintaining weight loss. You just learn to eat around it. I knew to the drop exactly how much ice cream I could eat without suffering. You're exactly right about the VSG in my opinion. It's a great tool to lose with, but I don't think it's going to have good long term numbers. Good luck with whatever you do. Also, be careful when you pick a surgeon. I know that Roslin is actively pushing the SIPS/SADI procedure. If you talk to him, make sure you're both talking about the true DS.