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Post by patxyz on Jan 5, 2012 23:37:40 GMT -5
Hi Everyone,
recently I have heard from a few people that a DS surgeon in Canada (not Gagner) has been claiming that doing the DS in two stages is safer than doing it all at once. They claim that two shorter, simpler surgeries are better than one longer and more complicated surgery, all things considered and have been suggesting doing the two procedures about a year apart.
My understanding from what I've read is that there is very little evidence to suggest that this is true in general, and may only be the case in a small subset of SSMO patients. The people I'm talking about all have BMIs in the 40s and 50s. I'm also concerned about the idea often previously discussed on OH that people who have two part procedures don't tend to lose in the same way as 'all at once' DSers do.
Do you know where I could get studies or other good information from leading DS surgeons that contradicts what this surgeon is proposing?
Thanks!
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Post by lisalou79 on Jan 5, 2012 23:41:35 GMT -5
Well, thanks for posting this issue/question. I definitely am looking forward to everyone's feedback on this topic as I am at a crossroads for this myself.
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Post by Paula on Jan 5, 2012 23:56:00 GMT -5
"Safer" is a very subjective term, I think. Its kind of a "6 of one, half dozen of the other" kind of thing in my honest opinion. I do understand that things can change during surgery and what was originally planned to be a single DS surgery might end up being a two parter. Or a surgeon may feel that given a specific patient's situation with previous surgeries or whatever might warrant a two part operation instead of a one shot deal. To my way of thinking, if a two part deal is the answer a person receives after consulting with two separate surgeons...then a two parter is probably going to be their best bet.
Is it safer to undergo general anesthesia twice versus only undergoing it once? Each time you go under, there's a risk. Whether you are doing both the stomach and intestines at the same time or doing one first and then the other....you are still doing the same procedures either way. Not exactly sure thats entirely safer or not.
With each surgery we have in a given area, we form adhesions and scar tissue that make subsequent surgeries more complicated. So doing one part of the DS first and then doing the other part of it at a later date means that the second surgery is going to have adhesions and scar tissue to contend with. Not sure if thats entirely safer or not.
For insurance purposes, does a two part DS count as one surgery...or two? If a person's insurance excludes a second bariatric procedure, doing the surgery as a two-parter might effectively screw up a person getting the second part covered. Its hard enough for a lot of people to pay for one surgery, let alone two. If I was in a person's shoes like I outlined, Id not consider it a safe thing financially to do.
Lastly, Ive heard talk of doing the DS all on one shot does something as far as the metabolism goes. This is obviously not a fancy technical medical term or anything, but I dont really know how to put it exactly. Is it safer to do a surgery where two parts work in conjunction together is done all at the same time or risk things not working as well metabolically if you do it in two parts? Pretty subjective.
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Deleted
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Post by Deleted on Jan 6, 2012 0:01:12 GMT -5
www.ncbi.nlm.nih.gov/pubmed/19640795Surg Obes Relat Dis. 2010 Jan-Feb;6(1):59-63. Epub 2009 May 13. Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI > or = 50 kg/m2? Topart P, Becouarn G, Ritz P. Source Société de Chirurgie Viscérale, Clinique de l'Anjou, Angers, France. philippetopart@wanadoo.fr Abstract BACKGROUND: Biliopancreatic diversion with or without the duodenal switch (BPD-DS) is a major bariatric procedure. The morbidity and mortality are likely to increase with an increasing body mass index (BMI), especially when > 50 kg/m(2). Controversy exists regarding the potentially increased risks of a single-stage procedure compared with the risks of sleeve gastrectomy first followed by the malabsorptive procedure after an initial weight loss. METHODS: From March 2003 to October 2008, 90 patients with a BMI > or = 50 kg/m(2) were candidates for single-stage BPD-DS. Two study periods were identified: before and after February 2007, corresponding to the periods during and after the learning curve. The results were analyzed globally and by comparing the 2 periods using Fisher's exact test and the t test for unpaired values. RESULTS: Of the 90 patients, 79 were women, the average BMI was 55.2 +/- 4.7 kg/m(2), 13 patients were super-super obese, and 4 patients underwent laparoscopic sleeve gastrectomy only. Of the 86 patients who underwent single-stage BPD-DS, 37 underwent surgery before (31 laparoscopically; group 1) and 49 after (48 laparoscopically; group 2) February 2007. BPD-DS was done as revision surgery for 14 patients with a failed restrictive procedure. The global rate of conversion to open surgery was 13.9%; 35.5% for group 1 versus 2% for group 2 (P = .0001). The morbidity decreased significantly between the 2 periods, with a rate of 16.3% for group 2 compared with 45.9% for group 1. Also, 1 postoperative death occurred in group 1. CONCLUSION: Single-stage BPD-DS in the super obese appears to be a relatively safe procedure with a low rate of conversion when a laparoscopic approach is used. Although from the published data, the morbidity and mortality are increased for super obese patients, especially men, the BMI itself cannot be considered a contraindication for single-stage BPD-DS, because other factors such as surgical experience also influence the outcome. Despite these variables, performing a sleeve gastrectomy first should be considered for heavier, male, and at-risk patients. ~~~ www.ncbi.nlm.nih.gov/pubmed/18936566Ann Surg. 2008 Oct;248(4):541-8. Duodenal switch operative mortality and morbidity are not impacted by body mass index. Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S. Source Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA. buchw001@umn.edu Abstract OBJECTIVE: This report examines the < or =30-day postoperative mortality and morbidity in our first 190 duodenal switch (DS) patients. BACKGROUND DATA: DS is the most weight loss effective and the most difficult to perform bariatric procedure. Indeed, certain surgeons have advocated a 2-stage approach to minimize complications, especially in the super obese (body mass index [BMI] > or =50 kg/m(2)). METHODS: DS procedures were performed (n = 190) by either open (n = 168) or laparoscopic/robotic surgery in an academic setting: common channel 75 to 125 cm, sleeve gastrectomy (approximately 100 mL gastric pouch), closed duodenal stump, end-to-side duodenoileostomy hand-sewn in 2 layers, with most staple lines oversewn, and all mesentery defects closed. RESULTS: For the 190 patients, 149 were female (78%) and the mean age was 43 years (range, 16-71). Mean preoperative weight 151.4 kg (range, 74.1-332.7); mean preoperative BMI 53.4 kg/m(2) (range, 32-107), with 100 (52.6%) of the patients super obese (BMI > or =50 kg/m(2)). Seventy-four patients had concurrent procedures, eg, cholecystectomy (n = 22), ventral or umbilical hernia repair (n = 19), and hiatus hernia repair (n = 10). Mean operating room time was 337 minutes (range, 127-771); mean hospitalization time was 6 days (range, 2-38). There were no deaths. Serious < or =30-day complications (n = 18 in 14 patients) consisted of 2 leaks (1.0%), which responded to drainage, and intra-abdominal bleeding (n = 3), splenectomy (n = 1), acute pancreatitis (n = 2), gastric outlet obstruction (n = 1), acute renal failure (n = 2), pneumonia (n = 2), respiratory failure (n = 3), acute myocardial infarction (n = 1), and duodenoileostomy stricture requiring endoscopic dilation (n = 1). The serious complication rate in patients with a BMI <50 kg/m(2) was 6.7% (6 of 90) and 12% (12 of 100) with a BMI > or =50 kg/m(2) (NS). Surgical site infections occurred in 7 patients with a BMI <50 kg/m(2) and in 12 with a BMI > or =50 kg/m(2) (NS). Overall complication rate in patients with a BMI <50 kg/m(2) was 14.4% (13 of 90) and 24% (24 of 100) with a BMI > or =50 kg/m(2) (NS). CONCLUSIONS: With attention to careful surgical technique, DS can be performed relatively safely in the morbidly and super morbidly obese, and does not require a 2-stage procedure.
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Post by lisalou79 on Jan 6, 2012 1:27:37 GMT -5
Diana, thank you for posting this medical research article! I found it very informative for me and my specific situation. I think I might have read in a medical journal a similar finding (that DS in BMI of 50 or greater is increase risk)
I am starting to see why Dr. Ungson may have suggested me to think about a 2-part DS because my BMI is over 50 AND I have had 3 C-sections for my girls and one appendectomy. This certainly would mean I have abdominal scar tissue. This, coupled with my high BMI, puts me at greater risk than most I suppose.
Either way, lovely info. Thank you again!
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Post by pattyl1 on Jan 6, 2012 1:46:52 GMT -5
I'll say it. Is it surgeon preference/skill, or is it really a significant benefit to the patient? Either way believe your surgeon. If he/she is saying they are not skilled enough to do it in one procedure, run like the wind. Unless you KNOW you are really sick and loaded with comorbs.
What does that say about your prospective choice if Rabkin, Buchwald, Baltasar and others can do the whole DS on 800lb people? Many surgeons don't cherry pick either and will take tough cases not just the easy ones.
We know this is easier for the surgeon. Is two surgeries easier on you? Can you afford and will insurance PAY for a 2 stage surgery? This whole issue is very debatable. There is also a significant amount of anecdotal data around here saying 2 stagers don't lose as much or as well.
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Post by stefaski on Jan 6, 2012 14:32:08 GMT -5
In the Spring of 2009, I was originally all teed up for DS surgery with Dr. Swietzer at Johns Hopkins - all requirements were completed except for a psych exam. He had agreed that given my history, the DS was appropriate for me (I was, of course, driving that conversation due to the wisdom gained from the DS vets - thank you!!)
In May 2009, I received a letter from his practice explaining that he was going to do the DS surgery in 2 parts since (and I am paraphrasing because I burned that letter in anger) his patients had great success with the VSG. If the VSG alone did not produce adequate weight loss, then the second half of the surgery could be considered at a later time.
I was livid. I knew in my heart that my weight issues were primarily due to an overefficient metabolism and not related to eating volume. Restriction alone was certainly not the answer. Not sure what his motivations were but I knew that I only wanted to do it right the first time. And for me, that meant the DS.
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Post by patxyz on Jan 6, 2012 22:09:58 GMT -5
Thanks everyone! I remember reading once about a Surgeon's theoretical explanation for why weight loss would be better with a one-stage DS than the 2 stage. Does anyone remember reading that? I think it was on the OtHer board sometime in the past couple of months. I've been searching but haven't found it yet.
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Post by msbatt on Jan 6, 2012 22:54:56 GMT -5
I just don't think having two surgeries when one would do is ever a smart move. I had a very high BMI, and my surgeon warned me (about 30 minutes before they put me under!) that he 'might' have to do mine in two parts. I'm VERY thankful that he didn't.
BUT---my DS was done open. It was scheduled to start at 11AM, and I woke up in recovery at 12:40.
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Deleted
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Post by Deleted on Jan 6, 2012 23:06:34 GMT -5
Diana, thank you for posting this medical research article! I found it very informative for me and my specific situation. I think I might have read in a medical journal a similar finding (that DS in BMI of 50 or greater is increase risk) I am starting to see why Dr. Ungson may have suggested me to think about a 2-part DS because my BMI is over 50 AND I have had 3 C-sections for my girls and one appendectomy. This certainly would mean I have abdominal scar tissue. This, coupled with my high BMI, puts me at greater risk than most I suppose. Either way, lovely info. Thank you again! I had a BMI of 63, a lifetime of scarring from ruptured ovarian cysts, a previous appendectomy and a previous hysterectomy. Dr. Peters did me in one procedure, open, very long incision and a lot of time spent working his way through adhesions. I came through just fine despite having pulmonary hypertension and right heart failure. Didn't even spend extra time intubated. I don't buy this two stage stuff, except for very specific exceptions. |
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Psyche
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DS ♦ 08/06/2009
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Post by Psyche on Jan 8, 2012 2:53:23 GMT -5
I don't buy this two stage stuff, except for very specific exceptions. That's how I feel about it, as well. I spoke with one of my doctors about it last May, when I was about to have a hysterectomy, and she said that they are not liking the trend of two stages, in part because of the likely adhesion issues that comes with multiple surgeries. |
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Post by goodkel on Jan 8, 2012 3:09:46 GMT -5
Agree with all here.
Two surgeries, twice the risk.
The 2 part DS is a myth.
First you have the VSG and then you have a REVISION to the DS.
It is not like he takes a coffee break and then comes back to finish the second part. THAT would be a 2-part DS.
And I discussed this with someone (the OP?) already. Dr. Ungson has performed a full DS on a 700 pound man. If she has ancillary risk factors that concern him, perhaps there are issues she should resolve prior to ANY surgery. She needs to communicate with him.
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Post by angelcake on Jan 8, 2012 4:51:27 GMT -5
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Post by jmckel1 on Jan 8, 2012 18:19:50 GMT -5
Angelcake, your idea about getting a quote in writing for the second part of the DS surgery is an interesting one. I was a lap-band to DS revision whose surgeon decided it would be safer to perform it in two steps after he got in there. I will be paying roughly the same amount for the second part as I did for the sleeve.
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Post by patxyz on Jan 8, 2012 20:19:10 GMT -5
Angelcake, your idea about getting a quote in writing for the second part of the DS surgery is an interesting one. I was a lap-band to DS revision whose surgeon decided it would be safer to perform it in two steps after he got in there. I will be paying roughly the same amount for the second part as I did for the sleeve. I'm grateful we don't have to deal with payment issues in Canada. It would be fully covered whether it is done as one procedure or two. I think the surgeon is hesitant to perform the DS, thinking that the VSG may be 'sufficient' and wanting to take a wait and see approach, but justifying it as a safety issue. So I want to demonstrate that there is no safety issue in going ahead with the full DS unless there is some specific risk that comes up in the pre-op testing. In my particular case, I have a genetic blood clotting disorder, but one that can be temporarily managed for surgery with a synthetic hormone. I'm seeing a hematologist who I am hoping will agree that there is less risk in me undergoing a single longer surgery rather than two shorter surgeries and will issue this report to the surgeon. For others with a different surgery, it just appears to be a preference on behalf of the surgeon, and I am suggesting they get a second opinion. |
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Post by patxyz on Jan 8, 2012 20:20:00 GMT -5
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Raven
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Post by Raven on Jan 8, 2012 20:37:14 GMT -5
I just am throwing another repeat of what the others have said. According to my surgeon, Prof. Weiner, who has been one of the pioneering surgeons in the DS and WLS - the 2 stage surgery is only needed in a handful of case with extreme weights.
He performs all of his surgeries laparoscopically and almost never does a 2 stage surgery. He explained to me that for some very high weight patients the size of the liver can be an issue and this is the only reason for a 2 stage surgery. The sleeve is performed first so that the patient can come down to a more reasonable weight and there is more room in the abdomen for moving things around for stage 2. He specialises in patients with BMI's over 50. My BMI was 51, almost 52 at surgery time and I was not considered to be a 'large' patient.
As far as the surgeries being shorter and therefore safer, I have to wonder. My surgery took under 2.5 hours for both stages. I don't think that is long at all. I also don't see how the risk of a second general anaesthesia gets overridden by a chance to shave an hour(?) off the surgery.
Talk to a few well researched surgeons before making a choice. Do exactly what you are doing and get the input of the folks on this board and read thru the old posts at the other board. There are so many morons with MDs after their names in this field it isn't even funny.
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Post by KathyF on Jan 8, 2012 21:44:36 GMT -5
Well, when I had my surgery my BMI was 59 and I had it in one stage. Surgery lasted about 5 hours.
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Post by Joanne on Jan 8, 2012 21:48:35 GMT -5
Depends. Safer when being done by a surgeon without the expertise to do it in one step? I would think so. But it's better and safer for you to find a surgeon who can safely do it in one step. There are plenty out there.
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