Single-Anastomosis Duodeno-Ileal bypass vs DS

[mandyloo]

I'd like to start a conversation. Please share your thoughts.

clinicaltrials.gov/show/NCT01685177

"Single-Anastomosis Duodeno-Ileal bypass with a 250 cm common/alimentary loop is a modification of standard duodenal switch in which a Roux-en-Y duodeno-ileal anastomosis is performed at 250 cm from the cecum and a 60 cm to 100 cm common channel is build up. Hypothesis of the study is that Single-Anastomosis Duodeno-Ileal bypass behaves at least equally to standard duodenal switch as a second step after sleeve gastrectomy in the super-morbid patient. Secondary aims are to demonstrate that single-anastomosis duodeno-ileal bypass is simpler to perform, quicker and has less postoperative short, mid and long-term complications.

Sleeve gastrectomy is a restrictive operation for morbid obesity which has a 60% success rate in solving both morbid obesity and related co-morbidities, mainly diabetes mellitus. When the sleeve is not enough for the patient, due to alimentary habits or to an excessive initial BMI before surgery (usually over 50 - 55), a second-step operation should be performed to increase effectiveness. Some patients are submitted to a second restrictive operation, i.e.: a re-sleeve, a gastric plication or sleeve banding. Other group are offered a gastric bypass. And, finally, a subset of patients, generally those with higher initial BMI, are offered a malabsorptive operation. While re-sleeve is adequate for many patients, gastric bypass is not offering a greater weight loss rate, and it is a complex operation requiring sectioning of the sleeve and two anastomoses. We support the performance of malabsorptive operations which warrant a better weight loss result for "resistant" patients needing a second-step. As Single-Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy (SADI-S) has behaved as a good primary operation for morbid obesity, we decided to test this one-loop reconstruction as a second step operation. Results will be compared to those obtained with a Roux-en-Y duodenal switch performed as a second step after a "failed" sleeve."

[mandyloo]

I thought this was interesting because the single-anastomosis duodenoileal switch is what my surgeon, Dr. Cottam, in SL, UT, did. It isn't the "traditional" DS. My common channel is longer, but the results are equal to those with shorter common channels, but with fewer complications and deficiencies over the lifetime. I'm interested in hearing your thoughts.

[mandyloo]

Thank you! I'll take a look at those links when I'm on my computer. I am not well versed in medical terminology, so maybe you can help me understand my specific anatomy in layman's terms. I've moved and can't get to the nutritionist and I'm not sure if I should follow their advice anyway, as I see a lot of people saying they don't really know what we need. And my circumstances are different. I'm a little lost about my needs. My sleeve is 4 oz, my common channel is 200 cm. my alimentary limb is 250 cm. I can't eat simple carbs. They give me really, really bad gas. Do I need to keep my fats down too?

I'm still eating basically liquids. I've tried soft foods and puréed foods. They still don't settle well.

[Joanne]

Dec 14, 2013 12:44:59 GMT -5 @mandyloo said:

Thank you! I'll take a look at those links when I'm on my computer. I am not well versed in medical terminology, so maybe you can help me understand my specific anatomy in layman's terms. I've moved and can't get to the nutritionist and I'm not sure if I should follow their advice anyway, as I see a lot of people saying they don't really know what we need. And my circumstances are different. I'm a little lost about my needs. My sleeve is 4 oz, my common channel is 200 cm. my alimentary limb is 250 cm. I can't eat simple carbs. They give me really, really bad gas. Do I need to keep my fats down too?

I'm still eating basically liquids. I've tried soft foods and puréed foods. They still don't settle well.

I don't understand the part about having a 250cm alimentary limb, and a 200cm common channel. In the SADI procedure they are really the same thing (Diana, Larra?).

Can you get a copy of your op report you can post here?

[mandyloo]

I checked out the links. Thank you. I think I *may* have the loop DS. Looks like I need to put a call into Dr. Cottam.

[mandyloo]

Oh man, I am soooo confused! I'm calling my surgeon on Monday. I'm going to see if I can send him the diagrams you've provided me (thank you) along with a traditional DS and ask him to show me which configuration I have.

[mandyloo]

I'll get a copy of my op report too. I was going to wait until I found a provider in my new area that they could send it to so I don't have to pay for it myself, but that report might help me find a new provider. I'll let you all know.

[mandyloo]

Dec 14, 2013 12:32:30 GMT -5 @dianacox said:

Dec 14, 2013 12:13:26 GMT -5 @mandyloo said:

I thought this was interesting because the single-anastomosis duodenoileal switch is what my surgeon, Dr. Cottam, in SL, UT, did. It isn't the "traditional" DS. My common channel is longer, but the results are equal to those with shorter common channels, but with fewer complications and deficiencies over the lifetime. I'm interested in hearing your thoughts.

WHY did he do this procedure on you? Did you know that's what you were going to get? Were you self-pay, and this was cheaper?

Sorry, missed this part. He did the surgery because I was self pay and asked for a DS. I liked the fact that there are better results for losing 140 lbs and less complications and deficiencies. I didn't even think to ask him about configuration. I thought a DS was a DS, only different lengths. Well, at this point I think my best course of action is to first figure out exactly what's going on in there and then determine what my new anatomy needs from me to get the best results and health.

[mandyloo]

Dec 14, 2013 13:43:54 GMT -5 @dianacox said:

Dec 14, 2013 13:21:09 GMT -5 @mandyloo said:

I'll get a copy of my op report too. I was going to wait until I found a provider in my new area that they could send it to so I don't have to pay for it myself, but that report might help me find a new provider. I'll let you all know.

I'm particularly interested in knowing whether Cottam is doing the loop DS at all, whether he is doing it as part of a clinical trial, whether he is "offering" it as an option only to self-pays as a cheaper alternative - in other words, I'm interested in not only WHAT he is doing, but the ethical issues behind what he is doing.

If you have a "proper" DS, and what you have is a 450 cm total alimentary track, witha 200 cm alimentary (food only) portion and a 250 cm common channel, I'd like to know what on earth was his reason for giving you such a long CC. A more usual proportional arrangement is a 250 cm food only portion, a 100 cm CC (total of 350 cm alimentary limb), and a 400-500 cm biliopancreatic limb.

I'd like these same answers too! The clinical trial link I posted was something I ran across googling my surgery. It isn't associated with Dr. Cottam.

[mandyloo]

See and I totally dismissed the potential for an experimental procedure because I thought legally if it was experimental, I had to be told so! Huh. I hate my insurance for excluding WLS on the policy. It never occurred to me that insurance could actually protect you!!

I'm getting myself all worked up. Right now I'm not sure at all that I have an experimental procedure. I will get answers and react as necessary then.

[Joanne]

Dec 14, 2013 14:16:24 GMT -5 @mandyloo said:

See and I totally dismissed the potential for an experimental procedure because I thought legally if it was experimental, I had to be told so! Huh. I hate my insurance for excluding WLS on the policy. It never occurred to me that insurance could actually protect you!!

I'm getting myself all worked up. Right now I'm not sure at all that I have an experimental procedure. I will get answers and react as necessary then.

I wouldn't classify it quite as "experimental". There are studies in Europe that look very promising on it, and I also know someone in real life who has it for 2-3 years and has done very well.

I know my surgeon has done a few of these and we talked about it at length (long after my DS). The issues I would have with it are a few.

First, from an informed consent perspective, you should have been told exactly what you were getting, and it shouldn't have been represented as a traditional DS.

Secondly, who knows if it's a good procedure or not? Initial reports look ok, but who knows for sure? I don't think there's enough data, and certainly not long term data. I wouldn't panic and feel doomed if I were you. It doesn't mean you cant do well. The issue is why would someone intentionally choose this over what is tried, true and known to work.

Yes, there is one less anastomosis, I suppose, in theory, less risk (?) but IMHO that is so slight it doesn't tip the decision to go with it. Perhaps the tradeoff is less fat malabsorption so in theory you wont have issues with ADEK? IMHO that can be controlled by supplementation, and ruins what I see as one of the most positive aspects of the procedure. I also suppose someone could argue with less fat malabsorption you will have less bathroom issues? Possibly, but IMHO those are vastly over-exaggerated.

There is also a concern, that Diana or Larra can probably best explain, around the direction of pancreatic/liver digestive fluids.

I feel confident you can make it work to a large extent, but you won't have the benefit of eating such a "fat as a free food" lifestyle that you read about with the standard DS. I don't know the stats for long term maintenance. I don't know what you can expect from overall malabsorption of calories.

My issue, in your case, is why did he choose it, did he make you entirely aware of what he was doing, did he give you a traditional DS as an option...that's what would have me up in arms.

[mandyloo]

Joanne, thank you. Actually, I thank both you and Diane for both educating me and putting my mind at ease. It's totally not proof, but too much fat does give me diarrhea. Could be I have a DS with a longer common channel. Then again, maybe I have a loop. Maybe I have something else entirely. Whatever I have, I feel confident I'll find the support here I need to get me on the right path, whatever that is. Thank you so much!

[Joanne]

Here is a published report on the surgery done in Spain. This is only the abstract. This looks promising but keep in mind it is only 100 patients, and at least here it doesn't mention how long the follow up has been, or regain.


www.ncbi.nlm.nih.gov/pubmed/22963820

Surg Obes Relat Dis. 2013 Sep-Oct;9(5):731-5. doi: 10.1016/j.soard.2012.07.018. Epub 2012 Aug 7.
Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients.
Sánchez-Pernaute A1, Rubio MÁ, Pérez Aguirre E, Barabash A, Cabrerizo L, Torres A.
Author information
Abstract
BACKGROUND:

Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified 1-loop duodenal switch with a 200-250 common channel. Our objective was to analyze the weight loss and metabolic results of the technique on a series of 100 consecutively operated patients at a tertiary center university hospital.
METHODS:

A total of 100 patients consecutively underwent surgery. The criteria of inclusion were morbid obesity or metabolic disease. In the first 50 cases, the common/efferent limb measured 200 cm. The length was changed to 250 cm to reduce the hypoproteinemia rate.
RESULTS:

No mortality and no severe complications developed. The mean excess weight loss was >95% maintained during the follow-up period. More than 90% of the patients experimented complete remission of type 2 diabetes mellitus. Two conversions to a standard duodenal switch with a longer alimentary channel were required because of recurrent hypoproteinemia. Hypertension was controlled in 98% of the patients, with a 58% remission rate. The mean number of bowel movements was 2.5/d.
CONCLUSION:

Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified duodenal switch procedure that is safe and quicker to perform and offers good results for the treatment of both morbid obesity and its metabolic complications.

[Deleted]

Dec 14, 2013 14:16:24 GMT -5 @mandyloo said:

See and I totally dismissed the potential for an experimental procedure because I thought legally if it was experimental, I had to be told so! Huh. I hate my insurance for excluding WLS on the policy. It never occurred to me that insurance could actually protect you!!

I'm getting myself all worked up. Right now I'm not sure at all that I have an experimental procedure. I will get answers and react as necessary then.

"Experimental" can mean a lot of different things. There are legal, ethical and professional definitions, and they vary some even within those groupings. The fact that a clinical trial of this procedure has been registered does not mean that it is an "experimental" procedure. Furthermore, there are no laws governing whether or not surgical procedures can be used, the way there are with medications.

From what I have been able to look up about Dr. Cottam, my impression is that he is a conscientious professional. His records are clean and he has a good long track record as a surgeon. I can tell from what some of his DS (or presumably DS) patients have posted elsewhere that his supplement advice is just as lousy as that of most other surgeons--assuming the patients are reporting his instructions accurately.

There are no laws that say a surgeon can only do blah blah blah procedures. It is legal for a surgeon to do a procedure like this on a consenting patient.

HOWEVER, and I'm sure Diana will be quick to jump on this part of the subject, what constitutes INFORMED CONSENT? It is clear that you didn't know what you were getting into, and that pisses me off a bunch. How could one consider that to be informed consent?

Perhaps Dr. Cottam has what he considers to be legitimate reasons for doing this procedure, such as the deficiency worries. Well, if he would give appropriate supplementation advice and education, some of that worry would be alleviated. He can't guarantee patient compliance, but hell, it would help.

The terminology issue is another bugger. This is NOT A DS, and any surgeon calling it that should be brought up short.

You are likely to benefit from DS style supplementation and probably also from DS-style protein consumption. I will be interested to see what you get from him about your OP report and all that jazz.

[mandyloo]

Thank you EN! Again, more great info. I don't want to give Dr. Cottam a bad reputation. He is an okay guy as far as surgeons go. I can tell you, there was no real discussion of surgical options. I didn't think anything of that, really. I thought a DS was a DS. He did tell me the lengths would be longer and why (to help avoid future deficiencies) and going by his reasoning, I was fine with that. As soon as I have my hands on that op report, I'll pass it on.

[Deleted]

Well, that discussion was insufficient and I am way pissed off on your behalf. Prepare for ranting and raving by vets who understand this stuff, k? The ranting and raving does not IN ANY WAY mean that you will not do fine. It will mean that the topic is a Very Big Deal and will be directed to included all readers, especially lurkers.

[Deleted]

Now there is another Cottam patient hair-patting A. Mouse/Alicia OvertHere, and telling her not to worry, because SHE has a 300 cm common channel!!

That is NOT a DS.

[mandyloo]

Sigh. I was hoping I’d have a little more time before coming clean, but the time has come. Dr. Cottam did not do my surgery. Dr. Ponce De Leon did. My name is not Mandyloo. It is actually Alicia. Hi there.

There is only one patient that you know of who received surgery from Dr. Cottam. She is the one who “hair patted” me on OH. I will be going to Dr. Cottam for consultation about my surgery so that I have someone educated to go to in the event I have any problems down the line.

What I did was sneaky and underhanded, I know, but I felt it was necessary for two reasons.

First, I need the information and I was not going to get it any other way because strong emotion had clouded your ability to help me. You have a lot to give and I have always been receptive to it, but you were not willing to give it to me because you didn’t like me.

Second, I wanted to show you what you can really do to help people when you don’t allow strong emotion to control you. You were very helpful to Mandyloo. You were not demeaning and you were very supportive. You could have accomplished that with Alicia IF you were able to prevent your emotion from getting in the way of that.

I apologize for the dishonesty.

[aflame]

Dr. Baltazar in Spain was insisting on this besides something called the Duodenal-Jejunum Bypass. Neither of which I find as good as the DS for accomplishing my health goals. OP, I am very new here so, I won't be able to contribute in a way that helps your situation. I am sure the vets will continue to provide useful insights. Actually, I believe it was on the forum that someone told me earlier when I joined that if a surgeon were vehemently discouraging a particular surgery, it's possible that they might not give me the full DS when all's said and done. As a self-payee, that turned me off Baltazar despite his great reputation. He just wasn't buying that the DS was best for me and was giving me all these horror stories about vitamin deficiencies and hell even liver failure.

I know someone on a diabetes forum whose colleague got the SADI in Spain. They didn't have a lot of weight to loose IIRC , but they were able to reach that goal and their diabetes was resolved as well. Now, since, no long term data exists, it's somewhat hard to predict long term outcomes re: weight regain and diabetes relapse. Again, IIRC, they are still testing normal for fasting blood sugar and haven't regained the weight.

Baltazar had fwded me some online documents on the SADI. If you like, I could fwd them to you or link them here.

[smokinstella]

I really hope someone shows this to Dr.Cottham so he can see how you were saying he did this "experimental procedure" instead of real DS on you so he knows to stay far, far away from this type of crazy. Saying stuff like this could possibly get a law suite thrown at you as well, given I wouldn't know a 100% I am sure some of our lawyer friends here would know much better then I.

[aflame]

Oh...oops well anyway. I didn't see the last post from OP. Was just trying to share a perspective.

[Joanne]

Dec 15, 2013 14:05:05 GMT -5 @mandyloo said:

Sigh. I was hoping I’d have a little more time before coming clean, but the time has come. Dr. Cottam did not do my surgery. Dr. Ponce De Leon did. My name is not Mandyloo. It is actually Alicia. Hi there.

There is only one patient that you know of who received surgery from Dr. Cottam. She is the one who “hair patted” me on OH. I will be going to Dr. Cottam for consultation about my surgery so that I have someone educated to go to in the event I have any problems down the line.

What I did was sneaky and underhanded, I know, but I felt it was necessary for two reasons.

First, I need the information and I was not going to get it any other way because strong emotion had clouded your ability to help me. You have a lot to give and I have always been receptive to it, but you were not willing to give it to me because you didn’t like me.

Second, I wanted to show you what you can really do to help people when you don’t allow strong emotion to control you. You were very helpful to Mandyloo. You were not demeaning and you were very supportive. You could have accomplished that with Alicia IF you were able to prevent your emotion from getting in the way of that.

I apologize for the dishonesty.

So you trashed the name of a surgeon, who had nothing to do with your case whatsoever, by lying about him in some desperate underhanded attempt to prove yourself right?

In addition to that, you had some of the people here spend time trying to help you, and copying and pasting links and articles? Do you realize most of us have families and full time jobs? That we do this because we believe in the importance of paying it forward and having a site here with accurate, ethical content?

The fake ID you posted under was treated with respect because that's the way those posts were written. If you were treated otherwise, it's because of your personality, not the actual facts of your situation.

You better start broadening your list of DS surgeons that MIGHT be willing to take you on for after care. First of all, not many do in general. And you can rest asssured that Dr Cottam will be warned about you.

[Deleted]

She has deactivated her OH account too, but the thread is saved - and her parting shot (to CVHarris) was:

I'm leaving OH too. Diana is angry that I got the information from her that I needed anyway and hell bent on not only NOT helping me herself, but making sure I can't get help anywhere I turn. And people told me not to take it personal.

Uh, riiiight. Like I'm even angry at all. I AM, however, outraged on Cottam's behalf that she would defame a surgeon for her own selfish and twisted purposes.

[Deleted]

Okay. Just when you think you've seen it all......

I wonder what her next fake ID and fake story will be and which surgeon she will defame in the process.

[larra]

I have kept quiet on this thread til now because at this point, no one really knows what to make of the so-called single anastomosis DS, and I didn't see the point of adding to the confusion.

But I have to dive in now. Alicia, Mandyloo, whoever you are, I am absolutely appalled that you would not only be so dishonest with us, but that you would lie about Dr. Cottam in a way that could potentially be harmful to his reputation and to his practice, which is his livelihood. You led us, and for all we know possible future patients of his, to believe that he had performed a non-standard procedure on you without proper informed consent as to the non-standard nature of the procedure or your other options. This is HUGE. I'm not an attorney so I have no idea whether or not there are any legal implications of your actions, but your sense of ethics, or lack thereof, is frightening.

No one here, including Diana and EN, said anything about disliking you as a person. It is you who has lashed out at them. No one made the slightest attempt to hurt YOU. You didn't like the feedback you got. You became defensive about your decisions and your own failure to either obtain adequate information about your surgeon or to think critically about the information you had and realize the numbers and complication rates you either were quoted or believed (who knows what you were really told) were impossible. That's not our doing.

Any number of people tried to provide you with knowledge that would help you now that what's done is done. But that wasn't good enough, you could not let go of the perceived slights and recognize that your experience could prove helpful to other people. No, it's all about you.

I'm glad Diana had the presence of mind to save your posts before their inevitable disappearance. I hope Dr. Cottam and his practice will not be harmed by your actions. And really, I just don't know what else to say.

Larra

[fallds]

Ok, I know this is an old thread but it drew my attention because of the SADI references which I have discovered is the operation I have had. Are all of the people involved in this convo no longer on this forum?

[PrettyGirlBounce]

Feb 18, 2014 10:03:33 GMT -5 fallds said:

Ok, I know this is an old thread but it drew my attention because of the SADI references which I have discovered is the operation I have had. Are all of the people involved in this convo no longer on this forum?

I've seen posts of late from Joanne for sure. Mandyloo is gone though for obvious reasons.

[Joanne]

Feb 18, 2014 10:03:33 GMT -5 fallds said:

Ok, I know this is an old thread but it drew my attention because of the SADI references which I have discovered is the operation I have had. Are all of the people involved in this convo no longer on this forum?

I'm still here

[fallds]

Yes, Thank you PGB. Joanne has been very helpful and great with her explanations. I hope you are doing well. I have been staying pretty busy so I haven't had as much time to lurk as I usually do. I miss chit-chatting with everyone though! By the way, I'm still completely obsessed with Jimmy!! haha

[Joanne]

Feb 24, 2014 8:26:47 GMT -5 fallds said:

Yes, Thank you PGB. Joanne has been very helpful and great with her explanations. I hope you are doing well. I have been staying pretty busy so I haven't had as much time to lurk as I usually do. I miss chit-chatting with everyone though! By the way, I'm still completely obsessed with Jimmy!! haha

Are you on Facebook? If you send me a PM here, I can tell you my real name on FB, and hook you up to the SADI person I know. She is also on FB but not here. She lives in the same small town as I do, I've met her in person a few times.