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Post by Mitchell Roslin MD FACS on May 14, 2012 13:23:04 GMT -5
Those of us who have chosen DS or sleeve seem to have had some understanding of the drawbacks of RNY and lap band even before this research was presented. Yet we still see so many bariatric surgeons push all their patients to RNY or band, regardless of their bmi or any other individual characteristics. We also still see many insurance policies that don't cover the DS, or cover it only under very limited circumstances for people with the highest bmi's. While coverage for the sleeve is improving, there are still lots of insurers who don't cover it at all. As a result, some patients opt for RNY or lap band because they feel they have no other choice, or even because they are unaware that other, potentially better alternatives exist. I realize that wasn't the topic of your presentation, but hope you could tell us what, if anything, is being done to address these issues. Thank you! Larra The next question comes from Larra. I think that the first thing is that, unfortunately, there are a whole lot of diverse opinions. I think that this forum obviously likes my opinions, so I’ve been asked to give these commentaries, but there are a lot of people that would disagree with my viewpoints. I believe that my viewpoints are based on a lot of years of education, a fair amount of research, and most importantly years of follow up with patients. I think that surgeons are very biased by how they were trained and what they feel comfortable doing, and then will find stereotypes about the things that they don’t feel comfortable, and will attach labels. Unfortunately there is nothing that can be done to change that. I mean people are entitled to their opinions, if that wasn’t true I wouldn’t have been able to develop my opinions. In terms of insurance coverage, I have absolutely no insurance issues getting the DS certified for the same patients as other surgeries. I know that certain insurances say only for BMI over 50, but all I write to them is show me the data that says that something that is better for our sickest patients is not better for some other patients, and I always seem to win that argument. Additionally, I know that I was very instrumental in getting coverage for sleeve, and if you believe in something you can get coverage. In terms of patients selecting to have operations because they feel it’s their only choice….I mean, I can never tell people what to do, but a lot of times people select convenience over intelligence, or making good decisions, or understanding their own options. In addition, they’re very much biased by the first person they see, especially if that person makes a favorable impression on them, because they believe that those are the right answers. You know, I think, that again, on an intent to treat basis, there is really very, very little data out there, and unfortunately in this line of work there are still more opinions than there are facts.
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Post by Mitchell Roslin MD FACS on May 14, 2012 13:31:17 GMT -5
Hi Dr Roslin, First I want to thank you for taking the time to address us and answer our questions. I also want to thank you on a personal level, as my surgeon, for all the time you've spent educating me on obesity and obesity surgery. My question is do you ever see a valid medical reason in which a patient would be better served with an RNY over a DS? There is a lot of talk about patients and their surgeons choosing an RNY because the DS sleeve might aggravate their GERD. I would think that the benefits of a pyloric preserving surgery far outweigh the fact that an RNY might better address the GERD (and I'm not sure it does). I do understand why there might be an instance where someone is better served with a VSG over the DS (ie Crohn's disease, or where the malabsoprtion simply isnt desired). But I want to understand if in your opinion there is ever a valid medical reason for a surgeon and patient to prefer the RNY to the DS, and if so, what would those reasons be? Thanks, Joanne B The next question comes from my dear friend Joanne, and I appreciate Joanne thanking me and actually doing all of the legwork to allow me to do this on Proboards. I think that as you mentioned, potentially for patients that have really, really severe GERD type symptoms you can make an argument. When you look at the Chicago series they said that all co-morbidities get better, more so with the DS than the bypass, except for GERD, which makes sense because the gastric bypass is a low pressure circuit. Another reason why I would select a bypass is somebody who requires a revision because they have a fistula and had a bypass that was done incontinuity and the staple line goes extremely low and the safest option is to cut out a new decent pouch and do a gastric bypass. Besides those, you know, another reason I guess, really in the verge of hypothetical reasons, is if someone was really concerned about esophageal cancer. You really cant use the stomach as a conduit to replace the esophagus when a switch or a sleeve is done, but you could potentially if you did a gastric bypass, that’s because the gastroepipolic vessel is taken. But I would say gastric bypass…if you go back and look at gastric bypass you can find media clips of me talking about gastric bypass and diabetes in 1996....Gastric bypass is the operation that I grew up with, gastric bypass is what put the Lenox Hill program on the map, and all I can say is that this year the elective gastric bypasses that we’ll do is a very, very small number, which makes me quite unique among most of my colleagues. What I would say is that what we need to do is to determine what the best gastric operation is, in other words the best way to make the pouch, and I believe that’s a sleeve, preserving the pylorus, and then figure out what the ideal intestinal length should be and the ideal way to construct the intestinal bypass. And I’d actually say that in this, we have very little data that objectively determines that. We have a lot of different methods and decent outcomes, but we really have never looked at different lengths by percentage in an academic series to determine the perfect level to get the benefits of an intestinal bypass without having too many of the nutritional risks.
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Post by Mitchell Roslin MD FACS on May 14, 2012 13:38:16 GMT -5
Dr. Roslin, Thank you so much for spending your time speaking with us and answering our questions. You mentioned that statistically about 30% of the post RNY patients experience significant regain - were there any commonalities in the patients that had the regain compared with the patients that were able to maintain their weight loss long term? First of all the 30% number is a number that I estimate, and I actually think that it may be higher. I think that the long-term weight regain following gastric bypass is actually higher than is reported. I think that even patients that haven’t regained weight, and I think again the people who have lived with these operations long, even on the duodenal switch, can chime in potentially better than me because I don’t have any life experience of living with these operations, only the knowledge that my patients have given me…what really bothers me most is that the patients following bypass I find are really, really hungry after they eat. Many of them tell me they’re hungrier than they’ve even been before. And I think that many of the ones that don’t regain weight it’s because, just like many of the people on these boards, they know where they came from. And no matter how hungry they are, they refuse to eat. And that may also be true of people that are maintaining weight loss and have never had an operation. It could be argued that the willingness to be hungry and not eat determines how people can maintain weight loss, and our operations make that easier. The only thing I can say is that when we looked at the RESTORE trial we found that the size of the anastomosis, once it was greater than 2CM, didn’t make any difference. And that the only thing that statistically correlated with the amount of weight regain was the length of time from surgery. Meaning that once people gained weight, the weight gain was progressive. But, I think that what happens is that once people start succumbing to their hunger, they begin to gain weight at a relatively rapid pace, and begin to travel down the same path that they did before. What concerns me most is not so much weight regain, because I think that no matter what the operation is there is going to be some degree of weight regain, I think that what really bothers me is that when I speak to a lot of patients they describe living with return of uncontrollable hunger, or hunger that even is described to me as greater than before gastric bypass. And that is something that is very difficult to quantify, but when you hear it from enough people you begin to believe that it’s very much real.
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Post by Mitchell Roslin MD FACS on May 14, 2012 13:44:07 GMT -5
goodkel, thank you for arranging this opportunity! Dr. Rosin, thank you so much for your valuable contribution to this community. just a little background info on me: i had gastric bypass surgery in 2003 and have maintained a 100-lb weight loss. truth be told, i wanted to DS but my surgeon said i did not need it. also, he did not then nor does he now perform it. my bmi is 28. while i am happy in my new healthy life, i never did lose as much weight as i wanted. it may interest you to know that i do eat VERY healthy and virtually grain-free (ergo low glycemic) but even so i get hungry every few hours and the hunger comes on with rapidity and must be satisfied with immediacy. this seems to support your hypothesis. what's more, across the last four years i have experienced two cycles of 25-lb weight regain followed by 25-lb weight loss. during the first cycle i had a stomaphyx (stoma plication). for full disclosure, i blog as My Bariatric Life on HealthCentral and maintain Twitter and Stumble Upon accounts under that avatar. here are my questions. 1. in regard to gastric bypass, you state "If they eat foods that are higher in the glycemic index, or simple carbohyrdrates what happens is they have a very rapid insulin response followed by a low sugar, and this makes patients develop a maladaptive eating pattern." Can you expound on what maladaptive eating pattern is developed? I am not clear on this. . What we’re saying is that certain foods will drive greater insulin production, especially glucose or simple sugar. And what’s in simple sugar? Table sugar is a combination of glucose and fructose. In addition, simple carbohydrates that are refined are very simply broken down into glucose and that these foods will stimulate more insulin production. What we mean by maladaptive eating pattern is what happens is that people get hungry, so they reach for pretzels, the pretzels get broken down into glucose, the glucose solicits a very high insulin response, followed by a very low sugar. The person feels very, very hungry or lightheaded, so what they then do is they reach for another pretzel, or a cookie, or some sort of candy, and they’re constantly cycling between very, very high glucoses and very, very low glucoses. And in order to combat the fatigue and instant hunger, they are drawn to go for the most convenient of foods, as opposed to going for foods that have a significant amount of fiber in them, and would take longer to break down, and thus have a lower insulin reaction than a simple carbohydrate.
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Post by Mitchell Roslin MD FACS on May 14, 2012 13:50:13 GMT -5
g 2. generally speaking what is your perspective on the long-term success, long-term adverse events or side effects, and benefits vs risks of conversion to DS for patients who've had significant weight regain after gastric bypass? i would hazard a guess that there is a lot of risk here given two complex surgeries being performed on an unhealthy patient (i assume this is why few doctors perform it and few insurers cover it). . I think that there are certain parts of this question that I would agree with, and some parts that I may have a slightly different opinion. In terms of long-term success, I don’t think there is any long-term data (and then when you use the word long-term what defines long-term?) on the conversion of gastric bypass to duodenal switch. If you take the total amount that’s been done, it’s not an exceedingly high number, and when you look at longer term or 5 year data, any results would be just merely anecdotal. I think there is a lot of logic to do it, because it allows you to go to an operation that has greater efficacy, and it makes more sense to go up the treatment pathway than to go down, for a lot of different reasons. In terms of why so few doctors perform it, I think there are very few doctors that are capable of doing a laparoscopic duodenal switch, let alone a conversion or really difficult revisional operations. In terms of the long-term adverse outcomes, I really think the difference between doing this operation and doing a primary duodenal switch is not the long term. I would tend to believe that the long-term issues would be relatively similar, but the real risk is the short-term risk of really doing a complex procedure, and I would have to say that the serious complication rate is at least 3 times greater, including the risk of death from doing this. And that’s because both the stomach’s blood supply as well as the tissue have been distorted. And I think that doing revisional surgery is far more complex, and doing revisional surgery is something that really requires a lot of experience, and I think very few people are trained to do it. It’s kind of something that when you come out of fellowship, even a bariatric surgical fellowship, it’s something that you learn with significant amount of experience, and is extremely, extremely challenging. In terms of insurance covering it, if there are real anatomic reasons to do it, I don’t think we’ve really had any greater difficulty getting these cases certified than other types of revisional operations.
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Post by Mitchell Roslin MD FACS on May 14, 2012 14:08:23 GMT -5
3. generally speaking what is your perspective on the long-term success, long-term adverse events or side effects, and benefits vs risks of band over bypass for patients who've had some weight regain or never achieved desired weight after gastric bypass? and what would you say is the profile of the ideal candidate for this? . I’ve had a fair amount of experience of placing bands over bypass. I think that the first thing that you have to realize is that you’re not going to have that different feeling of satiety. It’s just going to make you eat slower, and make it harder for you to eat, and for certain people that is enough of a signal. I’ve had patients that have done outstanding with bands over bypass, and patients that have done nothing at all. What I would generally say is that bands over bypass are usually effective for preventing the weight regain, and then a certain segment of patents, I would say about 50%, have significant weight loss. In terms of my opinion, and some of the changes going forward, I think that the band over bypass may be appropriate for the patient that has had nominal weight regain, and doesn’t have a drastically elevated BMI. However, for patients whose BMI is way above 40 or 50, or patients who have a recurrence of their diabetes, I think they may be better served, if their anatomy lends itself to it, to a conversion to the duodenal switch. What I’d also say, is that if you place a band over the bypass, that would make me very reluctant to go do a future conversion of that band over bypass later to a duodenal switch. While we hear a lot about bands being reversible, they’re not really reversible, they’re removable, and they leave behind a lot of scar tissue. I would say that one of the most common operations I do is the removal of a band to a switch or a sleeve, and it’s really important that you take down the whole plication, take down the pseudo scar, and then try to find a proper area to staple without compromising the integrity of the operation. So this would really create another barrier for people to potentially get a quality conversion in the future and may burn a bridge. So for people that I don’t think would be good candidates for bands to begin with - high BMI, considerable metabolic disease - I think that if they come to that level and have that type of recurrence, adding what is the lowest efficacious device in the bariatric chain won’t be successful. For the smaller people it may be fine.
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Post by Mitchell Roslin MD FACS on May 14, 2012 14:13:18 GMT -5
g 4. why do you not include prescription weight loss medication among your list of options for failed gastric bypass? Thanks so much -- really looking forward to your response!!! Thanks again for your time. I guess prescription medication would be an option, however when you look at the results of prescription medications that are currently approved, which would be currently Phentermine and Xenical, with the new combination of Topamax and Phentermine getting publicity, their results are relatively nominal. One of the other issues that comes up with weight loss medications is how long are you going to keep patients on these medications? If you stop the medications the weight that is lost is only going to return, so are these medications and their side effect profile appropriate for people to be on for years and years? Usually the people that I see are looking for the feeling that they had following the gastric bypass. Following the gastric bypass, it was like a load was taken off them. They were no longer hungry. They had to eat smaller portions, but yet they were satisfied with that. And now this raving hunger came back. They’re looking for a return of what they once had. I think when you look at revisional patients, go back to when anybody decided to have bariatric surgery to begin with. The reason you had bariatric surgery is that there really wasn’t an alternative that would be effective for you. So I think it would be naïve to expect that pharmaceuticals weren’t suitable to keep the majority of people that we see with BMI’s greater than 40 from having bariatric surgery, but that when there is weight regain that pharmaceuticals would be appropriate. The second thing and the final thing along this line of thought is it also depends on what your level is, the same answer as the last person. If you’re talking about nominal recurrence, and trying to halt weight regain, and trying to break a cycle, then medications may be fine. But if you’re going back to your pre-operative weight and having a recurrence of medical problems, then I think it would be naïve to think that these options would be effective for those types of patients. I think one of the things we have to do is tier our patients and look at them. Not all diabetics are the same, not all patients who have weight regain are the same. We need to basically tier them, and base their care based on their individual characteristics.
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Post by Mitchell Roslin MD FACS on May 14, 2012 14:40:43 GMT -5
P.S.S. (or is is P.P.S.?) I just thought of another question... will you indulge me? sorry but my mind does not think linearly but rather abstractly... i am creative and that's just the way i roll -- LOL! 5. why do you not include conversion from distal to proximal among your list of options for failed gastric bypass? OK, that's enough. I'm off to bed before more questions plague my curious mind. Thanks again :-) I think the best answer that I can give to this question is that those that don’t know history are doomed to repeat it. In order to have a distal intestinal bypass, a common channel of 100CM, or 150CM, or a common channel less, then for most patients you have to preserve either the fundus of the stomach or the pylorus. Preserving the stomach is done in the Scopinaro procedure, where the volume of the stomach is about 200-300cc. Dr Scopinaro has trained a lot of Italian surgeons, and actually that was the operation that was used in the most recent trial in the New England journal. All those patients had open Scopinaro procedures, and he does a 100CM common channel and a 200cm alimentary limb. So, the point is in order to tolerate a distal bypass you either have to preserve the fundus of the stomach, or the pylorus. The pylorus is called the gatekeeper. If you do not have one of those two structures, then what is going to happen is you are going to have a rapid emptying system and basically uncontrollable diarrhea in a subgroup of patients. Obviously there is individuality and certain people can tolerate that. So when people try to do these procedures, the actual risk of protein malnutrition is above 20%. I have not had to, in my DS practice, move anybody more proximal. Occasionally there have been people that have had other ailments like pseudo membranous colitis, and have had diarrhea where I’ve had to institute therapy and then once they got over their acute illness they were able to restore their protein levels. That would be a huge concern if you move standard gastric bypass that’s based on the lesser curvature of the stomach and hasn’t preserved the fundus, if you take it and you move it distally, then you are going to have a 1 out of 5 chance of having protein malnutrition. So this is a very easy operation, but a very, very, very poor choice and demonstrates a lack of understanding of the sophisticated physiology of the gastrointestinal tract. Again, long term, I would wager to guess that over years the majority of patients that this is done to would have to be reversed, especially if they had another medical problem. And I’ve seen a number of these patients from Brooklyn where they needed reversal 5, 7, or 10 years after it was done, because they couldn’t overcome other medical issues. So I would not recommend this as an approach.
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Post by Mitchell Roslin MD FACS on May 14, 2012 14:46:17 GMT -5
My question would be when can we expect the DS to become more mainstream? When will more doctors be trained in the surgery and care of DS patients and when will the DS ever be explained and touted on the news? I don’t think the DS is non-mainstream. I think that again, most surgeons have never ever seen a DS, and the majority have no idea how to do one, nor were they ever trained in it, so again, they’re going to encourage people to go for operations that they’re more familiar with. In addition they’re told that the patients have intractable diarrhea, micronutrient deficiencies, and the stereotype then plays into their desire to not learn necessarily new things. I think there are more doctors that are coming to Lenox Hill, and places like it, and are showing an interest in the DS, because the sleeve to DS is the most logical transition. But the real push will come from patients. Until patients are leaving doctor’s offices, they’re not going to really care until they’re losing market share in their community. Additionally, the majority of feedback that goes into the press about bariatric surgery is in the first year. I really think that the advantage of the DS operation is years down the line, and as physicians we’re only reimbursed for what we do in the short term. And in fact the reimbursement for DS, at least what we receive, is actually lower than other bariatric operations. So it’s certainly not an effective business model. So when you’re getting all this positive short term feedback, why not do an operation that you’re familiar with it, that you’ve been trained to do, that you’re experienced to do, rather than learn something new, if patients aren’t walking out of your center and going across town? And you can do more procedures and get reimbursed at a greater amount and probably have lower complications. So unfortunately, we’re not incentivized for long-term outcomes, and I think that’s really, really unfortunate. You know, people talk about the band being safe but I would argue on an intent to treat basis, and when you look long-term at how many of the patients have had to have revisions and removals, that there’s really no data that the band is safer. Yes, for a simple operation it’s shorter and has less complications from the perioperative period, but in the long-term I’m not sure that’s true.
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Post by Mitchell Roslin MD FACS on May 14, 2012 14:52:59 GMT -5
Do you foresee any WLS in the coming years that may replace the DS or be a even better option? I think there may be some things or some devices that mimic our operations, but I think it’s going to be hard to find something that is going to be more efficacious than the DS. But, where I think we really can learn a lot is what are the best intestinal lengths to use? Does it have to be a Roux with an alimentary limb? Can it be a loop? What is the perfect intestinal length? Is it a percentage of total intestinal length that gives people the most durable weight loss as well as minimizing any side effects and micronutrient deficiencies? Additionally, one of the things that I’m excited about is what we can learn from the DS. There is a reason why even the worst diabetic patients can get better with the duodenal switch and I haven’t see that with the gastric bypass, I certainly won’t see that with the sleeve gastrectomy. And that may identify certain mechanisms that we can potentially exploit in patients that don’t want surgery, or want lesser operations, and I think that’s very, very interesting. I think in the next few years we’re going to come to understand that type II diabetes is an inflammatory disease, and I think that the intestinal bypass component and fat absorption may be very important in the chain of events that affects people with type II diabetes. I see the number of Duodenal Switch patients increasing, but I don’t see any exponential growth and I don’t see surgeons running out to learn the procedure, because again we live in a world of short-term gratification. The short-term gratification with other bariatric surgeries, as well as the length of time and the learning curve to learn a new procedure, will keep people from doing so, and they’ll continue to talk more about their own personal bias….and they’ll continue to talk about micronutrient deficiencies, diarrhea and the poor lifestyle that DS patients have. I think many times these things are stated out of ignorance, because many of the people saying these things have very little experience with DS patients, or they’re said from patients of people that have done DS’s but maybe haven’t had the best outcomes.
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Post by Mitchell Roslin MD FACS on May 14, 2012 15:07:12 GMT -5
I have an off topic question: Looking back, how many DS procedures had you done before you were "good at it?" (I know that this can vary...but how much experience do YOU, as an experienced surgeon, think one needs to be considered an "Experienced DS Surgeon?") I think you hit on it. I think it really does vary as opposed to what you’ve done before to how comfortable you are in the duodenal area, and the pancreas, how comfortable you are suturing, how much experience you have doing revisions, and then how technically talented you are, and how you’ve learned. I mean I think I can honestly say that the technique that I have for doing the duodenal switch, and there are actually several on video, one on the Bariatric Video Textbook…you know I’ve had to kind of come up with exactly where to put my ports, the sequence of events, and the best way to do it myself. And I continue to still somewhat modify techniques as I learn more and understand more, and standardize, and I think I’d like to believe still improving as a surgeon. So I really don’t know the answer to it. And then there are people that you know, they get the job done, but you watch them do stuff and you’re generally uncomfortable. So I don’t have any one answer, but what I can say is that you guys know the world. You know who, when every patient comes in for a DS they end up getting a sleeve gastrectomy because the anatomy’s too difficult. And you know who completes the operations in 2 to 3 hours. I would say our time has come appreciably down where regularly we do DS’s in under two hours at the present time, and that includes doing the gallbladder. So, I think that the people on this forum know the answer to this question and I don’t think there is any one number that you can give. In terms of my own learning experience, in the early 2000’s we did a lot of open switches for people who had super morbid obesity, then everybody wanted laparoscopy so we kind of went away from it, to some extent. Then as we started to get the data from the RESTORE trial and started seeing more of the bypasses coming back, I’ve obviously gone back to it, and my approach is very, very different. So my thought process has been one in evolution over numerous years, and I think more people will be following that thought process in the future.
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Post by Mitchell Roslin MD FACS on May 14, 2012 15:17:45 GMT -5
Dr Roslin, Thank you for taking the time to answer as many of our questions as possible, your time is valuable and much appreciated. THANK YOU. My name is Pumpkin and my question is, Are you noticing any trends in post op revision complications that are revision specific ? I hope my question is clear, but if it's not, I'll give you a few examples of where my mind is headed. Example # 1 ( use any revision specific procedure ) Is there a trend in patients that have revised from LAGB to DS who are experiencing increasing frequency of GERD and/or GERD related conditions that could be attributed to their original WLS, yet still remain unresolved or may have worsened and why? Example # 2 ( use any revision specific procedure ) Is there a trend in patients that have revised from RNY to VSG who are experiencing increasing frequency of gastritis and or gastritis related conditions that could be attributed to their original WLS, yet still remain unresolved or may have worsened and why? Example # 3 ( use any revision specific procedure ) Is there a trend in patients that have revised from LAGB to RNY who are experiencing increasing frequency of ( Name of any trend you may have noticed ) and or ( noted trend if any ) related conditions that could be attributed to their original WLS, yet still remain unresolved or may have worsened and why? In hindsight, are there any revision surgeries that you no longer recommend ? For instance, what complications would a LAGB patient have to have in order for you to make the determination that it would not be beneficial to the patient to revise to any other type of WLS other then removal of the LAGB ? To Kelly, If you or anyone else can clearly articulate where I am going with this...please feel free to translate. ( I'm not the sharpest pumpkin in the patch ) ;D
Again, I think this is very, very different based on the level of experience the surgeon has. I think that, I will say that I don’t even think about going from band to sleeve and switch anymore. I will say in the last several months I’ve gotten extremely comfortable in standardizing my technique of going from bypass to switch, where I can get a real standardized looking switch afterwards. In terms of complications, I think the biggest thing that I’ve learned is to try to analyze what was done before. One of the complications that I’ve seen is when a large blood vessel was taken in a previous operation. And I think that’s really the hardest things when you do revisions, is that potentially certain parts of the anatomy were compromised that you didn’t expect to be compromised and that’s why when I see the previous bypasses I try to CT them, and maybe sometimes even get CT angiograms, to see the pouch and make sure that the anatomy is suitable for the revision. I think that we’ve gotten better at preventing complications in revisions by hand suturing many of our anastomosis, as well as upsizing our staplers to handle thicker tissue. I think that what patients need to understand is that revisional surgery is big boy stuff, and the type of revisions that we’re doing, few places in the country are doing. I mean we routinely do old fistulas, we routinely have done these non-divided staple lines that have failed, we’ve routinely do vertical banded gastroplasty to other operations, and have taken bands out, and now are seeing a number of patients with bypass who want to be converted to switch, which is a rather large operation. You know, I think that the real message is that the stakes increase each time somebody goes into your belly so it’s best to get it right the first time. One thing I’d add is that going from the sleeve to a switch I would really think of as two primary operations rather than a true revision.
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Post by Mitchell Roslin MD FACS on May 15, 2012 10:13:22 GMT -5
Hi Dr. Roslin, really appreciate your willingness and time to do this. I'm a RNY revision to DS as of 5 months ago. I'm 51, had my RNY 10 years ago. My question is along the lines of MsVee's. I too am curious about RNY techniques that might incur a refusal to perform a revision, or, if the revision is done, if there are techniques that might make the revision less successful. I know that it was difficult to undo my pouch and create the sleeve because of the types of sutures that were used. Can you clarify if there are indeed different techniques and/or documented elements that make the revision more or less successful? Thanks again for doing this. To begin, we are at the infancy of converting bypass to switch. While I am optimistic, early results favorable, and can give scientific rationale, (which I will be lecturing on at ASMBS) there is no guarantee that in several years we will not see failures. Thus the risks need to be weighed with the unknown long term results. It amazes me when patients are upset when physicians like myself feel that a complex operation is not in their best interest. For patients, many times their quest is to convince the surgeon to do the procedure. I need to balance their desires with the risks that I am best able to understand. Thus, at this stage it is intelligent to be cautious before embarking on bypass to switch conversion. I get CT scan on all patients. My relative contra indications are a non divided gastric bypass, especially if the staple line goes low on the stomach, and a very small pouch. I stay away from very small pouches because I will destroy the LES and the patient will have wide open reflux. I really think that these procedures are best done laparoscopically for many reasons. I realize that the majority have been done open, but think that is because the surgeons doing have not become comfortable with complex laparoscopic procedures. As I have standardized technique, I am convinced that laparoscopy allows us to get to a higher plane and clearly dissect pouch and GE junction. Realize that I did many open bariatric procedures in the late 1990's and open switches in the early 2000's. Laparoscopy standardizes exposure and provides magnification. We have performed the latest series of revisions in around 4 hours with gallbladder. Difficult cases are complex whether open or laparoscopic. Having the ability to get higher with the scope makes me certain that in the long run, these cases can be best done, and standardized by laparoscopy. As experience increases and outcomes clearer, I certainly can see myself getting more liberal.
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Post by Mitchell Roslin MD FACS on May 15, 2012 10:15:34 GMT -5
I had a VSG five months ago after a failed band. I have two questions: 1) What is your opinion on performing the DS on lightweights under 40 BMI who are not diabetic but have other comorbidities? Thank you. If patient is eligible for gastric bypass, then I am willing to perform DS. I know of no data that shows that smaller people have less reserve than larger. It is the opposite. Obesity means excess adiposity, not nutritional reserve. Thus why would smaller do worse. Additionally, I feel that the best procedures combine a good pouch with an intestinal bypass. I think sleeve is the best pouch and that a fixed length bypass is better, than small wider pouch, and random common channel and total intestinal length. I am not willing to do on patients outside NIH or cms guidelines.
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Post by Mitchell Roslin MD FACS on May 15, 2012 15:16:10 GMT -5
Hello, Dr. Roslin, Thank you very much for sharing your time and expertise with us. I am another WLS recipient (Lap-Band, 2005) and have some questions regarding a Band-to-DS revision: 1) Every time I do low carb for long enough, my Type II diabetes goes into remission. I’ve read about the DS’s 98% cure rate and heard someone say that the DS changes metabolism to correct insulin resistance. Is this due strictly to the low carb diet, the DS surgery, or a combination of the two? **************** I believe that the DS changes peripheral insulin resistance. I think that we will find that type 2 diabetes is an inflammatory disease. I think that free fatty acids help transport something in the GI tract that causes an inflammatory cascade. The distal bypass reduces free fat absorption, and thus the transport mechanism of the inflammatory factor is derailed. Of course there is a contribution from eating differently and weight loss. modified to fix quote code
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Post by Mitchell Roslin MD FACS on May 15, 2012 15:18:53 GMT -5
S? 3) My gall bladder is full of stones and I have mild to moderate attacks 3-4 times each month. I’ve read that many who have theirs removed are put on a low-fat diet and prescribed Actigall or bile acids. Would this conflict with the DS diet, where a higher-fat diet is encouraged? i believe you should take the gallbladder for several reasons. With DS, you can never have ercp, thus if stones go to common bile duct will be hard to teach. Gallbladder is right near duodenum and if got complex attack and required emergency surgery, I am concerned that the surgeon wil not understand the anatomy. Additionally, our Lap DS times are sometimes under 2 hours and generally under three hours.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:17:22 GMT -5
Hi Dr. Roslin, really appreciate your willingness and time to do this. I'm a RNY revision to DS as of 5 months ago. I'm 51, had my RNY 10 years ago. My question is along the lines of MsVee's. I too am curious about RNY techniques that might incur a refusal to perform a revision, or, if the revision is done, if there are techniques that might make the revision less successful. I know that it was difficult to undo my pouch and create the sleeve because of the types of sutures that were used. Can you clarify if there are indeed different techniques and/or documented elements that make the revision more or less successful? Thanks again for doing this. There are many variations on how a rygb can be constructed. In the field of revisions, you have to manage what was done before you entered the surgical field. The pouch can be short and narrow, long and wide or have any combination of the above. Most important, was the pouch created by dividing the stomach or using a stapler that only partitions the stomach. The technique of stapling in continuity has been abandoned in the laparoscopic era, but was quite common in the open era. Prior to 2000, almost half the rygb’s performed were done in continuity. To revise, this entire staple line needs to be resected. During revision, most old staple lines should be resected. The only one I preserve is the inferior staple line of the remnant that I use to reattach to the new pouch when converting bypass to switch or sleeve. Thus a bypass done without dividing the stomach would make more difficult. An extremely small pouch would also make more difficult. Finally, any damage to the nerve supply or vascular supply can make more difficult. Unfortunately, this is very difficult to recognize. As a general rule, never select a procedure that you believe may need revision, it is far more complex to revise, than do well the first time.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:19:59 GMT -5
There is also "common knowledge" that revised patients lose the weight at a much slower rate. Is there a metabolic or other scientific reason for this or is that just a myth? The biggest issue would be what brought the patient to revision. Let’s say that the patient had a real poor bariatric procedure that really did not chance their anatomy, then I think there would be little difference. On the other hand, say the patient had a properly done bypass and never lost weight, then there is probably something unique about that patient. If you take a population that has not succeeded, then it is more likely that they will not flourish, compared to a population that has succeeded. We all know people who did poorly in high school, and then did well in college. However, it is more likely that if we compared those who did well in high school, a greater proportion will do well in college. Thus, by the fact that people needed revision, we are in all probability selecting a group that is more likely to struggle. Another factor is where they start from. Patients that lose a lot of weight prior to surgery, will probably lose less weight from surgery, but reach the same nadir point. By this, I mean say patient x weighed 400 pounds, loses 100 pounds and then has a sleeve. Her lowest weight is 230 pounds. Now she only lost 70 from the sleeve. My guess is that her lowest weight is somewhat determined by her set point and if she had the sleeve earlier, would have reached the same overall low point, but just given the sleeve more credit. Thus, if you are programmed to go from 400 to 200 with DS, but have bypass that took you to 320, then you are going to lose less weight from the revision. On the other hand, for many bands to ds, that do not have esophageal dilation, I see little difference in outcomes. Weight loss is determined by many variables, the operation just being one of them.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:21:23 GMT -5
Dr Roslin, First I would like to thank you for taking the time to answer our questions. This is such an amazing opportunity to get information from a reputable source. What is a realistic percentage of weight loss for someone who is super morbidly obese? Again thank you for your time. MsVee Doctors can only guess results on a population ie what would be the average weight loss of 100 people who were similar. For any one person, that is what we refer to anecdotal. For any person, we do not know their genes, how much they eat prior to surgery, how active they were, or virtually any other variable. Following surgery, we are similarly ignorant. Thus, we can only speak in averages, and there is a real distribution. I have seen people who were more than 400 pounds, reach a normal bmi. On average, I would say that if your BMI is 55, average BMI following DS is around 32, compared to 38 with RYGB. I would estimate VSG to be around 40.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:22:28 GMT -5
How do you measure your patients progress/success? Is there a certain BMI level, percentage of weight loss, improvement of co-morbid conditions? Or do you simply use the industry standards? My measure is that the patients physical and emotional health improve, and the effect is long lasting. Additionally, assuming the patients objectives are within reason, that they were able to reach their goals. I do not think can answer this question across the board. For example, a 55 year old woman is in a wheelchair, my goal is to get her to ambulate independently, the amount of weight loss is clearly secondary. Also, if you lose a lot of weight, but not energetic, that is also not a positive outcome.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:23:53 GMT -5
What do you think of procedures like POSE and gastric plication for weight loss? Again thank you for your time. MsVee For disclosure, the patent on endoscopic suturing for revision of rygb is under my name. It would be great if it worked, but I see little evidence that after the liquid diet, there is long standing benefit. My advice is save your money. For plication, I see little advantage for gastric plication when compared to properly done sleeve in experienced hands. The only advantage is low cost, as there is no cost for a stapler. That seems to be a minor issue in the US. I think that plication will not last and will be difficult to revise. Additionally, the argument to keep that portion of the stomach is entirely stupid. It is useless, since the blood supply is compromised, thus has no use in case or a rainy day. The stomach can be a useful esophageal substitute for certain people. But a plicated stomach cannot ever be used as a substitute. Thus, it is like saving things in your home that can never be used again.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:27:58 GMT -5
2) Most band revisions seem to be done on folks who either never got to goal or had serious complications. I did hit a goal weight of 152 lbs. from 302 lbs. but could only maintain it for four months. The only complication I've had is gastritis for the last three years. As a WLS surgeon, would you consider me noncompliant and refuse to do a DS? Not knowing your specific situation, here is how I would answer in general, when asked If a band patient fails to maintain loss, is there any criteria that would make you label them as noncompliant and therefore not want to revise? Not based on their success or failure with the band. My question would be whether the person should have ever been considered for any bariatric procedure. Success or failure with the band would mean far less then stability in relationships, employment, and education.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:30:58 GMT -5
Hello, Dr. Roslin, Thank you very much for sharing your time and expertise with us. I am another WLS recipient (Lap-Band, 2005) and have some questions regarding a Band-to-DS revision: 4) I haven’t given it much thought of late, but in 1999 I had a diagnosis of gastroparesis (delayed gastric emptying) by a D.O./allergist who was a bit of a quack. Could this diagnosis be a problem with the DS if I have vagus nerve damage due to the gastroparesis? If vagus nerve is truly damaged, then pylorus may not function and certainly will not function well. So the answer is yes. That being said, very hard to recognize or know Would gastroparesis or vagus nerve damage contraindicate sleeve or switch?pre operatively. Gastroparesis, is used so often. Those with a severe form, vomit more than 10 times per day, thus are usually not morbidly obese. If there is person that has label, and no vomiting, then always concerned, but in face of morbid obesity, weight gain and no emesis, stomach probably works well enough. Nuclear meals are rarely helpful. I think more often after a patient who has a sleeve or switch has vomiting, they are often labeled with gastroparesis. More often the issue is technical or behavioral, rather than a motility issue. When these issues arise they are most challenging, and my suggestion is early use of a feeding tube.
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Post by Mitchell Roslin MD FACS on May 28, 2012 19:34:07 GMT -5
Re: " I think that if we're going to take credit for bariatric surgery causing weight loss and being the most effective treatment of obesity, when patients regain weight the operation also has to be a part of the burden. We have to realize that there may be a physiological reason for weight regain, not just behavioral changes and lack of compliance." This is such a refreshing and rare viewpoint on bariatric regain. We have yet to overcome the prevailing attitude by both the general public and medical professionals that diet and exercise alone are adequate to cure morbid obesity despite studies to the contrary. Now we want to take that a step further and alleviate the blame for bariatric regain. For the multitudes who have been blamed their whole lives by doctors, by family, friends, society, and too often by themselves for their uncomfortable and unhealthy state, thank you for lifting this painful burden from them. When Carnie Wilson's Band over Bypass story flooded the media recently, I rode her publicist's wave and sprinkled the link to this presentation like fairy dust in comment areas all over the internet. ABC, Huffington Post, Health sites, blogs, all over. But that was a drop of water in the ocean. What will it take for the medical establishment to fully embrace both the inability of diet and exercise to cure morbid obesity AND the fact that sometimes weight loss surgery, too, is not enough? And what can WE do to help? Thank you Dr. Roslin for this generous gift of your time and knowledge. We are honored beyond measure by your attention. Thank you also to Paul Hiam and Joanne Bathalon for your time and assistance organizing this wonderful opportunity. A special thank you to Joanne for providing her transcription services without remuneration beyond exaltation. I have placed many bands over bypass and for some people it works. For others, it does not. My present policy is that if the patient is unlikely to do well with a band to begin with, then do not place over bypass. Thus for patient that has regained 30 to 40 % of weightloss, does not have recurrent bypass, and is low bmi, band will prevent further weight regain and may promote weight loss. For those with high BMI's I have become reluctant to do. Certainly, placing band will compromise future effort if conversion to DS is shown to be best. In terms of press, it is the celebrity factor. Additionally, the press clumps all bariatric surgery together. The lap band has done a great marketing job telling the undeducated that you can have all the benefits of bariatric surgery without the risk, with band. Many physicians have helped foster this ignorance. Band removals are increasing. Other doctors will state that the band is not indicated for diabetes, because resolution is lower than rygb. The difference in studies is 75 for bypass and 55 for band. Why is the the difference with switch to bypass not significant, although the same as above. To get past this point will require research to explain why this difference occurrs. We are trying to do, and a great project would be to find grant support so that we can better understand the above. Without quality research, at the basic science level, everything that I said is just as believable as stating the band stops hunger by pressure on the vagus nerve. As someone who owns patents on vagus nerve stimulation, that is hogwash
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Post by goodkel on May 28, 2012 23:00:56 GMT -5
Thank you so much Dr. Roslin for taking the time to answer our questions. Thank you also to Paul Hiam and our own Joanne who both put in a great deal of effort to coordinate this for us. Thank you, also, to everyone who participated and helped make this a success. to all of you! If anyone is interested in becoming a patient, Dr. Roslin has recently hired a coordinator to work with people who will be traveling for surgery and he has two offices: Manhattan Minimally Invasive and Bariatric Surgery 186 East 76th Street New York, NY 10021 (212) 434-3285 www.nycbariatrics.com Northern Westchester Hospital 400 East Main Street Mount Kisco, NY 10549 914-242-8350 nwhsurgicalweightloss.org/default His personal email is mroslin@nshs.edu
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