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Post by nyuboi on Jul 30, 2013 16:09:33 GMT -5
Did you talk to Dan Herron? Or Inabnet? Met with Inabnet a year ago. He was willing to do a DS with a less aggressive common channel of 150. At the time I was 50 pounds less. According to his medical records I have with me, he suggests the RNY over all other procedures because of my severe reflux, but is "willing" to consider any of them. He also didn't know about my motility disorder though or the vomiting that began after the lap band came out. |
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Post by nyuboi on Jul 30, 2013 16:13:03 GMT -5
If you have a hiatal hernia repair (Nissen) just by itself, that would answer the question of whether your GERD could be treated, and whether you could do a DS, no? Put off the WLS until later? If you can do a DS, you could do the pork chop version? If not, I don't believe it will screw up the RNY either. Annoying to have to do two procedures, but the Nissen may well be done outpatient (my father spent one night in the hospital for his, which was a HUGE rip in his diaphragm, at age 78 or so). I would rather do that than agree to an RNY without trying to find SOME other solution. I will ask him about this. Is a hiatal hernia repair the same as a Nissen? I thought it wasn't. The problem is I am at a BMI where if I lose too much weight dieting I will not qualify. United Healthcare turned me down for an RNY last fall after the band came out. The only reason I was approved for DS a year ago with a 32 BMI was because of the lap-band having to come out, doing it all at once. Now that band is out I am like a normal patient starting from scratch. Had to go through all the nutritional, psych, and all all over again. They only approved me because my BMI jumped up to 39 with the sleep apnea and reflux and asthma. But if it drops below 35 in the coming months and I do nothing, WLS wont be an option. |
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Post by nyuboi on Jul 30, 2013 16:15:54 GMT -5
Why don't you go to Dr K? Insurance HMO only covers in-network doctors in New York. |
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Post by nyuboi on Jul 30, 2013 21:48:04 GMT -5
THIS JUST CAME IN FROM David Greenbaum, THE N.J. VETTED DS SURGEON ON THE VETTED LIST:
":I agree that a ds or sleeve would be a bad idea. A GBP fixes feed and gives good weight loss. I cannot comment much on the esophageal dismotility but that can be a significant problem which may improve with GBP but could also not get better and doing any surgery could be unclear as to what the results would be."
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Post by kennyk on Jul 31, 2013 1:56:39 GMT -5
Inabnet was recommended to me from Dr. Sudans office.
Since he was also not with my insurance I ended up using Dr. Kini from Mount Sinai.
My surgery went well with no apparent problems. Even though I did not get Inabnet. (prob good I had blinders on and did not know about vetted etc.) I just said I am here for a DS, no interest in anything else,
k
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Post by horsnhound on Jul 31, 2013 3:42:12 GMT -5
Nissen fundoplication is part of a hiatal hernia repair. Huhwha........? NF is a first line surgery to correct severe reflux, HOWEVER it is usually contra indicated for ALL WLS and it would most likely need to be reversed or taken down in order to have the bariatric surgery. |
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Post by larra on Jul 31, 2013 11:35:48 GMT -5
Huhwha........?
NF is a first line surgery to correct severe reflux,
HOWEVER it is usually contra indicated for ALL WLS and it would most likely need to be reversed or taken down in order to have the bariatric surgery.[/quote]
Not correct. If someone has had a prior Nissen fundoplication and now needs bariatric surgery, the Nissen can be taken down. However, for these patients, RNY gastric bypass is generally considered a good choice because it works best for GERD of any bariatric surgery, and with the Nissen taken down, the patient would again have severe GERD unless something else is done about it. And if the GERD wasn't severe in the first place, the patient wouldn't (or at least shouldn't) have had the Nissen done in the past.
Lap band and VSG would be poor choices for these patients as they are the most likely bariatric surgeries to make GERD worse, esp since many VSG surgeons are making tight sleeves to attempt to prevent weight regain. DS - more controversial as the size of the sleeve could be made looser than with VSG as a stand alone..but a lot of surgeons would recommend against it even so. I don't know what the right answer is on the DS.
Larra
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Post by newyorkbitch on Jul 31, 2013 12:31:25 GMT -5
So why not a DS without the VSG part?
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Post by nyuboi on Jul 31, 2013 20:34:44 GMT -5
I'm back from my long day in the city.. that's a story in itself.
Met with Dr. Roslin and all. But I think its maybe best I post about stuff in the morning. I just took an Ambien and I tend to write a lot and over-disclose when I'm on it, or just not think. I have an older friend who gambled away a 401k while on ambien, some sleep-drive, etc. My thing is I like to talk in bed on the phone with a friend late at night while im sedated. Love that hypnotic feeling. My favorite drug in the world. My RNY can take away my smoking, my drinking, my food, but it will never get my Ambien. lol
Goodnight my DS Friends.
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Post by horsnhound on Jul 31, 2013 20:51:31 GMT -5
Sorry Larra, I don't think I was clear in my above post.
What I should have clarified was with a NF, instead of "contra indicated", it would have to be taken down before RNY/VSG/DS. I have been informed of this personally by 3 different highly regarded bariatric surgeons as well as my gastroenterologist.
Hence my reply to Diana Cox "Huhwha" because it wouldn't make sense to have a NF only to have it reversed or taken down in order to have WLS.
I suppose the OP could contact Dr. Antone ( Walters surgeon) who, so far in all my years of research is the only surgeon I have heard of who has done the Nissen and the DS together.
Regardless-as the OP has had Barretts ruled out, he very well could have a modified (larger) sleeve made in order to avoid worsening reflux and go ahead with the DS.
Wish that I had that option!
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Post by larra on Jul 31, 2013 21:21:49 GMT -5
horsnhound, you are right, the Nissen would have to be taken down to do RNY, VSG or DS. The advantage here of RNY is that it's very effective for GERD, whereas VSG, esp if tight, will worsen GERD. DS is somewhere in between, because the sleeve doesn't have to be so tight (though there are some DS surgeons who prefer a tight sleeve and longer common channel with DS, which would be a bad combo for someone with GERD.
The point is that if you are having RNY, you no longer need your Nissen so it can be safely taken down, while with VSG you would lose your protection from GERD that the Nissen gave you and simultaneously do an operation that is likely to worsen that GERD.
With DS ? Less tight sleeve, but still lose the Nissen, which was done for a reason. Is there some other shape of sleeve, like this "pork chop" people are discussing, that would make a DS ok for someone with a prior Nissen? I have no idea.
Larra
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Post by Deleted on Jul 31, 2013 21:32:19 GMT -5
A Nissen is sometimes employed when doing a HH repair, but not always. I will have a HH repair as part of my DS procedure.
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Post by newyorkbitch on Aug 1, 2013 10:04:56 GMT -5
What about doing no VSG, just the Nissen and the malabsorptive component of the DS?
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Post by Deleted on Aug 1, 2013 10:28:25 GMT -5
What about doing no VSG, just the Nissen and the malabsorptive component of the DS? Great question. And to take it a step further, why not just make the sleeve larger than normal with taper at top (pork chop). Frankly I have never understood the need for a tiny sleeve when doing a DS when the switch portion does the majority of the weight loss control. 6-8 oz sleeve versus 2 oz 2 sleeve. Is there really any data showing that sleeve size determines weight loss long term? I believe everything I have seen in that regard has been inconclusive. |
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Post by newyorkbitch on Aug 1, 2013 10:35:37 GMT -5
FWIW, my "sleeve" hasn't been a "sleeve" in many years. My eating capacity is just as large as it was pre-op, it has been for a long time, and I'm 13+ years out and maintaining my weight loss pretty easily for a long time.
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Post by nyuboi on Aug 1, 2013 16:38:59 GMT -5
What about doing no VSG, just the Nissen and the malabsorptive component of the DS? I don't remember the scientific details behind it, but Dr. Roslin said this would be a bad idea. He said there would have to be some sort of pouch if not a sleeve. He referenced studies to this and I *think* said I would be a "shiting duck." I definitely asked about this, but I don't remember everything he said regarding it because they had thrown me on the phone with me unexpected without being prepared with my notes and all. Also, the studies showing the DS weight loss superiority over the RNY is based on a sleeve in conjunction with the intestinal bypass. I'm not sure if the numbers would be the same with no sleeve. According to Lenox Hill: LAP-BAND 1 year weight loss: 40-50% 3 year weight loss: 40-55% Note: lapband has highest chance of reoperation BYPASS 1 year weight loss: 70% 3 year weight loss: 60% SLEEVE 1 year weight loss: 60-70% 3 year weight loss: 70% DS 1 year weight loss: 75% 3 year weight loss: 85% |
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Post by nyuboi on Aug 1, 2013 16:41:03 GMT -5
A Nissen is sometimes employed when doing a HH repair, but not always. I will have a HH repair as part of my DS procedure. Also having the HH repaired during the operation. |
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Post by nyuboi on Aug 1, 2013 16:45:17 GMT -5
The advantage here of RNY is that it's very effective for GERD, whereas VSG, esp if tight, will worsen GERD. DS is somewhere in between, because the sleeve doesn't have to be so tight (though there are some DS surgeons who prefer a tight sleeve and longer common channel with DS, which would be a bad combo for someone with GERD. This is my problem. Even a "gentle" sleeve would add more "pressure" to my current situation. |
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Post by nyuboi on Aug 1, 2013 16:58:37 GMT -5
HAD MY PRE-OP FACE TO FACE WITH DR. ROSLIN YESTERDAY:
Basically, he said NO DS. He said "you are thinking of yourself as a weight loss patient. You are no longer a WLS patient. You are a patient with post-lapband esophageal damage, then comes the weight loss. If you didn't have a damaged esophagus from the band, then we would do the DS."
He went on to explain that even currently I am bad off with my esophagus (the vomiting every night, food not fully emptying into stomach, etc.) He said a RNY will lower the pressure from my current situation, (if anything, improve my current situation) and that a DS would raise the pressure from my current situation (if anything worsen it).
He agrees with me that the severe vomiting can't all be coming from the GERD. So it's not just the acid reflux, but the possible motility issue too.
My upper GI report says "A dilated and tortuous distal esophagus is again noted. Tertiary contractions are present." It was compared to previous UGI's when my lapband was in but had to come out.
My best friend is also having revisional surgery with Dr. Roslin in August (band to DS). But in his case the band just didn't produce weight loss, he still has a 40 plus BMI, but he has no complications from it.
As of now, I am scheduled for RNY on 8/13. I wish it was the DS, but there has to be some stock in what Dr. Roslin is saying when he is a surgeon that bashes the RNY and pushes the DS. I suppose the lap-band truly limited my options. :/
I hope I will still be welcome here.
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Post by nyuboi on Aug 1, 2013 17:44:05 GMT -5
Just got a phone call from: Hazem A. Elariny (off of DS vetted list, VA)
He feels a lot of the dismotility or esophageal problem could be coming from scar tissue and stuff. Dr. Roslin did not break any of that up when removing the band.
He said a restrictive procedure, including bypass, can have reflux cause of the obstructional passage of food. He said I would need a non-restrictive bypass -- unrestrictive. I don't like the sound of this because it wouldn't be as good for the weight loss - he said I might be able to eat a 12" sub in a year with this.
He said the high pressure of the sleeve is often a consequence of surgeons modifying the sleeve (making it smaller) and not following the original intended size.
He does a sling wrap similar to a Nissen to help with the acid reflux, possibly combined with a DS. He said a non standard anti flux procedure would need to be done with it. He also mentioned a possible Scopinaro procedure.
That was his feedback. Some of it was very technical so I'm not sure if I relayed his entire message. Bottom line is he would not rule out a DS.
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Post by nyuboi on Aug 1, 2013 17:45:29 GMT -5
From Dr. K: (referring to my motility studies)
Hello,
I think the problem that most GI specialist have is that they have not caught up with the science and the complications of Lap Band, and are still applying the old diagnostic criteria to patient with new problems.
Good luck.
Ara
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Post by nyuboi on Aug 1, 2013 17:49:28 GMT -5
From Vivek N. Prachand, off of the vetted list for Illinois at U. Chicago:
Based solely on the information you've provided and without having had the opportunity to perform a complete evaluation (which could reveal additional information and alter my perspective), I would agree with the recommendation to have RYGB, both from the perspective of addressing your GERD in a more predictably effective manner as well as the fact that your BMI is well below the "super-obese" (BMI >50) range. When we examined the rates of remission of comorbidities in our 2010 study comparing RYGB to DS, we found that while the metabolic conditions (diabetes, hypertension, dyslipidemia) had a higher rate of remission with DS, the rate of remission of GERD was higher with RYGB, most likely related to the mechanisms that Dr. Roslin described. I do not recommend Nissen fundoplication for patients whose BMI qualifies them for bariatric surgery, as it's effectiveness and durability may not be as robust.
I recognize that there is some controversy regarding BMI "cutoffs" for DS. I am a strong proponent of DS for appropriately motivated and educated patients with BMI >50 as well as "lower" BMI patients with severe diabetes. Your BMI falls into this lower category, and from your description, in many ways your GERD may be more problematic than your obesity. Be advised that there is a real possibility that the DS could make your GERD worse.
I hope that this helps, and let us know what you decide to do. You're in good hands with Dr. Roslin.
Sincerely,
Vivek N. Prachand, MD
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Post by nyuboi on Aug 1, 2013 17:51:18 GMT -5
From Albert T. Spaw (off of the vetted list, TN)
I also am a proponent of the DS. I personally recommend it to those patients who I feel may need a more potent procedure; perhaps numerous severe comorbidities or BMIs > 60. So with a BMI of 39 a DS would burden you with more malabsorptive issues than gastric bypass. I agree completely with Dr. Roslin on his preference for the gastric bypass in your particular situation. There's no question that the ONLY procedure I would recommend is the gastric bypass in your case. Finally, I don't know Dr. Roslin personally, however I have discussed difficult cases with him and I have tremendous respect for him because he is smart, a great surgeon and he's totally honest- he tells it like it is. He's the man, you need not go anywhere else!!
Albert T. Spaw, MD FACS FASMBS
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Post by nyuboi on Aug 1, 2013 17:52:53 GMT -5
From Dennis C. Smith (off of the vetted list, GA)
It's true that the RNY is a better anti-reflux procedure than the DS, but it's not a all or nothing type of decision. The DS will make reflux better in most patients, and if you have a hiatal hernia, the chances are even better that with a repair of the hiatal hernia at the same time your reflux would be better. I do the RNY as well, and am not wedded to the DS as the best operation for all patients, but it's just not as cut and dried, at least from what I know so far.
I was a chemical engineer before I was a doctor, and I don't buy the application fixed wall mechanics to bariatric stomach pouches. The "high-pressure" thing doesn't hold water, for me. To me there is no reason to call a DS pouch "high-pressure" and a RNY a "low pressure" pouch, if there's no outlet problem, kinking or stenosis with the DS pouch. That's my opinion, even though I know lots of Sleeve and DS surgeons have jumped on that bandwagon, perhaps as an explanation for the leak rate they're seen with sleeve pouches.
I have some other opinions that differ from those of most sleeve and DS surgeons, such as choice of staple height and long-term diet strategies, but those are off topic right now.
I would be willing to look at your studies, etc., and we could see if the DS might still be an option for you.
Dr. Smith
Dennis C. Smith, Jr., MD, FACS, FASMBS
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Post by Girlrocker on Aug 1, 2013 18:55:25 GMT -5
Well, this is quite a lot of information, it seems like you have gathered from the most and best sources possible; any idea on your next steps?
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Post by horsnhound on Aug 1, 2013 19:40:37 GMT -5
Nyuboi-
Good for you!
This is a huge decision and one you will have to live with the rest of your life.
You have talked to the experts and received a lot of good feedback.
Now- having taken everything they said into consideration, listen to what your head and heart tell you.
I actually made a pro and con list for both the DS and the RNY. The pro's on my DS list outnumbered the cons by far (better Diabetes resolution,able to take NSAIDS, retaining my pyloric valve, better chance of weight loss and maintenance...etc.)
HOWEVER, my Barretts esophagus in the end was a deal breaker for me. And that was the ONLY pro on my RNY list.
Go with your gut, and best of luck!
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Post by goodkel on Aug 2, 2013 5:45:29 GMT -5
Great work, nyuboi!
This is exactly what someone in your position should do.
~exalt~ for providing an excellent example of research.
But, I think you would be remiss if you did not contact Anthone. I am familiar with Walter and his story. He struggled for a long time to find a surgeon who would give him the DS and keep his Nissen. He would not consider any other bariatric surgery but the DS.
You've done so much work already. Why stop before you've consulted with a surgeon who has successfully provided the DS to someone with your same complications?
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Post by nyuboi on Aug 2, 2013 14:13:57 GMT -5
Dr. John M. Rabkin just called me. He was the second surgeon I had emailed a week ago when I contacted Dr. K. He got back to me via phone today.
He basically said two things:
1) He concurs with Dr. Roslin that the DS is a bad idea. He says Dr. Roslin is a very strong proponent of the DS and that if he is suggesting not to get one that this holds some serious weight. He felt the DS could exacerbate my current problems.
2) Having said that, he's not sure an RNY will help. He said it doesn't increase gastric pressure like the DS, but that it impairs the passage of food. He is concerned if my esophageal issues should be evaluated more before an RNY. He asked how long I have waited since the band came out, etc.
So in summary he said no DS, but didn't make me too comfortable about the RNY. I hope I'm not still vomiting at night after I get it.
He did say the RNY would be good for the GERD.
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Post by nyuboi on Aug 2, 2013 14:15:42 GMT -5
Great work, nyuboi! This is exactly what someone in your position should do. ~exalt~ for providing an excellent example of research. But, I think you would be remiss if you did not contact Anthone. I am familiar with Walter and his story. He struggled for a long time to find a surgeon who would give him the DS and keep his Nissen. He would not consider any other bariatric surgery but the DS. You've done so much work already. Why stop before you've consulted with a surgeon who has successfully provided the DS to someone with your same complications? Do you have the doctors contact information? |
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Post by goodkel on Aug 2, 2013 16:03:12 GMT -5
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