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Post by nyuboi on Aug 3, 2013 17:25:07 GMT -5
*** FROM DR. MITCHELL ROSLIN ***
YOU'LL SEE HE REFERENCES ME NOT GIVING UP ON A DS....
(this is a letter he sent my PCP that my PCP gave me a copy of yesterday)
The patient, many years ago, underwent laparoscopic adjustable gastric banding that was done out in Long Island. By the time we had seen him he had esophageal dilation and an esophageal manometric problem due from the long-standing banding. At that point in time he was contemplating revisional operations and we discussed the various operations. As the patient was then unsure of what to do, he then stayed with the band being in a very, very tight position for a long time until he developed profound dysphagia. This led to me removing his band approximately a year ago. Since that time he has obviously regained all of the weight that he has lost and is contemplating revisional surgery. When he saw me, despite having the band removed, he was still having some upper GI symptomatology. As a result, I referred him to upper GI series, endoscopy, as well as manometric studies. These findings are consistent with wide open reflux-type symptoms as well some minor motility disturbances of the esophagus, but clearly seemed to indicate that the conversion of choice for many reasons would be Roux-en-Y gastric bypass surgery. Essentially, to explain in summary, the patient's issues have some secondary to the high pressure created by the laparoscopic adjustable gastric band. While this is improved following removal of the band, he still has reflux secondary to damage of the esophagus and GE junction. As a result, I think it is imperative that we do an operation that creates a low pressured system, and clearly gastric bypass meets criteria. He has regained all of his weight that is lost. I think that this process would continue and further exacerbate his reflux if nothing is done. The options include sleeve gastrectomy and I would be reluctant to do this because he would have essentially an esophagus that has been exposed to high pressured then emptying into a high pressured system, and I think this would be detrimental. Additionally, I think the same thing would be true of a duodenal switch, which at one time I contemplated with the patient, but again, the esophagus and GE junction would be entering into a high pressured system, and I think a postoperative reflux would be predictable. As a result, I think gastric bypass is clearly the best option. I have been trying to voice this to the patient multiple times, and I am actually one of the biggest proponents to pyloric preserving surgery, but somehow I think that he keeps on coming back to things I have already stated clearly. He clearly needs surgical intervention for his reflux with his morbid obesity. The operation of choice is gastric bypass with concomitant fixture of any hiatal hernia, and I hope this letter is clear. I can be reached at XXX-XXX-XXXX.
Mitchell S. Roslin
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Post by nyuboi on Aug 3, 2013 17:35:26 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? I have just emailed Dr. Anthone. Hopefully he replies.
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Post by nyuboi on Aug 3, 2013 17:36:07 GMT -5
From DR. INABNET (vetted list, NY, Mt. Sinai)
Thank you for your email. I cannot conduct a consultation via email, please schedule an apt to see me in the office, please bring a copy of your films. Sincerely yours, William B Inabnet III, MD, FACS
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Post by nyuboi on Aug 3, 2013 17:36:53 GMT -5
I POSTED A COPY OF DR. ROSLIN'S NOTES ABOVE...
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Post by nyuboi on Aug 3, 2013 17:55:37 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 I HAVE JUST SENT THIS REPLY TO DR. SPAW: (in addition, a similar email to Dr. Prachand, who spoke of BMI controversy issues in the previous email I posted). Dr. Spaw, Thank you for your feedback. I realize your time is valuable and I really appreciate it. Are you basing your position more on my low BMI or more on the GERD and potential motility issue? I ask because I want to be clear that Lenox Hill and Dr. Roslin perform the DS on any patient of a 35 BMI or higher who has comorbidities or BMI of 40 plus without. They feel if you are eligible for one surgery, then they wouldn’t rule out a DS. They believe very much in pyloric valve preservation, and generally recommend the sleeve and the DS to most patients. I am not concerned with malabsorptive issues, as I am on top of monitoring my blood work and reliable with taking the appropriate vitamins and treatment. In fact, I believe it’s this very malabsorption that keeps the weight off long-term. (I am NOT that happy with long-term RNY statistics with weight regain, and would generally be going for an DS if I didn’t have any medical issues from the band). My best friend has a 40 BMI but is getting a DS (from a lapband) with Dr. Roslin, but he had no issues or complications, just inadequate weight loss. When you say the “only procedure” you would recommend is the RNY, I want to be sure you’re not basing that solely on my 39 BMI. Very truly yours,
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Post by goodkel on Aug 3, 2013 17:59:43 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? I have just emailed Dr. Anthone. Hopefully he replies. If he doesn't, you should call him. Maybe you should also pm Diana and see if she knows how to contact Walter. He was turned down many times before he met with success.
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Post by newanatomy on Aug 3, 2013 18:13:44 GMT -5
Nyuboi, I admire your diligence in your research and your effort to have the DS. The DS is not for everyone. I am trying to get one, too. I will be so disappointed if, for some reason, I am told no. I just hope that I am told no if it happens that it would be a huge mistake for me to have this surgery. Every surgery I have had seems to exchange one set of problems for another set. In reaching a decision for any surgery we have to weigh the consequences. At this point, I am positive that the DS is right for me but, if the doctors come up with some huge negative, I will factor that into my decision at that time.
My sister could not get the DS due to diverticulitis which cost her many feet of her intestines. She opted for the RNY. She is three years out, a size 6 and thrilled. She eats almost anything she wants, in moderation.
I hope that however it works out for you that you have the very best results possible. Good luck!
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Post by horsnhound on Aug 3, 2013 23:00:25 GMT -5
Nyuboi~ I agree with goodkel and Diana- see if you can contact Walter and his surgeon Dr. Anthone. I think talking with someone who has had-and done this procedure- will round out all the information you have received and help you make the best decision for you. Good luck, and please continue to keep us informed. Ericka
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Post by horsnhound on Aug 4, 2013 3:22:16 GMT -5
Diana~ that was me.........hope he sees it.
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Post by nyuboi on Aug 4, 2013 16:02:45 GMT -5
FYI, Walter is around - he posted on OH this evening to someone looking for a DS revision surgeon in the midwest (he is not the most articulate typist/poster, but you can get his drift): walter A. on 8/3/13 8:32 pm - lafayette, NJ DS on 11/12/10 with Gary Anthone Dr. garry anthone in omaha ne. He cared for my revision when 7yrs nycds docs turned me down. Only he and ganger were willing to do me ETA: Someone posted to Walter trying to get him to come back over here and respond to this thread. Do you have a link to this post so I can click PM on him?
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Post by nyuboi on Aug 4, 2013 16:22:25 GMT -5
If I go across the country for a DS surgeon, I will have no coverage. I do not have out-of-network benefits and Dr. Roslin is one of the few top surgeons who take HMO plans.
Dr. Pomp, Dr. Bessler, Dr. Inabnet, and Dr. Fielding I all paid out of pocket to see for consults.
I AM REALLY TORN. I want the DS and in my book the advantages far outweigh the disadvantages, from a general standpoint. I hate the small pouch eating ability versus a partial stomach -- my friend with DS will be able to eat more than me when we go out, while I eat for a golfball of a stomach. And I want malabsorption.
Having said that, I do believe Dr. Roslin that I am playing with risks if I get the DS. The vomiting up at night every few days now is really not pleasant, and if that was made worse it would be a really bad situation. When they took me off of the PPIs for the bravo implant pH testing, I was miserable all day long. I am decent now that I am back on Nexium and Prilosec. I don't love the RNY, but would opt for it over nothing.
My United HealthCare plan was decent with approving this. If I change insurance companies to get other surgeons in-network I may get declined. EmblemHealth GHI just declined my friend getting the DS from lapband (his BMI is in the 40s) and they are doing a peer to peer. I'm lucky I didn't have to go through all that appeal stuff.
This is just so tough. I know Dr. Roslin loves the DS. A year ago when I said RNY to him (before knowing about my problems), his response was "Why wouldn't you want to preserve the pyloric valve?" He pushed DS on me before we knew about the lapband damage to the esophagus. Freakin lapband has really screwed my options on this one.
Lap-band Reversible my ass. They should say removable, not reversible.
I remain scheduled for the RNY next week, Tuesday 8/13.
I do believe I will lose a ton of weight with the RNY over the next year, the fear is keeping it off. I don't want to be a statistic 3 years later where I went from 70% weight loss to 60% while the DS patient goes from 75% to 85%.
I just look at all of you and see how so many of you got to normal BMIs, and from your starting point it is truly amazing. I am at 270 now... with a goal weight of about 170. Think the RNY will drop me below 190 if I work hard, but not sure how realistic getting to a 25 BMI will be.
Sorry I am rambling as the surgery date gets closer.
I just don't know if I want to throw away an insurance approval for next week's RNY on a chance that the DS won't be "detrimental" (as Roslins dictation note above put it). Not to mention finding a surgeon willing to do it, and somehow getting approval for such when insurance is going to say I have reliable in-network surgeons in the NYC area.
Lenox Hill is out for performing a DS on me. That leaves insurance coverage with NYU, and Dr. Fielding directly if I change my insurance company. (He is willing to do a DS on me, But this is also the man who wanted to attempt to leave my lap-band in when my esophagus was getting damaged, when Dr. Roslin intervened and said he was out of his mind...)
Ironically as I post I am seeing an advertisement at the bottom of my screen for "New York Bariatric Group." I met with them, Shawn Garber MD. He doesn't do DS though and was willing to do an RNY on me for 25,000 dollars when my BMI was below 35.
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Post by newyorkbitch on Aug 4, 2013 18:57:14 GMT -5
Did you ask Roslin about doing the malabsorptive component of the DS and not the VSG...fixing your hiatal hernia but not doing a sleeve?
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Post by horsnhound on Aug 4, 2013 22:18:37 GMT -5
Nyuboi, I know exactly how you feel. Really, I do. I had my heart set on the VSG, and finally the DS 5 years ago. I went to 4 different Bariatric surgeons here in Northern CA. Not one of them recommended the DS with my Barretts Esophagus. They all said RNY was the surgery to correct for severe GERD. I am NOT happy with the overall weight loss statistics of RNY. I also happen to have out of control diabetes and am on massive doses of insulin, and really think the DS would be much better for resolution of this. I DO NOT see dumping as a positive reinforcement but as my body telling me I need my pylorus! Reactive hypoglycemia scares the hell out of me. Taking vitamins is no deterrent as I already take about 25 pills a day. I could find no downsides to the DS EXCEPT for reflux. And unfortunately, as I said before, that alone was the deal breaker with my Barretts. Obviously this is still very hard for me to accept as you can see I am STILL, 5 years later, trolling the DS boards looking for information on any breakthroughs on DS surgery with controls in place for avoiding reflux. I am SURE it will happen eventually. Unfortunately time is running out for me as my diabetes is really starting to affect me. I am going to go ahead and get the RNY, and be diligent in my diet and exercise and do all I can in my power to KEEP the weight off. We can do this!
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Post by nyuboi on Aug 5, 2013 18:07:58 GMT -5
Nyuboi~ I agree with goodkel and Diana- see if you can contact Walter and his surgeon Dr. Anthone. I think talking with someone who has had-and done this procedure- will round out all the information you have received and help you make the best decision for you. Good luck, and please continue to keep us informed. Ericka ** DR. ANTHONE (Nebraska) CALLED ME TODAY ** I missed his call but he left a detailed voicemail. He said his team and him concur with Dr. Roslin. He said anyone with a history of a motility disorder and/or highly severe reflux would be better served by a smaller pouch than a sleeve gastrectomy. He said an RNY would be what he agrees with versus the first stage (sleeve) of the DS.
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Post by nyuboi on Aug 5, 2013 18:13:54 GMT -5
Did you ask Roslin about doing the malabsorptive component of the DS and not the VSG...fixing your hiatal hernia but not doing a sleeve? Yeah. Below is a copy/paste of the previous page where I posted about it. Basically, he referenced studies of it where its been done. .... 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% Read more: weightlosssurgery.proboards.com/index.cgi?board=talk&action=display&thread=7138&page=3#ixzz2b8hJyEn2
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Post by nyuboi on Aug 5, 2013 18:15:27 GMT -5
BTW, when they say "no smoking" before surgery, are electronic cigarettes okay? I ask because they have nicotine in them. I will email him about that...
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Post by newyorkbitch on Aug 5, 2013 18:18:50 GMT -5
Ask him specifically about doing no sleeve - just fixing the hiatal hernia and doing the malabsorptive part. It might take you longer to lose the weight - but so what. Don't think about 1 year and 3 year - think long term. I am 13+ years out and my stomach size is irrelevant to my maintaining my weight.
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Post by newyorkbitch on Aug 5, 2013 18:20:04 GMT -5
STOP. SMOKING. NOW. (chew the nicotine gum if you must)
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Post by nyuboi on Aug 5, 2013 18:21:07 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 I HAVE JUST SENT THIS REPLY TO DR. SPAW: (in addition, a similar email to Dr. Prachand, who spoke of BMI controversy issues in the previous email I posted). Dr. Spaw, Thank you for your feedback. I realize your time is valuable and I really appreciate it. Are you basing your position more on my low BMI or more on the GERD and potential motility issue? I ask because I want to be clear that Lenox Hill and Dr. Roslin perform the DS on any patient of a 35 BMI or higher who has comorbidities or BMI of 40 plus without. They feel if you are eligible for one surgery, then they wouldn’t rule out a DS. They believe very much in pyloric valve preservation, and generally recommend the sleeve and the DS to most patients. I am not concerned with malabsorptive issues, as I am on top of monitoring my blood work and reliable with taking the appropriate vitamins and treatment. In fact, I believe it’s this very malabsorption that keeps the weight off long-term. (I am NOT that happy with long-term RNY statistics with weight regain, and would generally be going for an DS if I didn’t have any medical issues from the band). My best friend has a 40 BMI but is getting a DS (from a lapband) with Dr. Roslin, but he had no issues or complications, just inadequate weight loss. When you say the “only procedure” you would recommend is the RNY, I want to be sure you’re not basing that solely on my 39 BMI. Very truly yours, DR. SPAW replied below. I was making sure he wasn't saying this just cause of a low BMI, because he referenced doing on patients with a 60. So I wrote the above to him explaining a 35 BMI is all that's needed for a DS at Lenox Hill. DR. SPAW replied below: I am basing the bypass choice strictly on your severe reflux issues, not BMI. Dr. Roslin is correct that the sleeve is a high pressure pouch. A DS or sleeve would potentially make your reflux issues worse. Should they become intollerable, you might have to be converted to a bypass. You've already had one gastric procedure. Those are my thoughts. Albert T. Spaw, MD FACS FASMBS
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Post by nyuboi on Aug 5, 2013 18:30:14 GMT -5
STOP. SMOKING. NOW. (chew the nicotine gum if you must) I was using electronic ones to quit. But they have nicotine and run on battery. Dr. Roslin said smoking after surgery is worse with a RNY than a DS because of no stomach lining to protect against ulcers, etc. I know smoking is over. No smoking. No eating. Drinking will "dump" into small intestines (with RNY), I have great times a head of me! Perhaps I'll just become a DS forum addict.
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Post by nyuboi on Aug 5, 2013 18:31:42 GMT -5
Ask him specifically about doing no sleeve - just fixing the hiatal hernia and doing the malabsorptive part. It might take you longer to lose the weight - but so what. Don't think about 1 year and 3 year - think long term. I am 13+ years out and my stomach size is irrelevant to my maintaining my weight. Pasted from above: 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. Read more: weightlosssurgery.proboards.com/index.cgi?board=talk&action=display&thread=7138&page=4#ixzz2b8m6dMP4
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Post by newyorkbitch on Aug 5, 2013 19:33:19 GMT -5
What I'm telling you is ask again, this time prepared, and DO remember what he says. Do this before you go under the knife for the RNY. If it's easier to write him an email, and he tends to respond thoroughly and quickly, then do that.
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Post by horsnhound on Aug 5, 2013 20:20:20 GMT -5
[/quote] No smoking. No eating. Drinking will "dump" into small intestines (with RNY), I have great times a head of me! Perhaps I'll just become a DS forum addict.[/quote] You rang Why do you think I troll this board? So I can live VICARIOUSLY as a DS'er! Oh hey - also there is a much higher rate of alcoholism/transfer addiction as an RNYer! Sorry not trying to be a downer- I'm in the same boat as you are. I am really impressed with your dogged persistance- you have really done exhaustive research here. HOWEVER- You really have to cut out ALL nicotine NOW! Should have done it 2 weeks prior to surgery. End of rant.
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Post by nyuboi on Aug 6, 2013 15:07:00 GMT -5
What I'm telling you is ask again, this time prepared, and DO remember what he says. Do this before you go under the knife for the RNY. If it's easier to write him an email, and he tends to respond thoroughly and quickly, then do that. I put the first line so as not to piss him off and act like I'm still challenging his DS denial. Dr. Roslin, I know and have accepted I am getting the RNY next week. I just wanted to ask so I know what I am talking about on the internet forums: What is the reason we arent doing a sleeveless DS (the intestinal bypass portion only?) I want to be able to share it with the DS patients online. Thanks,
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Post by nyuboi on Aug 6, 2013 16:30:15 GMT -5
One last try: Walter (low BMI, Nissen) was refused a DS by Roslin as well (I'm almost positive), and the other NY surgeons too. He went to Anthone in Omaha, and got his porkchop sleeve, kept his Nissen, and his Barrett's is in remission. Roslin is conservative. Some would say too conservative. But it's of course up to you. I CALLED DR. ANTHONE BACK ON THE PHONE: He said he believes Walter was turned down by the NYC surgeons because of the low BMI, not the Barretts. He said both an RNY and DS would help with Barrets because theres no way to reflux bile anymore. He recalls the Nissen on Walter. He said he has been doing the sleeve on DS patients since 1992. And that now, as he does the sleeve alone in a lot of patients, they are coming to see about 5% of people with a sleeve (including DS patients) have worse reflux and heartburn symptoms after the surgery. He said someone like me who is pre-disposed to it would likely be a "given" that it gets worse. He thinks I would be better served with a smaller gastric pouch.
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Post by nyuboi on Aug 6, 2013 16:43:21 GMT -5
What I'm telling you is ask again, this time prepared, and DO remember what he says. Do this before you go under the knife for the RNY. If it's easier to write him an email, and he tends to respond thoroughly and quickly, then do that. I put the first line so as not to piss him off and act like I'm still challenging his DS denial. Dr. Roslin, I know and have accepted I am getting the RNY next week. I just wanted to ask so I know what I am talking about on the internet forums: What is the reason we arent doing a sleeveless DS (the intestinal bypass portion only?) I want to be able to share it with the DS patients online. Thanks, FROM DR. ROSLIN: you mean long distal bypass if u do not have fundus or pylorus u r asking for trouble you need low pressure low pressure and distal bypass not good combo
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Post by newyorkbitch on Aug 6, 2013 18:32:27 GMT -5
I say go for the RNY, in that case. I don't pretend to understand the pressure issues, but I am sure Dr. Roslin does. Good luck.
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Post by nyuboi on Aug 6, 2013 19:47:52 GMT -5
I say go for the RNY, in that case. I don't pretend to understand the pressure issues, but I am sure Dr. Roslin does. Good luck. That's the reality setting in. I am seeing NYU/Fielding on Thursday to see if he would do a DS on me, but im not sure I would take his word over Roslin's. Fielding wanted to keep my band in and I would have had further esophageal damage. Maybe I should stop speaking to doctors and just enjoy this time before my surgery. Pre-op testing and all is done.
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Post by nyuboi on Aug 6, 2013 20:05:35 GMT -5
I put the first line so as not to piss him off and act like I'm still challenging his DS denial. Dr. Roslin, I know and have accepted I am getting the RNY next week. I just wanted to ask so I know what I am talking about on the internet forums: What is the reason we arent doing a sleeveless DS (the intestinal bypass portion only?) I want to be able to share it with the DS patients online. Thanks, FROM DR. ROSLIN: you mean long distal bypass if u do not have fundus or pylorus u r asking for trouble you need low pressure low pressure and distal bypass not good combo From what I am reading online it looks like doing a DS without a sleeve is similar to doing a "distal gastric bypass." The malabsorption is about the same. www.dsfacts.com/history-of-duodenal-switch.html
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Post by Deleted on Aug 6, 2013 20:06:06 GMT -5
I put the first line so as not to piss him off and act like I'm still challenging his DS denial. Dr. Roslin, I know and have accepted I am getting the RNY next week. I just wanted to ask so I know what I am talking about on the internet forums: What is the reason we arent doing a sleeveless DS (the intestinal bypass portion only?) I want to be able to share it with the DS patients online. Thanks, FROM DR. ROSLIN: you mean long distal bypass if u do not have fundus or pylorus u r asking for trouble you need low pressure low pressure and distal bypass not good combo Did he misunderstand or did I? If he leaves your stomach alone you would have both your pylorus and fundus. It looks like he is thinking you were asking about a pouch and the DS intestines. I thought that you were asking him about doing the intestinal portion only? That is widely done in Europe and has been for years as a cure for Type II.
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