LOOP Duodenal Switch
I have reviewed the comments above, and I still have the following concerns and reservations about this:
I could only find one published article on this procedure, published in 2010, with results on 50 patients, with 1-3 year follow-up. Obviously, the number at 3 years was very low. The results look good, but without being able to read the paper (I'm not paying for it), it's hard to know what they mean. There are also important reservations about extrapolating the results from these 50 patients (and I realize Roslin may have additional updated information directly from the Spanish team, but I can't comment on what I can't see):
- The patients in this study had a mean BMI of 44, which is on the light side
- These were all VIRGIN surgeries, and extrapolating these results to RNY revisions is a big question to me
- I am STILL not understanding how Roslin does the procedure and considers that it has only one anastomosis, for example, because there is the matter of the 100-150 cm piece of intestine from the distal portion of the duodenum to the proximal jejunum that is still attached to the blind stomach pouch of an RNYer - when he does the revision to the duodenal loop, does he amputate this piece and just throw it away, or does he reattach it to the top of his loop?
- There is STILL the matter of Roslin's (and Greenbaum's) recent reluctance to reconstruct the stomach of certain RNYers - those who are NOT transected, for example - what happens to them?? I think they are still ONLY being offered ERNYs.
I was glad to see that in SOME cases, Roslin is redoing the pouch into a sleeve, but I share Larra's concern that THIS is the hard part of an RNY to DS revision, so I don't see how doing the loop DS instead of a normal switch construction helps enough to be worth the compromise to use an unproven procedure, especially in an RNY to DS revision, because they need all the help they can get.
I could only find one published article on this procedure, published in 2010, with results on 50 patients, with 1-3 year follow-up. Obviously, the number at 3 years was very low. The results look good, but without being able to read the paper (I'm not paying for it), it's hard to know what they mean. There are also important reservations about extrapolating the results from these 50 patients (and I realize Roslin may have additional updated information directly from the Spanish team, but I can't comment on what I can't see):
- The patients in this study had a mean BMI of 44, which is on the light side
- These were all VIRGIN surgeries, and extrapolating these results to RNY revisions is a big question to me
- I am STILL not understanding how Roslin does the procedure and considers that it has only one anastomosis, for example, because there is the matter of the 100-150 cm piece of intestine from the distal portion of the duodenum to the proximal jejunum that is still attached to the blind stomach pouch of an RNYer - when he does the revision to the duodenal loop, does he amputate this piece and just throw it away, or does he reattach it to the top of his loop?
- There is STILL the matter of Roslin's (and Greenbaum's) recent reluctance to reconstruct the stomach of certain RNYers - those who are NOT transected, for example - what happens to them?? I think they are still ONLY being offered ERNYs.
I was glad to see that in SOME cases, Roslin is redoing the pouch into a sleeve, but I share Larra's concern that THIS is the hard part of an RNY to DS revision, so I don't see how doing the loop DS instead of a normal switch construction helps enough to be worth the compromise to use an unproven procedure, especially in an RNY to DS revision, because they need all the help they can get.
NoMore B.
on 7/9/11 9:31 am
on 7/9/11 9:31 am
Diana
I tend to agree with you. I know Dr Roslin fairly well, he's done 6-7 WLS on my family members. What I do know about him is that he's very conservative. In his mind, if he can get acceptable results with less risk that will be the way he goes. In fact he told me that if the patient doesnt have acceptable results with the loop it is fairly straight forward to revise to the Y configuration. My question was if it's straight forward why not do that to begin with? - But that's his approach...well at least to offer it as an option. As I said he will do a full intestinal DS if the patient wants that, and he agreed the more complex part of the surgery is the stomach reconstruction to revise the pouch and preserve the pyloric function, which he does.
I think his basis of offering the loop is that he believes that malabsorption and the common channel concept is too simplistic of a way to look at the DS. He believes that the malabsorption is there, obviously, but he thinks it inly plays a part in how the DS works, and that it works much more in a hormonal and metabolic boost fashion.. In fact I sat through his seminar agian this week where he replaced "malabsorptive" and "restrictive" in his PowerPoint to say intestinal and gastric. He strongly believes restriction and malabsorptive are too simplistic of principles and is in the process of having some of his studies peer reviewed for publication on that.
Not saying I agree, or am defending his position, I'm just repeating the conversation.. Again, I can see where he's coming from and I have a world of respect for him, but if it were me I would still want the tried and true full intestinal DS. At least until there is more evidence. He was pretty quick to say how easy it would be to revise the loop to a Y - but again to me he's looking at it like a surgeon - not like a patient that would need the time and insurance approval to undergo the revsion. Just my 2 cents.
I tend to agree with you. I know Dr Roslin fairly well, he's done 6-7 WLS on my family members. What I do know about him is that he's very conservative. In his mind, if he can get acceptable results with less risk that will be the way he goes. In fact he told me that if the patient doesnt have acceptable results with the loop it is fairly straight forward to revise to the Y configuration. My question was if it's straight forward why not do that to begin with? - But that's his approach...well at least to offer it as an option. As I said he will do a full intestinal DS if the patient wants that, and he agreed the more complex part of the surgery is the stomach reconstruction to revise the pouch and preserve the pyloric function, which he does.
I think his basis of offering the loop is that he believes that malabsorption and the common channel concept is too simplistic of a way to look at the DS. He believes that the malabsorption is there, obviously, but he thinks it inly plays a part in how the DS works, and that it works much more in a hormonal and metabolic boost fashion.. In fact I sat through his seminar agian this week where he replaced "malabsorptive" and "restrictive" in his PowerPoint to say intestinal and gastric. He strongly believes restriction and malabsorptive are too simplistic of principles and is in the process of having some of his studies peer reviewed for publication on that.
Not saying I agree, or am defending his position, I'm just repeating the conversation.. Again, I can see where he's coming from and I have a world of respect for him, but if it were me I would still want the tried and true full intestinal DS. At least until there is more evidence. He was pretty quick to say how easy it would be to revise the loop to a Y - but again to me he's looking at it like a surgeon - not like a patient that would need the time and insurance approval to undergo the revsion. Just my 2 cents.
"to me he's looking at it like a surgeon - not like a patient that would need the time and insurance approval to undergo the revsion"
I think this is the crux of the matter. A revision to a surgeon is a 2 hour block of time. To the patient, it is the months of struggling with issues; the fear that you are failing; the fear that it can't be fixed; the misery of trying multiple non-surgical treatments; the fear of surgery; the insurance hassle, possibly not overcome-able; the rearranging your life to have the surgery, including travel, hotel if out of town, child care, missing work and paychecks; the PAIN of another surgery; the RISK of something going wrong with anesthesia, infection, blood clots; the recuperation and eating modification and diarrhea and related issues.
I think this is a BIG issue that perhaps he doesn't appreciate.
I think this is the crux of the matter. A revision to a surgeon is a 2 hour block of time. To the patient, it is the months of struggling with issues; the fear that you are failing; the fear that it can't be fixed; the misery of trying multiple non-surgical treatments; the fear of surgery; the insurance hassle, possibly not overcome-able; the rearranging your life to have the surgery, including travel, hotel if out of town, child care, missing work and paychecks; the PAIN of another surgery; the RISK of something going wrong with anesthesia, infection, blood clots; the recuperation and eating modification and diarrhea and related issues.
I think this is a BIG issue that perhaps he doesn't appreciate.
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