VSG diabetes question.

https://asmbs.org/patients/life-after-bariatric-surgery

Q: Which medications should I avoid after weight loss surgery?
A: Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the ?Non-steroidal anti-inflammatory drugs? (NSAIDs), which can cause ulcers or stomach irritation in anyone but are especially linked to a kind of ulcer called ?marginal ulcer? after gastric bypass. Marginal ulcers can bleed or perforate. Usually they are not fatal, but they can cause a lot of months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.

Some surgeons advise limiting the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary in some situations. Some long-acting, extended-release, or enteric coated medications may not be absorbed as well after bariatric surgery, so it is important that you work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is high enough. Finally, some prescription medications can be associated with weight gain, so you and your doctor can weigh the risk of weight gain versus the benefit of that medication. There may be alternative medications in some cases with less weight gain as a side effect.

Note also that some on these forums complain that "some surgeons" also advise a soft diet of oatmeal, cream or wheat, mashed potatoes and apple sauce, so the advice of "some surgeons" should be taken with a few kilos or rock salt.

Congrats on your new surgery.

I want the surgery where I can pop Advil,eat toast,and never need a vitamin. That surgery inventor will be so rich.

I wish you the best..particularly this magic first year. Posting often helped me.

Overall diabetes success seems to be similar overall for both, clustering in the 80-85% range, with some practices reporting better results with one procedure or the other. Specific expertise or experience in the different procedures plays as big a role as any, as we see some of the sleeve specializing practices reporting remission rates in the 90% range and others for whom the sleeve is more of an afterthought reporting lower rates and better success with their preferred bypass. So, in addition to searching out larger studies, it also pays to query individual practices as to their specific success rates and preferences.

As noted by others, the DS tends to have better success than either (typically in the 98-99% remission rate range) and also seems to have better sustainability long term; this should not be a big surprise as the DS started as a procedure specifically developed to treat diabetes, to which the VSG was added to make it a weight loss procedure. This should be in one's calculus if diabetes is a major concern.

Its interesting that practices that focus exclusively on VSG say they have the same diabetes remission rates as RNY. They are wrong.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566335/

Every study I have seen says just the opposite. RNY seems to be 50 percent better than VSG at putting diabetes into remission in the year following surgery. At 3 and 5 years out, the rate of relapse is 3 times greater for VSG than RNY.

Why should it be a surprise that practices that specialize in a particular procedure would get better results than those that do it as a sideline?

They don't get better results as far as diabetes remission. That has nothing to do with surgical technique. They claim to get better results because th e.g. are in the business if selling surgeries.

There are a very, very few surgeons who specialize in DS. Just about all other surgeons can do RNY and VSG. Surgeons who "specialize" in VSG do so because it's more profitable for them, not because it's better for the patient.

There are very few who specialize exclusively on the VSG (Alvarez in MX and Cirangle in SF that I can think of, though Cirangle also does the DS as he came from that camp but prefers the VSG in most cases and has done a lot to extend its effectiveness to wider populations) but there are quite a few who specialize in sleeve based procedures - the DS and VSG. This is where one should look for guidance as that is where the expertise resides, having done sleeves for many years before the VSG started to become routine. Most of the DS guys started with the RNY and still offer it when appropriate in specific cases, but prefer the DS and VSG as they offer better overall results.

Most get into them because, as their predecessors, they are looking for something better than the status quo. The shortcomings of the RNY (dumping, reactive hypoglycemia, bile reflux, marginal ulcers, malnutrition, etc.) have been well recognized since the outset some forty years ago when it was adapted for weightloss from the then century old Billroth II procedure, but it was overall a better tradeoff than current vertical banded gastroplasty and jejunoileal bypass. The DS was developed later and on average provides better overall weight loss and regain resistance with similar to lesser side effects and limitations than the RNY, but its complexity keeps it away from many practices. The VSG flowed from the DS by simply doing the sleeve part of the procedure and has shown to offer similar overall weight loss and regain characteristics to the RNY with fewer side effects and limitations, with acid reflux being its primary side effect. It is little wonder that there are some surgeons out there who seek to prioritize what they see as being an better way to go and develop these newer procedures, as their predecessors did when they developed the RNY. Time marches on.

There have been failures along the way - the mini bypass and sleeve plication have never gained traction with the ASBS/ASMBS or US insurance industry; the SIPS/SADI/"loop DS" is being promoted as being "almost as good as the DS/better than the RNY" but "more accessible" than the DS (simpler so more surgeons can do it) - the jury is still out on it

VSG offers better overall results than RNY? Fewer side effects and limitations? Im guessing you live in a state where pot is legal. And sell cars for a living.

5 years ago, many thought VSG was the entire future of weight loss surgery, as you still do. They once thought that way about the band, too.

Now people are having sleeves revised to RNY, just as they did with bands. All of the shortfalls are coming into focus, and the news is not good. But still, surgeons are recommending sleeves to those who suffer from acid reflux, and NOT because it's best for the patient. It's because it makes the most money for surgeons. And when a great many of those ill-advised sleeves convert to RNY after suffering for years from gerd, those surgeons will make even more money.

You are living in the past.

Hi Grim,

I have not been on the boards nearly as much lately. Is your comment regarding VSG's being revised to Rny more frequently now anectdotal observation from the boards or support groups, or is this a ASMB type research-based finding? Please know that it is not my intent to sound snarky, quite the opposite. I just realized it is quite possible I am no longer up-to-date with Vsg outcomes and that there would certainly be more patients and resulting research now compared to when I had it done.

Not necessarily better performance - I didn't claim that - but similar weight loss and regain performance with fewer side effects and limitations (acid reflux potential vs. potential for dumping, reactive hypoglycemia, bile reflux, marginal ulcers and malnutrition), so typically a better overall compromise. The DS does on average have better overall performance on weight loss and regain resistance, with a similar if not somewhat lower level of side effects; so also a generally better trade off, if one engages one of the surgeons with the skills to do them.

Yes, some may need a revision to treat severe reflux problems that may occur, much as some need to get bypasses reversed or revised due to severe ulcer problems. Sometimes there is a simple mismatch between patient and procedure - look up Dr. Mitchell Roslin's discussion here on OH about whether the patient fails the procedure, or the procedure fails the patient. One of the learning curve problems that we see these days is that while most surgeons are now producing reasonably competent sleeves, unlike a few years ago, many don't know how to correct problems with that may occur with those sleeves (either induced by intrinsic patient problems or by their own prior inexperience) so they have a bias toward doing a revision to something that is within their comfort zone (a bypass) rather than a repair that they don't yet really know how to do. Somewhat like a mechanic *****places an engine rather than repairing a bad head gasket. This is why anyone facing such a revision should always get a second (or third) opinion, preferably from a surgeon who is well experienced with sleeves (extensive DS experience is a good proxy for this.)