I would like to communicate with others that need to lose weight b4 surgery
My apologies for calling you Denise, Diana. Blind moment..
However, Dr fisher can be self assured, arrogant etc etc whatever youd like to call it, (in my eyes), his work speaks for itself. Would you want a Dr to do a DS on you thats NOT arrogant or absolutely confident in his work?? It seems that youre VERY biased about the DS in the first place. To each his own.. My reply was to Ted, as far as WHY dr's ask for PT to lose weight. Kaiser does not preach "that studies find if you lose weight prior, that you will have a better outcome" (well not during my process) It has nothing to do with that. I assist in Surgery everyday, I deal with the complications as well. Heavier PTs are difficult, not just for the surgeon but the whole team who's responsible for that PT in the O.R.. Im not here to argue, Im here to simply help someone understand why a Dr would want a PT to lose before a surgery. It's NOT because he's trying to make life difficult. If he's asking for an 80 lb loss, that tells me there is alot of weight around the abdominal area. I wish everyone the best of luck!
Diane, you do have great links on your page. However, just because we dont like what the Dr asks us to do, or because we have had a different experience with Dr Fisher, I dont think its necessary to bash them on forrums and tell people to file appeals and get a DS. That should always be the last resort. My suggestion would be for Ted to get a second opinon from a different doctor. I love your hunger/ passion to help people and Ive never really heard of the DS, but Im happy to see you've done so well in your journey. I think people need more folks like you around when they reach this particular fork in the road..
However, Dr fisher can be self assured, arrogant etc etc whatever youd like to call it, (in my eyes), his work speaks for itself. Would you want a Dr to do a DS on you thats NOT arrogant or absolutely confident in his work?? It seems that youre VERY biased about the DS in the first place. To each his own.. My reply was to Ted, as far as WHY dr's ask for PT to lose weight. Kaiser does not preach "that studies find if you lose weight prior, that you will have a better outcome" (well not during my process) It has nothing to do with that. I assist in Surgery everyday, I deal with the complications as well. Heavier PTs are difficult, not just for the surgeon but the whole team who's responsible for that PT in the O.R.. Im not here to argue, Im here to simply help someone understand why a Dr would want a PT to lose before a surgery. It's NOT because he's trying to make life difficult. If he's asking for an 80 lb loss, that tells me there is alot of weight around the abdominal area. I wish everyone the best of luck!
Diane, you do have great links on your page. However, just because we dont like what the Dr asks us to do, or because we have had a different experience with Dr Fisher, I dont think its necessary to bash them on forrums and tell people to file appeals and get a DS. That should always be the last resort. My suggestion would be for Ted to get a second opinon from a different doctor. I love your hunger/ passion to help people and Ive never really heard of the DS, but Im happy to see you've done so well in your journey. I think people need more folks like you around when they reach this particular fork in the road..
I just looked up the info on the DS, very Interesting. My question now is WHY isnt that procedure common? If you could help me understand that. Kaiser doesnt offer it and as a Sutter employee ive never seen it. It sounds like it should replace RNY based on the studies.. Id love to educate myself more on this , Ill be sure to ask my Surgeons when I get back to work.. :@) Had no clue it was apart of the VSG.. Again, thnx for the links Diana.
Why the DS isn't as common (I'm glad you asked):
1) It is a more difficult surgery to perform and to learn - a long and steep learning curve. Stitching the duodenum is like stitching wet tissue paper, according to the DS surgeons. Interestingly, the duodenum is rarely the site of any leaks, but the physical manipulation is difficult.
2) It can't be learned in a weekend seminar. Proper training requires proctoring with another, experienced surgeon. That often means the surgeon taking a sabbatical, giving up a lucrative practice while sitting second chair for months with an experienced surgeon - most bariatric and general surgeons don't have the willingness to take that time, or the ego to become a student again.
3) The DS takes longer to perform - it can't be done surgery-mill style like the other surgeries. The best surgeons can only do 2/day.
4) Therefore, it is more expensive. And the insurance companies DON'T WANT TO PAY MORE.
5) The consequences of not following the requirements occur more quickly than with the RNY (and for the most part, failure to supplement with a Lapband and VSG will take much longer to manifest). Protein requirements are higher, as are fat soluble vitamins. Of course, this does not take into account the very real and terrible issues RNYers can have from not absorbing B vitamins, in particular B12, as well as iron and calcium - DSers retain the intrinsic factor producing portions of the stomach, and a portion of the duodenum where cations are absorbed, in the alimentary tract. In fact, on average, long term non-compliant RNYers can be in VERY serious trouble. But DSers can get in trouble more quickly if we don't eat enough protein or take fat soluble vitamins in the proper dry form. It's not hard to comply, but non-compliance isn't an option.
6) Did I mention insurance companies and money? It's worth repeating.
7) In order to keep costs down, and to favor the majority of surgeons who can do the cheaper and easier (and less effective) surgeries, and who are WILLING TO ACCEPT CRAPPY INSURANCE REIMBURSEMENT RATES in order to have business steered to them by the insurance companies, the insurance companies and other bariatric surgeons have concocted a conspiracy (and yes, I truly believe it is one) to malign the DS. They deliberately cite data relating to two old and now discredited surgeries as evidence of the "dangerousness" of the DS, despite the fact that the modern DS avoids the majority of the issues related to them (the old JIB and the old BPD), and have little in common with them, other than technically involving some intestinal bypass.
I put some of the blame for this on the DS surgeons themselves - bowing to the ego of the elderly, venerated and pompous Dr. Scopinaro, who developed the BPD, which has roughly the same intestinal configuration as the DS (except it had a MUCH shorter common channel, and the stomach part was completely different - a lateral gastric resection to form a large pouch, and they took the distal end of the stomach, pylorus and proximal duodenum out and DISCARDED them, making a revision impossible) - who insisted that the new procedure developed by Dr. Hess by using a vertical sleeve gastrectomy instead, preserving the pylorus, be called a "BPD/DS" as if it were a mere modification to the BPD - which not only makes no medical sense, it provided the basis for the insurance companies to tar the safety of the DS with the BPD data (which while good for weight loss, was pretty awful for malnutrition, maloderous gas and stools, with all the negatives of a pou*****luding marginal ulcers and dumping, due to the short common channel and pouch).
In June 2004, I spoke to the DS surgeons at the ASBS annual meeting in San Diego, and begged them to stop using the BPD terminology for this reason, and just to use DS or GR-DS (gastric reduction-duodenal switch) or VSG-DS. They seem to finally be moving away from the BPD terminology.
In the meantime, more and more insurance companies have caved in to the REAL data behind the DS and are covering it. Some still limit access to those with high BMIs (>50), but if the patient appeals, with submission of new publications amply demonstrating the low risk and superior outcomes of the DS for even lightweight patients, the restriction can almost always be overturned.
One particular campaign by committed DSer occurred in 2005, when Medicare announced that they were reviewing their WLS guidelines. I and a number of other DSers rallied our vets and got our surgeons involved in a letter writing campaign to Medicare, and in February 2006, when the new guidelines were issued, Medicare included the DS as a covered benefit, without restriction to high BMI patients.
8) As for the DS being "apart" of the VSG, you've got that backwards. In some high risk cases, some DS surgeons felt it was prudent to do the VSG on some DS patients first, and then to go back and do the switch later, when they had lost some weight and were healthier (and to reduce op time). Some of these patients did well enough with the VSG alone that they chose to not go back and have the switch done (at least in the short term). From these results, some surgeons began offering the VSG as a stand-alone operation. There are still no long term studies for this procedure, and I have serious doubts about whether the vast majority of patients, especially those with a BMI >45, are going to have adequate long term results. However, as a stand-alone, restriction-only procedure, it is far and away better than the CrapBand.
BY THE WAY - IN CA, SINCE 2004, BOTH NORCAL AND SOCAL KAISERS HAVE LOST ALMOST EVERY SINGLE APPEAL OF PATIENTS WANTING THE DS, WHO WERE WILLING TO GO ALL THE WAY TO THE DMHC FOR REVIEW. And yet Kaiser still maintains that it is "experimental." But recently, NorCal (I'm guessing by bypassing Fisher?) has been sending some of its sickest, fattest and oldest patients who want the DS to Rabkin without making them do more than two internal appeals.
Progress?
1) It is a more difficult surgery to perform and to learn - a long and steep learning curve. Stitching the duodenum is like stitching wet tissue paper, according to the DS surgeons. Interestingly, the duodenum is rarely the site of any leaks, but the physical manipulation is difficult.
2) It can't be learned in a weekend seminar. Proper training requires proctoring with another, experienced surgeon. That often means the surgeon taking a sabbatical, giving up a lucrative practice while sitting second chair for months with an experienced surgeon - most bariatric and general surgeons don't have the willingness to take that time, or the ego to become a student again.
3) The DS takes longer to perform - it can't be done surgery-mill style like the other surgeries. The best surgeons can only do 2/day.
4) Therefore, it is more expensive. And the insurance companies DON'T WANT TO PAY MORE.
5) The consequences of not following the requirements occur more quickly than with the RNY (and for the most part, failure to supplement with a Lapband and VSG will take much longer to manifest). Protein requirements are higher, as are fat soluble vitamins. Of course, this does not take into account the very real and terrible issues RNYers can have from not absorbing B vitamins, in particular B12, as well as iron and calcium - DSers retain the intrinsic factor producing portions of the stomach, and a portion of the duodenum where cations are absorbed, in the alimentary tract. In fact, on average, long term non-compliant RNYers can be in VERY serious trouble. But DSers can get in trouble more quickly if we don't eat enough protein or take fat soluble vitamins in the proper dry form. It's not hard to comply, but non-compliance isn't an option.
6) Did I mention insurance companies and money? It's worth repeating.
7) In order to keep costs down, and to favor the majority of surgeons who can do the cheaper and easier (and less effective) surgeries, and who are WILLING TO ACCEPT CRAPPY INSURANCE REIMBURSEMENT RATES in order to have business steered to them by the insurance companies, the insurance companies and other bariatric surgeons have concocted a conspiracy (and yes, I truly believe it is one) to malign the DS. They deliberately cite data relating to two old and now discredited surgeries as evidence of the "dangerousness" of the DS, despite the fact that the modern DS avoids the majority of the issues related to them (the old JIB and the old BPD), and have little in common with them, other than technically involving some intestinal bypass.
I put some of the blame for this on the DS surgeons themselves - bowing to the ego of the elderly, venerated and pompous Dr. Scopinaro, who developed the BPD, which has roughly the same intestinal configuration as the DS (except it had a MUCH shorter common channel, and the stomach part was completely different - a lateral gastric resection to form a large pouch, and they took the distal end of the stomach, pylorus and proximal duodenum out and DISCARDED them, making a revision impossible) - who insisted that the new procedure developed by Dr. Hess by using a vertical sleeve gastrectomy instead, preserving the pylorus, be called a "BPD/DS" as if it were a mere modification to the BPD - which not only makes no medical sense, it provided the basis for the insurance companies to tar the safety of the DS with the BPD data (which while good for weight loss, was pretty awful for malnutrition, maloderous gas and stools, with all the negatives of a pou*****luding marginal ulcers and dumping, due to the short common channel and pouch).
In June 2004, I spoke to the DS surgeons at the ASBS annual meeting in San Diego, and begged them to stop using the BPD terminology for this reason, and just to use DS or GR-DS (gastric reduction-duodenal switch) or VSG-DS. They seem to finally be moving away from the BPD terminology.
In the meantime, more and more insurance companies have caved in to the REAL data behind the DS and are covering it. Some still limit access to those with high BMIs (>50), but if the patient appeals, with submission of new publications amply demonstrating the low risk and superior outcomes of the DS for even lightweight patients, the restriction can almost always be overturned.
One particular campaign by committed DSer occurred in 2005, when Medicare announced that they were reviewing their WLS guidelines. I and a number of other DSers rallied our vets and got our surgeons involved in a letter writing campaign to Medicare, and in February 2006, when the new guidelines were issued, Medicare included the DS as a covered benefit, without restriction to high BMI patients.
8) As for the DS being "apart" of the VSG, you've got that backwards. In some high risk cases, some DS surgeons felt it was prudent to do the VSG on some DS patients first, and then to go back and do the switch later, when they had lost some weight and were healthier (and to reduce op time). Some of these patients did well enough with the VSG alone that they chose to not go back and have the switch done (at least in the short term). From these results, some surgeons began offering the VSG as a stand-alone operation. There are still no long term studies for this procedure, and I have serious doubts about whether the vast majority of patients, especially those with a BMI >45, are going to have adequate long term results. However, as a stand-alone, restriction-only procedure, it is far and away better than the CrapBand.
BY THE WAY - IN CA, SINCE 2004, BOTH NORCAL AND SOCAL KAISERS HAVE LOST ALMOST EVERY SINGLE APPEAL OF PATIENTS WANTING THE DS, WHO WERE WILLING TO GO ALL THE WAY TO THE DMHC FOR REVIEW. And yet Kaiser still maintains that it is "experimental." But recently, NorCal (I'm guessing by bypassing Fisher?) has been sending some of its sickest, fattest and oldest patients who want the DS to Rabkin without making them do more than two internal appeals.
Progress?
The ASMBS, his own medical specialty organization says mandated pre-op weight loss has NO MEDICAL JUSTIFICATION. Insurance companies KNOWINGLY use mandated weight loss requirements to deter and deny access to care. If you don't believe that, you are blinded by hero worship.
My own surgeon has done lap DS on 800 lb people. He said that bariatric surgeons KNOW they are going to encounter huge livers, and they should have the tools and skills to deal with that. He prefers to have his patients arrive on his operating room table as well nourished and as unstressed as possible, rather than starved and stressed by being on starvation diets for weeks leading up to surgery.
Personally, from what I have seen and heard, I think many if not most bariatric surgeons harbor thinly veiled disgust for their patients, and they see the pre-op diet requirements as some kind of justifiable hazing process. That is my opinion - because otherwise, WHY are they torturing people when there is no evidence-based proof of need to do so???
No, I do NOT want an arrogant SOB surgeon - they are people who put their scrubs on one leg at a time, and if they chose to remain hidebound and stuck in their own skill set, I have no need for them. I taught biochem to med students when I was a grad student, and they are not necessarily the brightest bulbs in that rarified box - especially the surgeons.
My point is, making someone suffer to lose weight acutely pre-op has NO MEDICAL EVIDENCE for necessity, with a very few exceptions. The ASMBS recognizes this, the CA DMHC recognizes this, numerous published studies have PROVEN this - and yet insurance companies and certain surgeons continue to require it - and I say it is SOLELY to torture and often deny services to these most vulnerable patients, who often lack the self-esteem to challenge these baseless rules. Money and arrogance are at the root of this issue, not science.
My own surgeon has done lap DS on 800 lb people. He said that bariatric surgeons KNOW they are going to encounter huge livers, and they should have the tools and skills to deal with that. He prefers to have his patients arrive on his operating room table as well nourished and as unstressed as possible, rather than starved and stressed by being on starvation diets for weeks leading up to surgery.
Personally, from what I have seen and heard, I think many if not most bariatric surgeons harbor thinly veiled disgust for their patients, and they see the pre-op diet requirements as some kind of justifiable hazing process. That is my opinion - because otherwise, WHY are they torturing people when there is no evidence-based proof of need to do so???
No, I do NOT want an arrogant SOB surgeon - they are people who put their scrubs on one leg at a time, and if they chose to remain hidebound and stuck in their own skill set, I have no need for them. I taught biochem to med students when I was a grad student, and they are not necessarily the brightest bulbs in that rarified box - especially the surgeons.
My point is, making someone suffer to lose weight acutely pre-op has NO MEDICAL EVIDENCE for necessity, with a very few exceptions. The ASMBS recognizes this, the CA DMHC recognizes this, numerous published studies have PROVEN this - and yet insurance companies and certain surgeons continue to require it - and I say it is SOLELY to torture and often deny services to these most vulnerable patients, who often lack the self-esteem to challenge these baseless rules. Money and arrogance are at the root of this issue, not science.
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