I know how scary making the decision as to which procedure you will get can be. We all went through it at one time.
The biggest question seems to be if you want a procedure with malabsorbtion or not.
There is great debate about this. I am not comfortable with a malabsorbtive procedure. Yes you may lose more weight with malabsorbtion but you are also at higher risk with it. Most people have no major problems so long as they are vigilant about their vitamins and minerals and other supplements.  My concern is that the people that I know that did have problems had them in a major way even though they took everything as prescribed.  For me the risk was not worth it. That is  a decision you will have to make for yourself.
If you are OK with malabsorbtion RNY and DS are what you want to check out. Go on their boards and talk to folks that have been there and done it.
RNY overall is easier to get, more insurances cover it, more MD's do it and so forth.  Stats show that DS gets better results because you are absorbing only 20% of all fat. The "pouch" (for lack of a better term) is basically the same as for a sleeve patient. 
The thing about all of the surgeries that trip up most folks seems to be the carbs. Even with the DS you cannot overindulge in carbs and still lose.
The other piece is that just cause you have the RNY does not guarantee you will dump or get sick on carbs, fats and sugars. Most do but some don't so you may not want to count on that with 100% certainty.

Thank you so much for giving me an objective overview. I will "chit & chat" with others that have had all the surgeries- I'm still leaning toward VSG- I just want to be sure.  Onward to my investigation!!

With your BMI, I strongly suggest the DS. Those of us with really high BMIs really seem to NEED malabsorption to 'fix' our screwed-up metabolisms. And frankly, the DS is THE form of WLS that really does 'fix' a broken metabolism.

Not only have I lost weight effortlessly with my DS, but I've notcied a huge boost in my immune system---in the past five years, I've a had TWO colds. Pre-op, I usually kept a cold all winter. I no longer have frequent upset stomach trouble, like I did pre-op. I feel rested and energertic on 6-7 hours of sleep, instead of tired and cranky on the 10-11 hours I needed pre-op. It's really turned me into a 'normal' person, and not just weight-wise.

And yes, going into surgery my doc told me he *might* have to do my DS in two stages, because my BMI was 74. The first thing I asked after waking up was "Did he do it all?" Thankfully, the answer was "Yes".

I KNOW that the malabsorption has been VERY good for me. My cholesterol numbers are FANTASTIC, and I would NEVER have been able to 'diet' the weight off, even with the greater restriction of the VSG.

I LOVE MY NEW INTACT & FULLY FUNCTIONING  TINY TUMMY!   

Please see my profile / blog to see my journey and get some links to VSG research.  Also, please visit the VSG Forum.  There are *lots* of people our size choosing VSG *as a stand alone procedure* and experiencing terrific success!

I wish you much success on your journey towards a healthier, happier, and longer life!

Amy

Thanks, I've been on the VSG site- I've posted over there a few times.  I will check out your profile.  I'm just making sure I have all the info to make an informed decision.

Let's see how your data looks in, say, three to five years. I predict that unfortunately, VSG data will look a LOT like Lap Band data, with the positive side being that you won't have the foreign object related issues, and you'll still be rid of all that ghrelin and acid-producing tissue. But I'll be very, very surprised if the maintained EWL is any higher than the Lap Band, which is to say an average of around 50% EWL.

~Namaste~

I don't think that it's "fair" (I know that's not the right word, but it's at least civil) for an individual to discourage VSG based upon a personal opinion that is not qualified by any indication of formal education or expertise in the medical profession nor even links to primary source material from current (2007 to current) medical research.  Predictions, made by a person of unknown qualification but obvious bias, are simply worthless.  Indeed, rather than being supportive or at the very least, merely providing pro's and con's of different procedures based upon medical and anecdotal research so that a person is capable of making an informed decision, in conjunction with the advice of a qualified bariatric surgeon, this type of thinking breeds malcontent, fear, and avarice.   I would bet that in the early to mid 1990's many RNY patients were making the similar accusations againsts DS.  To discount a "new" medical procedure based upon lack of long term success data is sophomoric. 

I believe that every person considering WLS should know the pros and cons of each prodeure.  A con for VSG is most definitely lack of long term success data.  A con for DS is the necessary commitmet to taking massive amounts of vitamins and minerals for life in order to counteract the malabsorptive feature of intestinal revision.  Facts should be provided so that a person can make an informed decision.  Opinions, while certainly welcome, are like ******** we all them.  Prophecies, especially those that ignore trends in scientific/medical research, are much more distasteful.  Personally, I'll continue to give more weight to opinions on WLS and any corresponding advice, to those people who have the initials M.D. and F.A.C.S. behind their names.

Amy

Fair??  Are you kidding??  Do you think it is fair for me to predict -- without waiting to see the result -- that if I drop a glass off a 10 story building, it will break?  Well, as I have 5.5 years of experience with my DS and know how much my initially 3-4 oz stomach has stretched, I think I can guess how it's going to go for the VSGers.  I also know from YEARS of reading the scientific literature that restrictive-only procedures end up being JUST like a calorie-deficient diet in terms of damaging the metabolism, so the odds are significant that you WILL regain, and possibly even more than you lost in the first place.

But here's some new data for you, hot off the presses:

 Obes Surg. 2009 Jan 24. [Epub ahead of print] Links

 

Midterm Results of Primary vs. Secondary Laparoscopic Sleeve Gastrectomy (LSG) as an Isolated Operation.

Uglioni B, Wölnerhanssen B, Peters T, Christoffel-Courtin C, Kern B, Peterli R.

Department of Surgery, Claraspital, Kleinriehenstrasse 30, 4016, Basel, Switzerland.

BACKGROUND: We investigated early and midterm results of laparoscopic sleeve gastrectomy (LSG) as an isolated primary and secondary operation after failed gastric banding. METHODS: Between May 2004 and October 2007, a total of 70 patients (female 77%, mean age 43 (21-65) years, mean initial body mass index (BMI) 46 (35-61) kg/m(2)) were prospectively evaluated and operated by LSG. In 41 patients, LSG was performed as a primary operation (group 1) and in 29 patients as a secondary procedure after failed gastric banding (group 2). The overall average follow-up time after LSG was 24 (12-53) months; follow-up rate 1 year after operation was 100%, after 2 years 98%, and after 3 years 95%. RESULTS: There were no intraoperative complications, no conversion with shorter operation time in group 1 (91 vs. 132 min, p = 0.001). Early morbidity of LSG was 5% (major) and 7% (minor); mortality was zero. Average excessive BMI loss after 1 year was 65% (9-127%), after 2 years 63% (13-123%), and after 3 years 60% (9-111%). Midterm morbidity was 13%. There was no significant difference between the two groups regarding early and midterm morbidity, reoperation rate for complications (11.4%), or insufficient weight loss (7%). CONCLUSIONS: LSG is a safe bariatric procedure with good weight loss in the first 3 years postop. It can be used as an isolated initial treatment and as a secondary treatment after failed gastric banding. However, in the absence of long-term results, we suggest LSG to be performed only in controlled trials.

Those are trends in the wrong direction -- and imagine how much worse it was for the SMO folks -- the mean BMI in this study was 46!!



 

Yes, go ahead blind us with current scientific data, by real doctors, Diana.

But the REAL question is, did the glass break????

Nicolle

The analogy to dropping a glass off of a ten story building is absolutely ridiculous.  When you choose to do that, tthe outcome is 100% certain.  WIth new medical procedures, the outcome is unknown, especially long term.  However, as I have stated repeatly, current research (see John Hopkins Ghrelin Study as reported in the Dec OH magazine or at at the University website), is trending towards VSG as being as effective as bypass in percentage of EWL..  And as far as the required quantities of vitamins/supplements for bypass patients, in comparison to restrictive procedures, it is indeed copious.  As a matter of course, I am required only to take 3500 mg of calcium citrate and 4 chewable multi-vitamins daily. 

JOHNS HOPKINS RESEARCHERS SUPPRESS “HUNGER HORMONE"

Johns Hopkins Medicine
Media Relations and Public Affairs
Media Contacts: Maryalice Yakutchik; 443-287-2251; [email protected]
Audrey Huang; 410-614-5105; [email protected]
September 11, 2008

--New Minimally Invasive Method Tested in Pigs Yields Result as Good as Bariatric Surgery

Johns Hopkins scientists report success in significantly suppressing levels of the “hunger hormone" ghrelin in pigs using a minimally invasive means of chemically vaporizing the main vessel carrying blood to the top section, or fundus, of the stomach. An estimated 90 percent of the body’s ghrelin originates in the fundus, which can’t make the hormone without a good blood supply.

“With gastric artery chemical embolization, called GACE, there’s no major surgery," says Aravind Arepally, M.D., clinical director of the Center for Bioengineering Innovation and Design and associate professor of radiology and surgery at the John Hopkins University School of Medicine. “In our study in pigs, this procedure produced an effect similar to bariatric surgery by suppressing ghrelin levels and subsequently lowering appetite."

Reporting on the research in the September 16 online edition of Radiology, Arepally and his team note that for more than a decade, efforts to safely and easily suppress grehlin have met with very limited success.

Bariatric surgery — involving the removal, reconstruction or bypass of part of the stomach or bowel — is effective in suppressing appetite and leading to significant weight loss, but carries substantial surgical risks and complications. “Obesity is the biggest biomedical problem in the country, and a minimally invasive alternative would make an enormous difference in choices and outcomes for obese people," Arepally says.

Arepally and colleagues conducted their study over the course of four weeks using 10 healthy, growing pigs; after an overnight fast, the animals were weighed and blood samples were taken to measure baseline ghrelin levels. Pigs were the best option, he says, because of their human-like anatomy and physiology.

Using X-ray for guidance, members of the research team threaded a thin tube up through a large blood vessel near the pigs’ groins and then into the gastric arteries supplying blood to the stomachs. There, they administered one-time injections of saline in the left gastric arteries of five control pigs, and in the other five, one-time injections of sodium morrhuate, a chemical that destroys the blood vessels.

The team then sampled the pigs’ blood for one month to monitor ghrelin values. The levels of the hormone in GACE-treated pigs were suppressed up to 60 percent from baseline.

“Appetite is complicated because it involves both the mind and body," Arepally says. “Ghrelin fluctuates throughout the day, responding to all kinds of emotional and physiological scenarios. But even if the brain says “produce more ghrelin," GACE physically prevents the stomach from making the hunger hormone."

The research was funded by the National Institutes of Health.

Authors on the paper are Brad P. Barnett, Tarek T. Patel, Valerie Howland, Dara L. Kraitchman, Ashkan A. Malayeri, and Arepally with Johns Hopkins and Ray C. Boston of University of Pennsylvania.

On the Web:

http://radiology.rsnajnls.org/

 

http://www.hopkinsmedicine.org/vascular/staff/physicians/arepally.html

Even in the study posted by Dianacox  results are better than th 50% figure tossed out by the person to whom I initially replied due personal opinions on VSG EWL success percentages without citing the soure that may have informed her opinion.  Neither do i ever see DS patients tauting as pro's the very serious issues that may arise from the malabsorptive feature of intestinal revision when attempting to steer pre-ops to DS..  And yet, even OH has information on common complication:

Vitamin Deficiencies and Weight Loss Surgery http://www.obesityhelp.com/forums/revision/vitamin-deficiencies-and-weight-loss-surgery.html

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Weight loss surgery patients most commonly experience deficiencies in two classes of vitamins, fat soluble vitamins and some B-vitamins. These vitamins are as follows:  Fat Soluble Vitamins: vitamins A, D, E and K B-Vitamins: B-1, Thiamine, Folate, B-12

Due to the efficacy of oral vitamin supplementation and vitamin injections, revision weight loss surgery is rarely needed or used to treat conditions of vitamin deficiency. Deficiencies in fat soluble vitamins are most commonly found in Duodenal Switch patients with patients experiencing vitamin-D deficiency most frequently. Malnutrition and protein deficiency is treated by elongation of the common limb, which can also be performed to treat vitamin deficiency.

Additionally, it is my experience that in conversations such as this, that DS patients rarely, if at all, talk openly about possible long term complications of DS.  The following is from the website http://www.dsfacts.com/ of which, DiannaC is a featured contributor:

Duodenal Switch Risks and Complications

Potential Duodenal Switch risks and complications are listed below. Keep in mind all surgical procedures involve a degree of risk however this must be balanced against the significant risks associated with severe obesity without surgical intervention.

Possible Duodenal Switch Risks and Complications

Intra-Operative

• Bleeding
  
• Blood Transfusion
  
• Injury to Liver, Spleen, Esophagus, Large Bowel

Immediate Post-Operative

• Bleeding
  
• Deep-Vein Thrombosis (blood clot)
  
• Pulmonary Emboli (blood clot traveling to the lungs)
  
• Infection
  
• Abscess
  
• Bowel Obstruction
  
• Perforation involving small bowel, Duodenum, Stomach (leak)
  
• Pancreatitis
  
• Pneumonia

 

Long Term

• Hernia
  
• Bowel Obstruction
  
• Excessive Weight Loss
  
• Anemia
  
• Osteopenia/Osteoporosis
  
• Kidney Stones
  
• Malodorous bowel motions and flatus (stinky bowel movements and gas)
  
• Diarrhea

 

 

More on Malnutrition

Malnutrition is an uncommon and preventable risk after Duodenal Switch. [2] DS patients must be committed to taking vitamin and mineral supplements, consuming a high protein diet and having their blood tested each year. Deficiencies in vitamin D, vitamin A, calcium and protein can result in osteoporosis and anemia. Have your blood-work monitored and adjust your supplements as necessary.

 

More on Gas and Diarrhea

Remember back in the lesson on the History of Duodenal Switch we mentioned that DS is often confused with other surgeries? That confusion accounts for some of the exaggerated information about the frequency and volume of loose stools after the Duodenal Switch procedure.

Following Duodenal Switch, many patients experience excess gas if they eat too many carbohydrates or specific kinds of carbohydrates. Many will also experience diarrhea if they eat too many fats. In most cases patients have control over when and if this occurs because it can be controlled through diet. Patients have reported a varying degree of how much smellier their gas and bowel movements are post-op compared to pre-op and to control malodorous or loose stools patients are encouraged to frequently ingest yogurt and probiotics. [2] When necessary some are prescribed metronidazole (Flagyl). [2]

81.3% of Duodenal Switch patients experience normal gastric emptying according to Martínez et al. [36]

Anthone [9] reported the average number of bowel movements per day for 43 pre-op patients was 1.9, 421 patients six months post-op was 2.7, 316 patients twelve months post-op was 2.6 and 113 patients > thirty six months post-op was 2.8.

In a study by Wasserberg et al. [19] they found that although Duodenal Switch is often associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass.

In the Marceau et al. 15 year study Duodenal Switch: Long-Term Results [2] they say "The negative side-effects with DS were not benign. The unpleasant odor of stool and gas and the frequent abdominal bloating were the price to pay for these patients and it was a major preoccupation for many of them. However 95% of patients declared themselves satisfied despite this handicap and no one has required reversal of the procedure for this reason." (1428) In the same way that RNY patients accept "dumping", DS patients accept stronger odor of gas and stool.

 

Statistics on Possible Risks and Complications

Generally the perioperative mortality rate (admission, anesthesia, surgery and recovery) is between 0.5% and 1.5%. [2],[9],[14] It will vary by surgeon and can be affected by the number of high risk cases they take. Ask your surgeon about his/her complication and mortality rate.

Marceau et al [2] reported that over 15 years of follow-up...

 

• Revision for protein malabsorption or diarrhea was required in 9 cases (0.7%). Of those nine, six had their alimentary and common channel lengthened and in 3 the diversion was reversed.

   

   

• Kidney stone incidence increased from 6.3% prevalence before surgery to 14.8% during 15 years of follow-up. This is not different than the reported 16% during 11 years of follow-up after long Roux-en-Y gastric bypass. [16], [18]

   

   

• Bowel obstruction in 6% of patients which required a laparotomy for intestinal obstruction during the 15 years of observation.

   

   

• Incisional hernia was repaired in 13% of patients and is within expected outcomes after major abdominal surgery.

 

Hess et al. [1] reported the following major complications after DS in the first 1,300 patients (42% of patients with a BMI > 50)...

 

• Gastric leaks 0.7%
  
• Mortality 0.57%
  
• Reversal 0.61%
  
•  

• Revisions 3.7% (22 were for excess weight loss and protein deficiency and 2 were for frequent diarrhea. In these cases the common channel and alimentary limb were lengthened. 7 revisions were for inadequate weight loss and the common channel was shortened.

Now look, my original intention in my reply to Elizabeth N was not to argue about which procedure is best for WLS patients starting with a bmi OVER 50.  It was, howeevr a request to refrain from posting opinions that are not accurate based upon current medical research.  Additionally, it was a request to be transparent and honest in facts presented.  I believe in providing information, verifiable and scientific data, on all procedures so that a pre-op can make an informed decision.  I admited that the lack of long term success data on VSG as a stand alone procedure for larger BMI's was non-existent given the realtive newness using gastrectomies solely for weight loss.  Why can't people who;ve had other procedures be honest about the risks and complications of their surgery?  Lay it all on the table and give people the opportunity to review all pertinent information and then make an informed decision.

Amy