Rabkin-Keshishian-Husted-Greenbaun-LONG

Chad,

I had a revision with Dr. Husted in 2009.  I know I can no longer get a hold of him.  Is there a concern on how he did his revisions?  I haven't had issues other than losing a whole lot of weight real fast

Thanks

Bonnie

The main thing I have heard was people going to him and being talked into other things that weren't really DS's. If that were the case I would think (hope) he would have said something to you about it. I would review your operative report if you have it, or do your best to get a copy.

Chad,

I had a series of PM's with Dr, Husted back in January about this subject and I asked him specifically if it would be OK to post his answers and responses and he said yes and that he wants people to know what he is really doing. Anyway, here's the PM thread I had with Dr. Husted so you can see what he's actually saying about this, just remember this is a PM thread so it's in reverse order:



Not at all, Kerry. Go ahead and relay this. I like people to be armed with as much info as possible.

I followed up with a post on the revision board, as well. Please, feel free to share.

John D Husted, MD

Kerry J. wrote:

Dr, Husted,

Thanks so much for the detailed explanation of this procedure; I believe I understand all of what you're saying. If I find there's something I'm confused about, I'll ask you a specific question in that regard. But from what I read, it sounds quite straightforward. Your detail of what is done with the old roux limb helps me envision how all this is done.   

Since this is a PM from you to me, I will not share this information with others on the boards, unless that's OK with you. I'm sure there are a number of people who would like to know about this and that will be very pleased to hear that you are indeed still committed to the DS as the best WLS available today. However, I respect your privacy and wouldn't think of talking about what you have told me in a PM unless I'm sure you don't mind. If you don't mind, please let me know and I'll write a post about our conversation and post it to the DS Board. 

Thanks again for your service and willingness to educate me; I really do appreciate it.

Best regards,

Kerry Johnson

DrHusted wrote:

Thanks Kerry,

The correct name for this procedure is simply Bilio-Pancreatic Diversion, or BPD. Keep in mind that "BPD" does not necessarily mean the "Scopinaro Procedure" as most people knowit, where the downstream stomach is removed. The proper full name for the Scopinaro Procedure is "Bilio-Pancreatic Diversion with Ad Hoc Stomach". Quite a mouthful, but the take-home message is that the term "BPD" refers to the intestinal configuration that results in the malabsorption and the metabolic effect of a DS procedure.

I don't like the term "hybrid DS" because that term really doesn't have a recognized definition, and what most people mean by that is a BPD anyway.

I only perform this type of revision on patients who are already eating the way a DS patient should. One of the many advantages of a DS over a RNY is that the ability to eat dense meats and whole veggies is relatively preserved, while RNY patients typically have a pouch that does not tolerate these foods, is very restrictive, and results in a high likelihood of soft-calorie preference and maladaptive binge eating, in addition to the issues with ulcer disease. Many post-RNY patients that I see for revision surgery, however, are able to tolerate dense meats and fibrous veggies already, just like a post-DS patient would be expected to be. In other words, they have shown through the test of time that they have not developed the disadvantages of he RNY. Certainly, this could not have been predicted before they had their RNY surgery, but the proof-is-in-the-pudding, after the fact.

The limb lenghts, including common-limb length, are the same as for any DS (although with revision patients, in general, I tend to err on the short side, given the stubborness for weight loss that revision patients seem to generally exhibit). I then connect the alimentary limb to a small cuff of roux limb just downstream from the pouch. I think that some other surgeons then excise and throw out the rest of the old roux limb, but I reconnect it back into the new bilio=pancreatic limb, in order to increase the surface area through which the pancreatic enzymes flow. There is very convincing evidence that the longer the bilio-pancreatic limb, the greater the weight loss. Re-plumbing the old roux limb back in accomplishes this. For this reason, although a BPD-only revision is not as aggressive as a revision to a full DS, it still is a bit of work.

The advanage is that it is less surgery for the patient to endure, with a typically shorter hospital stay. In addition, there is less uncertainty as to how the reconnected stomach is going to behave post-op, as the existing function of the stomach is already known, and not subject to change after surgery. I perform both BPD and DS revisions laparoscopically, so the incisions are the same. The decreased hospital stay seems to be related to a decreased time for the reconnected stomach to heal with the full DS revision. 

The disadvantage would be if the patient cannot eat appropriately after surgery, in addition to the general disadvantages of RNY compared to DS stomachs. This disadvantage, though, is ultimately an error in patient selection. Again, this revision is not for everyone; only for those patients who have proven through the test of time that they do not already exhibit the various disadvantages of the RNY pouch. 

In a BPD revision, there is no surgery on the duodenum, so the duodenum remains "unswitched". The old pouch outlet acts as the stomach outlet instead of the pylorus, which, is okay, as long as patients are already eating as if they were eating through their pylorus already. 

I hope this answers your questions. It can be a little difficult to explain in words alone, without the benefit of a dry-erase board and pictures, but I hope you get the idea. 

John D Husted, MD
 

Kerry J. wrote:

Dr. Husted,

Thanks you for the personal message; I had heard that you were not doing full RNY to DS revision, it's good to hear that this is not the case. I also read your post about the confusion between ERNY and DS and the Hybrid Revision you're talking about where the pouch is left intact.

I had posted some questions to Dr. Keshishian about this subject on the Revision Board, but maybe you could answer my questions; here's what I asked:

"I have a question about the hybrid operation some surgeons are proposing and doing these days when they say they are revising an old RNY to DS, but are leaving the pouch intact. I don't believe this is a version of the DS but I'm no surgeon so what I think doesn't mean much. The questions I have about this are:

1. What would the correct name of this surgery be or what should it be called?

2. Are there any advantages to this surgery?

3. What are the disadvantages?

4. How would the switch be accomplished? Since the duodenum is already bypassed, how can a switch involving the duodenum be done?

5. Would you be able to use the Hess method to divide the small bowel into alimentary and biliary limbs? 

6. Would the common channel be the same as with a full DS?"

For me, much of the confusion about this is how the "Switch" part of the DS could be accomplished while leaving the pouch intact. Can you detail how this is done and how it would be different from ERNY?

Thanks so much for your time and efforts; I truly admire and respect your service to the obese community and your skills as a surgeon.

Best regards,

Kerry Johnson

DrHusted wrote:

Kerry,

I saw that you recently posted that I may be performing revisions to DS. You are absolutely correct. I have done about 200 revisions to DS over the past 8 years or so, and have been very pleased with the results. I wanted to clarify this with you because you had made mention of it, and because of some recent confusion on this issue.

Recently, there was wild speculation that I was no longer performing revisions to DS; this is absolutely not true. I don't know where this rumor got started, but it seemed to gain some traction on the OH board.

When I evaluate a patient for a RNY revision to DS, I look at the end-point of what a DS accomplishes. The three metrics are restriction, malabsorption, and metabolic effect. The last two - malabsorption and metabolic effect - is accomplished by the BPD portion of the DS; the restriction endpoint may or may not have already been reached by the patient. In other words, what to do with the stomach depends on what the stomach is already doing. Many RNY patients are only modestly restricted in their eating, and are able to eat meat, dense veggies, etc., just like a DS patient. In many of these patients who are already at "goal" with their DS stomach function, I leave the staomach as is, completing the revision with the BPD portion of the operation alone. I think this may have lead some to believe that I no longer perform RNY-DS revisions, which is not true. As a patient active on the boards, I wanted you to be aware of this. I hope this clarifies some things.

John D Husted, MD

Thanks Kayla I was thinking the same thing... I was afraid I was going to have to stop reading

I can't read what you wrote, but I know from the other posts what it is about,  I got my packet from dr. K today, and it said to call them upon reciept.  THe receptionist said that had to be paid up front, no exceptions.  I too would have to travel, and stay in a hotel for the min of 10 days. 

 I called my present surgeon, and they want to see me tomorrow.  The nurse said with the complaints that I have, thar he may have to do something, but didnt know if he would o it in one surgery... not interested in that! ( she said he would put the stomach back together.. let me heal. and them go back and do the sleeve... I don't think so.

I will proably do some creative financing and go with dr K, as I am not going through 2. 

 

I understand! I wouldn't do two either! I'm just between a rock and a hard place! (ouch-hurts)

If choosing a doc. I would highley recommend DR RABKIN. He is the finest in the country. I was so grateful that I chose him to do my DS. His staff are wonderful, friendly and very helpful.
 I live 4 hrs from San Francisco and most of my consults were done by phone. get my blood work done, fax it to SF and the phone call comes a couple of weeks later.
Had to go down there for my 1 year, spent 3 days in the city, just because and had a great time with my girls.
Hope everything works out for you.
Evelyn

if it's any consolation - I was out of town and had surgery w/ Dr. K.  I got there on a Tuesday and left the following Monday.  Not as long as I thought, thank God.

Debbie M.

Another option in the Midwest would be Dr. Buchwald at the University of MN in Minneapolis.  He is a very experienced revision surgeon, with no program fees.

http://www.surg.umn.edu/Faculty_Alpha/buchwald_henry/home.ht ml

Best of luck to you with whatever surgeon you choose! 

In a very brief google search, (I am running out the door at the moment) a long-limb Roux-en-Y gastrojejunostomy is a viable revision for a failed VBG and there are several studies through the NIH clearing house that state that it is.    One of the studies was authored by Buchwald.     I think I googled "gastrojejunostomy"+"failed VBG" maybe.
Whatever the case may be (and I do not disagree at all that Rabkin, Keshishian, Greenbaum are the more skilled DS revisionists out there) I'd really appreciate a post made with some clarification on this issue.  Dr. Kemmeter is an extremely skilled  committed DS surgeon.  He believes that different procedures meet the needs of different patients and allows his patients the choice of what surgery they want to have.    He attends our DS gatherings to answer questions and talk to patients, follows up on patient issues and works to get his practice more currently in line with post-DS'er nutritional needs.  He has had his support staff contact older DS'ers like myself to assist with this.   His reputation as a surgeon is an impeccable one.    I'd really like it to stay that way.