What would you do? VSG to DS Long post

Hi Guys,

Posted the other day about my sister's dilemma. Went to see Dr. Gary Anthone (always a pleasure to hear him talk) great human being. Rehash she was 425 down to 315-325 after 1 year with sleeve (200) would be great, just stopped losing weight after 6-7 months. Has some hormone and autoimmune disease issues and has certainly made poor food choices as well, but felt the surgery should have worked better for her year one.

Talked about everything going on, he said adding the DS to the sleeve in place at this point, she wouldn't see a big loss of weight and would probably be disappointed. He said she would need to add some restriction along with the DS. But he's not a fan of re-sleeving and thinks the Dr. that did the first sleeve didn't (hug) the bougie along the staple line and left to much stomach. The original Dr. used a 40 bougie, I had a 32 and she could out eat me at 7-8 months, I'm 10 years out and still have good restriction. She can still eat half of what she used to BTW. So he felt converting the sleeve to a pouch would be better.

So he gave her three options.

1: Get a Panniculectomy, $8-10K?he estimated 35-40 lbs. Her original Bariatric surgeon thought 40-45 lbs. Get some relief and more mobility from a plastic surgeon, then add a bypass with new restriction later.

2: Get a Laparoscopic Roux-en-y with one of the other surgeons he works with, about $24K convert sleeve to a pouch. We know the Roux-en-y will lose it's bypass effect overtime so there is a downside and Get plastics later.

3: Get the DS with him (open procedure) $32-35K and convert sleeve to pouch but do a DS hybrid of sorts would be most effective he mentioned, resolve the diabetes altogether hopefully. Probably help keep the weight off the most long term. Get Plastics later.

She's self pay for all of this and the last option would be a doozee financially, current employer doesn't pay for WLS. Time off not a problem can work from home. But even self pay for WLS hospital said 3-6 months supervised weight loss. Don't really wanna weight that long.

She has a couple appointments with plastic surgeons and another Bariatric surgeon. Anybody been through something similar and what did you do or how would go about it. She needs both knees replaced and mobility is really becoming an issue. Any thoughts are welcome.

Thanks,

Bubba

DS Hybrid? I wouldn't want that. A stanard DS, yes!

I'll admit to getting lost in the terminology he used. He wanted to create a roux-en-y pouch out of the sleeve but do the intestines as a DS. That's how I understood it hence me calling it a hybrid of sorts.

If he wanted to do anything on top, I'd ask for a tighter sleeve.

That's what we were thinking or hoping but Anthone isn't a fan of resleeving, to many risks apparently. He would just do a roux-en-y pouch.

I wouldn't get a hybrid anything. I would get a straight up ds, even with a larger sleeve the malabsorption helps to lose weight.

Different DS surgeons have different theories about what is most important in a DS. Some go for more restriction (i.e. a narrower sleeve) and less malabsorption, others think a larger sleeve is ok as long as you have really good malabsorption.

It's certainly possible that the initial sleeve was not done as well as possible, but also possible that the original surgeon was being careful not to make too narrow a sleeve, which can cause serious problems with reflux. The size of the bougie doesn't tell the whole story, as it also depends on how tightly the surgeon stapled against the bougie.

So, given that none of the above options sounds great, I would recommend a second opinion with another DS surgeon, and the one I would recommend is Dr. Ara Keshishian in Pasadena, CA (near Los Angeles). He does a lot of revision surgery, and his philosophy goes more to the larger sleeve, more malabsorption end, which might be just what your sister needs. Though of course, if the sleeve is truly malformed, she may need a re-sleeve, but this is something to discuss with him. Given that your sister is going to be self-pay, she may as well pick the surgeon that suits her best.

Larra

I will pass that along about a second opinion, which are hard to come by where were at. It's cool Dr. K Skypes, this might help her make up her mind. I personally feel the DS is the way to go but $ is always a factor.

Thanks,

Larra

I can understand a pouch hybrid if she was having significant reflux problems such that it would be desirable to go to a "low pressure" system (sort of like a higher restriction/lower malabsorption Scopinaro procedure) that would also avoid the extreme NSAID intolerance of an RNY, distal or normal. But I don't see that a pouch is significantly more restrictive than a properly done sleeve as the RNY and VSG overall give similar results. As you say, he may not be a big fan of resleeving, and that may just be a preference; revisions, even fairly straightforward ones like a VSG/DS "completion" are more complicated than virgin procedures, so styles and preferences between surgeons, even amongst the group of long experienced DS guys, can vary quite a bit. I'm a fan of getting second (and third) opinions, particularly when dealing with less than textbook cases such as revisions, so it is good that she is proceeding in that direction as well.

Likewise, I think that it would be a good idea to consult with another of the legacy DS guys; I know Dr. K does quite a bit of consults via phone/email/skype, etc. so it doesn't have to involve a lot of travelling, at least for the initial consult, and it's a pretty easy way to get some diversity of knowledgeable opinion.

Good luck....

She currently doesn't have any reflux problems (Only had heartburn once and has never thrown up in the year since she had the sleeve done. We seem to think more and more after I've been reading alot that she simply have that much stomach removed. I don't care for the idea of a Roux-en-Y pouch, but it will ultimately be her decision.

Will definitely pass along the consult info about Dr. K.

Thanks,

bubba