Pressure from surgeon to have RNY, not sleeve?

Just posted this on another site as well. Trying to get as many opinions as possible...

Does anyone feel pressured by their surgeon to do the RNY/bypass over the sleeve?

Like everyone else, I sat through the initial info session my surgeon offered and I felt like she was really selling the RNY. The whole session was about the RNY, in fact, and how it's the "gold standard" and best procedure. 

Then, I met with her for my initial appointment. She predictably said I was a better candidate for the RNY. I am 5'2" and weigh 250. Fair enough. I went home and had my mind set on the bypass.

But then I started doing my homework and, after much thought, I decided the sleeve may be better for me for many of the same reasons as others who make this decision: I have no comorbidities, research seems to say it's less invasive, no rerouting, no dumping, no vitamin/medicine probs and it would cut out the hunger hormone grehlin. Equally as important it would restrict the amount I can eat and, according to the many pieces of research I read, offer practically the same amount of weight loss as the RNY over the long term, albeit at a slower rate.

I am also a cancer survivor and I had concerns about the malabsorption that comes with the RNY and whether or not I could effectively be treated in the future (if needed) if my body would no longer absorb medicines (including oral chemo).

That said, I did have a couple of concerns about the sleeve. One, I'm not a necessarily volume eater and this is obviously a purely restrictive procedure. And two, I have a career, a lot of business travel, and a toddler, so I can't commit to constantly exercising like others do. I wondered if I wouldn't lose enough and then regain what I do lose because I won't have that malabsorption so many people benefit from with the RNY.

So, I made a second appointment with my surgeon to discuss all of the above and she was still all about the RNY -- which is totally fine. She is the expert and I am turning to her to help me make an informed decision. However, she mentioned several things that were contrary to everything I've read. She said...

--Malabsorption only lasts six months at the most for both calories and nutrients/medicine (yet, her required nutrition classes talk about the life long vitamins, etc???)

--People don't lose weight from the RNY because of the malabsorption or restriction; they lose weight because they're bypassing all the hormones in the first part of the small intestine, something you don't get with the sleeve (so malabsorption has very little to do with the weight loss)

--The RNY is safer than the sleeve; the sleeve is actually more invasive and dangerous to recover from because it's more prone to leaks due to the length of cut and pressure that builds in the sleeve.

--The sleeve causes less weight loss and you will regain more in the long term. I have read that the long term results are VERY similar to the RNY. She says no, long term for RNY is much better.

--The least I can ever weigh with the sleeve is 180-190 lbs (currently 5'2" and 250 lbs) and I likely won't get that low.

--I can take time release medicines in the future and they will probably work.

--The sleeve will rarely be performed five years from now because it's not effective; but I thought the sleeve was becoming the WLS of choice

I was confused by what she was saying, so she referred me to the Cleveland Clinic's "Stampede" study, as it compares the RNY to the sleeve. But I read it and it is all about the effects of both surgeries on diabetic patients. I don't have diabetes.

Does any of this sound like what you've understood from your surgeons?

My surgeon is loved by all. She is smart, has great bedside manner, has been doing this for over ten years and has one of the Bariatric Centers of Excellence. I do trust her, but some of this sounds strange to me. In the end, I want solid info so I can make the decision that's best for me.

Any thoughts on why surgeons might try to "sell" the bypass more often?

p

Also, any thoughts on what she said to me when I went in to ask her about doing the RNY vs. the sleeve?

Thanks!

All surgeons have their opinions, but truly great ones will tailor their recommendations to your situation, not just their preferences. I had to switch course from VSG to RNY, but that was due to my severe GERD, and the data backed up my surgeon's recommendation. My husband had the same concerns as you about malabsorption and intestinal re-routing, although he was always just a volume eater, so our surgeon thought VSG was a great choice for him.

It sounds like you've done an impressive amount of homework on your own, but it might be worthwhile to get a second medical opinion. The surgeon you saw may just not be comfortable performing the VSG, which is why she tries to talk everyone into RNY. There are pros and cons to both, but they're usually weighted by your specific situation. Before committing to RNY, I talked to two surgeons, two endocrinologists, the NP and NUT at my surgeon's clinic, two PCPs (I switched when mine retired), and two gastroenterologists. Despite having different surgeries, my hubby and I are both confident we each made the right decision for ourselves.

Also remember that any type of WLS is a tool -- if you pick it up and use it, it will work great for you, but if you leave it on the ground, it won't do you any good, regardless of whether it's a spade or a shovel. My grandparents have a friend who gained back every pound he lost post-RNY about 15 years ago. A coworker of mine had VSG last year and gained everything back in about 4 months (yes, 4 months). Both kinds lose effectiveness over time (caloric malabsorption is temporary, and both sleeves and pouches mature to a larger capacity than they start at). Both can be "eaten around." But with constant vigilance (Mad Eye Moody style!), both can and do work wonders at helping maintain long-term weight loss.

Like was said, all surgeons have their own opinions.  My doctor was more prone to do sleeves instead of bypass but that is what I wanted.  I don't know much about the sleeve, but to say its a WLS that is on its way out is totally not true.  RNY is considered the "gold standard" but the sleeve is very successful, part of another WLS, and def not on its way out.  The band, yes.  The sleeve, no.  The other comparisons I cannot speak to because I do not know enough about the sleeve to compare.

What it comes down to, ultimately, is what is best for your individual situation.  I firmly believe you will work the tool you have the most confidence in.  That is what I was focused on.  

Hi Maya,

I'm not sure about all of the bullet points your surgeon went over, but I did find an article supporting #2.

"It is unlikely that the difference in efficacy between RYGB and vertical-banded gastroplasty results from either RYGB-induced malabsorption (which is not clinically significant after the proximal procedure)" (Source).  It goes on to describe the effectiveness of the RNY/RYGB as being attributed to bypassing the Ghrelin-producing portion of the intestines.

Additionally, according to another article (Source) "A two-year analysis of the trial, reported last June [2012], showed that while both surgical techniques resulted in similar weight loss at 2 years, bypass patients had greater losses in android fat -- popularly known as belly fat -- and better rates of diabetes remission."

These two reasons were brought up by my surgeon and definitely convinced me that RNY was the way to go.  For me, as a revision from a lap-band to another surgery, I had tried the restrictive procedure and it didn't work for me because of my hunger. RNY seems like the perfect tool because it does provide restriction as well as 'bypassing' the area where the hunger hormone is mostly produced.

I hope some of this is helpful to you!  I'm sure some well-armed vets will also chime in with their own knowledge. :)

My surgeon did the same thing but it was based on my history of yo yo dieting, I did end up choosing the RNY and had it done 8/6.

-Malabsorption only lasts six months at the most for both calories and nutrients/medicine (yet, her required nutrition classes talk about the life long vitamins, etc???)     Actually, malabsorption of fats and calories usually lasts about 18 months, but it varies from person to person.  Malabsorption of vitamins and minerals is FOREVER, so we must supplement for the rest of our lives.

People don't lose weight from the RNY because of the malabsorption or restriction; they lose weight because they're bypassing all the hormones in the first part of the small intestine, something you don't get with the sleeve (so malabsorption has very little to do with the weight loss)  Malabsorption plays a very small roll in weight loss after RNY.  It does help you lose weight a little faster than VSG.  The key to any WLS is total compliance with the new lifestyle and proper food choices.  No surgery is going to stop you from making bad food choices.  I have never heard that we lose weight from "bypassed hormones".  Losing weight is all about the food choices... period.

-The RNY is safer than the sleeve; the sleeve is actually more invasive and dangerous to recover from because it's more prone to leaks due to the length of cut and pressure that builds in the sleeve.  Any surgical procedure has it's risks.

--The sleeve causes less weight loss and you will regain more in the long term. I have read that the long term results are VERY similar to the RNY. She says no, long term for RNY is much better.  There is the potential for re-gain with ANY WLS.  People find ways to eat around their surgery.  They graze, eat off plan, over indulge, etc.  If you stick to your program and do the mental work you need to do to figure out why you became obese in the first place, either surgery will be successful.  Remember, the surgery is on our stomachs, not our brains.  It's up to us to work out our own "food demons".

-The least I can ever weigh with the sleeve is 180-190 lbs (currently 5'2" and 250 lbs) and I likely won't get that low.  There is no set weight that you will be limited to.  It really is calories in...calories out.  The amount you lose is in direct response to how hard you work the program.  You can lose as much as you want to lose.

I can take time release medicines in the future and they will probably work.  It is my understanding that, because of the bypassed area of the stomach/intestines, most timed released meds are not as easily absorbed.  That is forever.  Some timed released meds will work in some people.  Trial and error.

The sleeve will rarely be performed five years from now because it's not effective; but I thought the sleeve was becoming the WLS of choice.  No idea about this one.

It sounds like your surgeon is more comfortable doing the RNY surgery than the sleeve.  Have you ask her how many sleeve surgeries she has done?  I would want a very experience surgeon to be working on me.  If you are sure you want the sleeve, I would find another surgeon.

Ok, well, you got some really BAD information from that surgeon (more about that below).  If it were me, THAT alone would be enough to have me go to a different surgeon. If you cannot trust your surgeon to give you unbiased, accurate information, then -- IMO -- you cannot trust them to do the surgery and provide good care and advice on post-op matters.  Do you want a doctor who flat out lies to you?!?

Your surgeon may be "loved by all" (although even excellent surgeons have people who don't like them for one reason or another), but clearly she has some kind of an agenda. A COE designation really has more to do with paperwork trails, immediate post-op complications, and HOSPITAL compliance with a set of guidelines.  It does NOT guarantee that a surgeon is ethical, nor does it guarantee that they are well educated in post-op nutrition.  

With your history of cancer, I think you are wise to strongly consider the malabsorption of meds in your decision.

I would also steer clear of any surgeon who actively "pushes" for one surgery over another without a significant medical reason based on YOUR medical situation. Surgeons often push for one surgery over another either because they are much more comfortable wth a single surgery (in which case, do you really want that surgeon doing a procedure that (s)he is so much less comfortable with that (s)he will push patients NOT to select it?!?) OR because they can make more money with RNY than with VSG (which, again, begs the question of whether you want a surgeon who cares more about money than what is right for you...)

As far as the bad information:

1) that you can only get down to 180 pounds with a sleeve is just plain bull****  NO surgeon has any way to tell ANY patient what they can or cannot lose, and many, many people lose A LOT of weight with the sleeve.

2) Caloric malabsorption lasts for about 18 months or so. It starts to fade gradually very soon after surgery, but it is nonsense that it only lasts for 6 months.  People lose weight much more quickly during the first six months, but that has a lot to do with how every little they are able to eat AND the fact that the daily caloric deficit (and therefore the rate of weight loss) is greatest when you weigh more... It takes twice as many calories just to fuel a 300 pound body as it does a 150 pound body.

3) Vitamin malabsorption, on the other hand, is permanent after RNY!  That a bariatric surgeon wild tell you it o ly lasts 6 months is almost criminal, because if you have RNY, you will need to take vitamins at least four times a day for the rest of your life.

4) Every study I have ever seen comparing long term (5+ years) results from RNY and VSG indicates that the weight loss is comparable two years out and beyond.  Two extensive studies  both found that beyond the 5 or 7 year points, the type of surgery was insignificant as far as maintaining teh weight loss.  What DID matter at that point is how compliant people were with permanently changing their eating habits.  Those were compliant maintain their weight loss; those who didn't, did not. 

5) VSG is becoming the most widely performed surgery. I have no idea why she would tell you that in five years they wouldn't be doing it. That might be very true of the band, but not of VSG.

6) Statistically, the RNY actually has more potential surgical complications than the VSG. A leak along the extended suture line is about the only significant complication with the sleeve (assuming that we are excluding post-op complications that can happen with any surgery, such as blood clots, infections, etc.).  That is because the VSG is a less complex procedure.  With RNY, potential surgical and immediate post-op complications can include leaks (smaller chence than with VSG, though, since the area is smaller), strictures at the manually created stoma (which may have to be stretched multiple times), problems with the reattachment points of the intestinal bypass, and -- if the surgeon is one who does not completely sever the pouch from the stomach -- problems with failure of the suture line between the pouch and the stomach.

I would strongly recommend that you at least consider another surgeon.  Go to an informational seminar given by another surgeon and take that opportunity to ask THEM about the things you are being told (incorrectly) by the other surgeon.  

It amazes me that this surgeon would give you so much bad information in a blatant attempt to get you to opt for HER surgery of choice (for which she will make as much as double the amount of money she would make for doing a VSG). Remember, YOU are the one who has to live the rest of your life with your decision.  Once the surgery is over, your surgeon can just walk away.

Lora

Hi Everyone -- I just posted this in the VSG forum too.

Thank you so much for your feedback. This helps a lot.

I'm still very conflicted. I went back to my surgeon today and one of her staff members told me they don't even normally do the sleeve for people of my weight because they just don't see the results they need. All that said, they agreed to do the sleeve for me if I want to go that route.

Honestly, I have a friend who weighed around 350 and she lost over 100 lbs -- so she has been successful, but she is having trouble losing the rest of her excess weight.

So, I'm still really confused -- and I'm not sure how much of it is because my surgeon and her office are encouraging me to do the bypass or what I have seen with my friend and her sleeve.

Also, I spoke with my oncologist and he said that if I were to ever need treatment in the future, I could be treated if I have the bypass or the sleeve.