Question about Dr. C and his bougie technique

Thank you Frisco.  I'll be printing this information out to go along with all the other information everyone has supplied me with.   I tend to think in mechanical terms so this  helps me a lot.

"I don't know if he oversews or anything else I've read about Dr. C doing. "

FYI: Dr. C doesn't oversew. He does reinforce the staple line at the point where each cartridge ends and the next one begins but this isn't oversewing -- oversewing is when they go over the entire staple line and cinch it up. There is controversy over this technique with some surgeons swearing by it and others saying it actually increases your chance of leaks.

This is my take on it:

I happen to think that surgery technique is very important. BUT the way to judge if your surgeon has a good technique isn't to quiz him over whether or not he does exactly what some other surgeon does who has good stats. It's to look at the program's stats.

Because technique is only one variable. Plus, two surgeons could have two techniques that work but are different. And, in the end, what matters is results.

An example of that is that I know a surgeon who does 3 leak tests on sleeves and has never had a leak. I know another surgeon who does no leak tests and has never had a leak since he stopped doing leak tests. Some people will tell you that you HAVE to have a leak test. I say I'd rather have a surgeon with a 0% leak rate than one who does a leak test and has a 1% leak rate.

The bottom line is: if a surgeon has good stats, then their technique, combined with their program, works. If their stats are below average, then either their technique or their program (or both) have room for improvement. Since you can't separate the two, it kind of doesn't matter which one it is.

As for Dr. C skewing his stats, I have never heard of *any* surgeon reaching out very much to patients who don't come for follow up when they publish stats. So since the purpose of looking at the stats is to do comparisions between surgeons, what matters is that you are comparing apples to apples. In this case, I think you are. Not only that, but Dr. C takes on a lot of high risk patients who other surgeons turn away. Yet still gets better than average results.

(This is also true about deaths. I remember someone on OH boasting about his or her surgeon and saying he'd only had one death early on but now he's more careful about who he lets in the program, not taking high risk patients, and so now he hasn't had any deaths. And they said this with a straight face as if it means their surgeon was better than average instead of the opposite. I was just shaking my head over that one... if your surgeon has no deaths but also never operates on anyone with a BMI over 50, big whoop.)

Another area to be careful of in the stats is what they consider to be 100% of excess weight. Most programs I've seen use 24.9 as 100%. But some use a BMI as high as 27! Dr. C uses 24, btw, so on that stat he's actually stricter than average. (But not by much. Only .9 percent.)

Another thing to ask when you ask them what their "success" rate is, is how do they define success? Some programs define success as achieving 66% excess weight loss. Others as getting out of the obese category. Some have higher standards. Some only care about you reaching that goal, not whether or not you maintain it. Others judge by 2 years out, others by 5 years. Obviously those are some big differences. So you need to know the definition when you are judging the program.

In the end, if you want Dr. C's technique, I think you should go to Dr. C. If you aren't willing to do that, then you should interview a bunch of surgeons and figure out which one has a program that suits you (stats mean nothing if the program rubs you the wrong way -- statistics don't predict individual results) and had reasonable results and low complication stats.

For example, my own criteria was:

-Done at least 250 sleeves (but preferably more)
-Leak rate under 1%
-Success rate at least as good as for RnY but preferably higher than average
-Program that treated me like an adult able to make good choices and didn't micromanage
-Program that was largely evidence based rather than based on tradition or treating sleeves exactly like they are bypasses

I knew within 10 min. of the introductory meeting that Dr. C was the guy for me just like I knew withing 15 min. that the Stanford program would have driven me insane. I was also willing to travel, but only if I couldn't find someone local who met my standards because being local was important to me (it's not for a lot of people).

Thank you so much!  You make many, many good points.  Either I'll make a good impression when I see him because I'll be able to have an intelligent discourse with him, or I'll really annoy the crap out of him!

Either way, I'm more concerned with what I am asking him and understanding what I'm asking him.  I appreciate everything you have done for VSG'ers with your blog and contributions.

I think you are asking some very serious and relevant questions and concerns. The feedback that you have received is stellar. When I was pre-op, I did a lot of research, read research articles, went to support groups, and read OH. I would just caution you, complications can occur with the best surgeons and some things are out of your control. I thought that I was well prepared and I was, but I ended up with 2 very serious complicaions. One was exacerbation of a pre-existing condition that no one knew about and one was related to the surgery. I ended up spending two weeks in the hospital. So much for being in control and prepared. I was shocked, because I thought that I knew what I was getting into. Little did I know that I would get slammed. Just a word of caution. Some things you are in control of, and other things can happen that you have no control over. Prepare for the worst and hope for the best.


Gail

I do feel very blessed and fortunate with all of the important feedback.  I am very sorry to hear that you had such terrible complications.  Complications are an issue that one doesn't like to think about, but still need to be faced.

Glad you are OK now.

I am sorry that I am late to this party, but it seems to me that you have already received fantastic advice from the other VETs.  I will tell you my truth, your truth can be different.  I researched surgeons in my area and outside of my area for almost one full year.  I had very strict criteria and my insurance did not cover WLS.  I was going to be self-pay no matter who I chose.  This game me a certain amount of freedom to make my choice based on excellence rather than convenience.  The papers that Dr. Cirangle wrote that Ruggie has alluded to, have all been read by me and studied in detail.  I also read every single thing I could get my hands on to do with VSG.  I went to the Stanford library and worked with the librarian there to maximize my research.  If a paper has been published and some form of VSG was involved, I have read it ( up to about three years ego).  It was only then that I started interviewing doctors.  It was apparent to me within a few minutes of my interview with Dr. Cirangle that he was going to be my choice.  I have also refferred my closest friends to his care and they too are doing incredibly well.  How much of this is his doing, and how much is my own persistence and commitment?  I really don't know.  I know is that stacking the odds in my favor was incredibly important to me and I would have done almost anything to put my thumb on the scale and make it more likely that I would succeed long term after this surgery, because the truth is, there is no plan B for me.  If this doesn't work, I am done.  I would not consider doing the DS unless I was SMO and that is not going to happen.  This had to work, work well, and work for the rest of my life. 

You are really prepared for this, much more than most people that undertake this journey.  I would have a long talk with your surgeon after reading all the papers from Ruggie and I would ask him about his opinion about Dr. Cirangle's work.  I would want to hear what his attitude and thoughts on smaller sleeve.  I would not wish to persuade him, but I would want to know his thoughts.  Then you can make the best choice for you.  I can honestly tell you, that I would not go to anyone who has not done over 300 VSGs.  I know that even Dr. Cirangle has changed and refined his technique based on what he observed in the early years.  A doctor who has not had the same opportunity would be at a disadvantage in my opinion.  Good luck to you and I know that you will make any situation work for you, but I also understand your desire to improve your chances of permanent success.

Thank you, Elina!  I'm not sure how many VSG's Dr. Crooms has done since he first started doing them some time ago.  Here in Tallahassee, he is the only surgeon within a three hour drive of anywhere.  When I first heard about the VSG, it was not covered by Capital Health Plan, which insures probably between 125,000 and 150,000 or more in this area.  There may be a few others, but if you work for the State of Florida, FSU, FAMU, TCC, Leon County School Board, Leon County, City of Tallahassee and quite a few private companies, it's a pretty good bet that you have CHP.   Wow, after typing that last sentence, I see that CHP pretty much has a monopoly on health care here!!!

Now that it is a covered procedure, I know the number of VSG's performed will rise greatly.  I'm pretty much stuck with having the procedure done by Dr. Crooms.  He does have a reputation as a very skilled surgeon so I can only hope that, in his desire for excellence in surgery, he applies this to the VSG as well.  Every bit of information that everyone has provided me with will be read over and over again so that when I meet with Dr. Crooms, I can have an intelligent conversation with him.

In the long run, I realize that it ultimately comes down to me and my willingness/motivation to do what is best for me and my health.

Thanks so much, Elina!

p.s you can go to the lapsf.com website and look under dr. credentials and publications and get link to /dr. c publications that might interest you.  diane

Thanks, Diane.  I have done, and will continue to so. 

One thing I can't find, and I would swear I had seen it on lapsf, is the protocol for eating, post operatively.

If I remember correctly, Dr. C has his patients stay on clears, purees, etc. for longer periods of time than other doctors.  I want to model my post-op recovery and eating plans as closely to that prescribed by Dr. C as I can.  I'll keep looking.

Thanks again!

No, he doesn't have us on them for longer than others, at least not for the sleeve. In fact, other programs often are much more elaborate about the post-op eating plans. I call it eating micromanagement and I don't really approve as there is no medical reason for it.

In our program,  you are never on clears but on "thin" liquids for 2-3 weeks and then "softs" for 2-3 week and then regular food "as tolerated" for the rest of your life. Bandsters are on liquids for 3 weeks period as Dr. C wants the band to settle in and scar tissue to form around it as is supposed to happen. He has a much lower incidence of erosion and band slipage than average and I suspect insisting they stay on liquids for a full 3 weeks is part of it.

The reason to be on liquids for 2-3 weeks is to allow the staple line to heal with minimal stomach churning. The reason to go on softs is to have a gradual transition during a time when eating is hard so you lessen the chance of getting foamies and other bad things and maximize your chance for eating success.

There is no reason to be on clear liquids post-op according to the ASMBS and it's a practice I strongly disagree with as immediately post-op we need to be consuming maximum protein to help with healing and not starving our bodies any more than they have to be. (here are programs that have you on clears for 10-14 days and then full liquids for another 10-14 days and then mushies and then softs and there is no reason for that.

I'm also not a big fan of givign patients long lists of foods and saying "start X food at 7 week, Y food at 2 months, etc" up through the first year. There is no need for that as every patient is different and what they can and can't tolerate and when they can start tolerating it is different. It just rubs me the wrong way to hear a grown-up saying "I'm not allowed to eat tomatoes until I'm 6 months out" as if they are a child.