Pressure from surgeon to do bypass instead of sleeve?

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?

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

Thanks!

She's right on one point but I disagree with almost all of her other points.

I think it is a common misconception that the VSG is "less invasive" because intestines aren't re-routed. The length of the staple line does lead to more leaks and the complication rate IS higher (though still very, very low). However, I chose the sleeve because it maintains the pyloric valve. For a number of reasons, that was important to me. 

You need vitamins for life with either surgery. The VSG actually causes malabsorbtion of some vitamins as well. From what I've read, with regard to calorie malabsorbtion and the RNY, the body compensates for caloric malabsorbtion eventually but vitamin malabsorbtion continues forever. So maybe that's what she meant.

I think it's increasingly clear that long term results for RNY and VSG are equivalent. I think there had been some studies that RNY lose weight faster, but by 5 years, it's a wash between the two.

My surgeon is an RNY pusher. I think he's more comfortable with it and he's definitely done more RNYs than sleeves. I really like him (and his reputation is that he's "very careful" which is a quality I appreciate in a surgeon!) and I'm glad I stuck with him, but I wonder sometimes if some of this has to do with their own experience rather than what actually works for patients. Judging from my support group, I've done as well or better than many of the RNY patients in the first year. 

Both are great surgeries. You can be successful with either. There are many people here with your starting stats who totally got to their goal with the VSG. Every provider I saw pushed the RNY for me, and honestly I don't know if I would have had a better or worse experience with the RNY, but I am very happy with my sleeve. 

Wow -- there is actually great empirical research out there that disputes almost every point she's telling you.  I would be very, very leery of a surgeon who is pressuring you to do one surgery over the other.  Primarily because it indicates to me that SHE is more comfortable with that surgery and has more success with it.  This would indicate to me that she doesn't do as many sleeves as she does RNY.  

You are actually a perfect candidate for VSG (look at my stats below - we are very similar).   I would urge you to do the research (medically based research not just what you can Google off forums like this) and check to see which surgeon in your area does lots of sleeves.  For that matter, ask this surgeon how many RNYs she does a year and how many sleeves she does a year.  The answer would be interesting - I'm certain she does very few sleeves and - honestly - you don't want somebody with little experience or poor outcomes with that surgery operating on you.  

Decide on the surgery you are comfortable having and THEN find a surgeon that is great at doing that surgery.  

I got my sleeve in the end of July last year and my dad got RNY in mid-October last year.  So, as far as results go, we are a pretty good comparison.  I lost 100 pounds in 7 months and reached my goal of 120 lbs in 11 months.  He lost 120 lbs and reached his goal in 10 months.  He takes chewable vitamins, I take regular vitamins, but we both still take vitamins.  He had to get RNY according to his surgeon because he has Barrett's Esophagus which made the sleeve not an option.  The biggest difference between us is what we can and can't eat.  I don't have any foods that my body doesn't tolerate.   (Although, maybe this isn't typical of most sleevers, I don't know.)  My dad however, is very restricted.  His doctor told him he can never eat salad again, he can't eat bread unless it is very well toasted (I don't eat much bread, but if my mom makes some homemade bread, I eat some, he can't).  He has foods that he just can't eat but he hasn't identified them all and he throws up quite a bit, I think. 

I hope this helps.  We don't have any long term stats, of course, since we are both new.  Good luck in your choice.

It sounds to me that you have a surgeon who is much more comfortable with the RNY than the sleeve.  Just remember, the surgeon performs the surgery, but you have to live with it.  Take her comments and opinions into consideration, then decide what works better for you.  If you want the sleeve, go find a surgeon who is comfortable with the procedure. 

--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???) - it may last 6 months, or 12, or 18, and will probably always be there in some form.  Many RNYers complain at about the 2 year mark that they're doing the same thing and gaining weight.  That's the sign that it's ended!  The CALORIE malabsorption ends; the vitamin malabsorption is permanent.

--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).  RNYers lose weight because of restriction and malabsorption.  I've never seen anyone say otherwise.

--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.  Your doc is correct that the incision line for the sleeve is longer, and there is certainly an art in getting the line right.  But the same stapler is used for both the RNY and the sleeve.  Both procedures involve internal staple lines.  And you have more with the RNY because the intestines are stapled and I assume there's either stapling or stitching to create the stoma.  There is a risk of leaks for both.

--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 most recent studies say the ultimate weight loss is about the same.

--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.  Bull****

--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  My surgeon thought just the opposite - that the sleeve is becoming the gold standard.

she makes more money for the rny, for one thing.

apso Google dumping and reactive hypoglycemia.

A comment from a fellow cancer survivor.  

My oncologist very supportive of WLS in general but he said that "if there is a choice" then go with the one with fewer absorption issues.  I think much of that has to do with medication absorption but, as you know, there is a lot else going on doing chemo, too.  The less weirdness, the better.  

I know my surgeon prefers RNY for most people like me (starting BMI >60, not diabetic but getting very close) because there is just a bigger volume of outcome data available as well as practical experience.   But my oncologist's preference and my preference ruled the day with no issues.  By the way, she gives all patient's the choice as long as there is no compelling reason to go one way or another.    

Most cancer drugs are by IV or IM but there has been an explosion of oral drugs that are only available orally. They aren't necessarily long acting formulations but many are fussy creatures.  If you for some reason you don't get the whole dose, it simply doesn't work.  There are not necessarily ways to measure if you are getting the whole dose. 

The comment about timed released medications "probably" working seems a bit cavalier to me.  For a lot of disease states, that is ok.  If the timed release doesn't work, then move to immediate release.  If that doesn't work then move to a different drug.  This sort of drug dance is ok with many disease states but not so much with cancer. 

On occasion, I see comments that a correct dose for RNY patient can be figured out by a good pharmacist based on the patient's particular type of RNY and knowledge of the drug's pharmacokinetics.  As a pharmacist, I can tell you that is a gross overestimation of what information is actually available.  For example, I am on tamoxifen, an old drug, you would think there would be a ton known about where it is absorbed.  As it turns out, there is virtually no hard information on it and what was available was someone's best guess.  If I had gone with RNY, my surgeon would have recommended a liquid formulation to control for any dissolution issues, but that would be all we could control for. 

Good luck with finding your path.   

Really great point on absorption of meds for cancer patients. I am 6'2'' and took Tomaxifen post VSG. I started at the typical starting dose and eventually had to be tested to check therapeutic levels due to side effects. Turned out I needed half the dose of most women even though I am a total Amazon and 185 pounds at the time. I can't imagine how much harder it would be if I had Rny and trying to figure out how much I am or am not absorbing of medication. 

Yup, you can't tell just by looking at someone, right?  

If I had gone with RNY, I would have literally needed an anti-anxiety med because my brain wouldn't be able to stop thinking about possible non-absorption.  If cancer returned, I would always worry that my choice may have contributed to tamoxifen failure.  

I am stressed just thinking about it.  So glad VSG was an option. 

I responded to you on the RNY board but wanted to throw this out too -- my hubby had his VSG 2 weeks after my RNY. Our vitamin regimens are identical, and neither of us has any restrictions on what we can eat (although we both voluntarily restrict what we choose to eat). Our recoveries were pretty much identical too, except he developed some reflux after surgery while my pre-existing reflux went away.