Why RNY over DS?

I know it's silly to be researching it now, but why do they do the RNY over the DS?  I wasn't really given an option as the doctor that I was sent to seems to do the RNY only, but I still should have done more research. 

The DS seems to make a little more sense.  They remove the portion of the stomach is responsible for ghrelin production, therefore taking away hunger.  And you get to keep your pyloric sphincter so there isn't a risk of strictures.  It sounds like there are a lot less complications with the DS.  From what I've read, it sounds like you have to convince a surgeon to do the DS or am I wrong?  If so, what would you argue?  It makes more sense?

A little late, but I'd like to know.

Thanks in advance,
Julie

I won't assert for myself which has more or less complications, because any such assertion will call for someone on the board to argue with me - and I hate those conversations on OH. I will tell you what Dr Sohi told me: Humber will not do the DS - they consider it a much more complex and riskier surgery. He said that they have had to do revisions for many DS patients who obtained their surgery out of country. I had an extremely high BMI and was interested in perhaps doing a staged surgery - VSG then a year or two later a DS if I did not get down to goal. They said I would need a BMI of over 70 to consider that, and even then it would be a VSG to RNY.

In the end, I did not want to go out of country. I wanted local follow-up and local care. I wanted a surgeon in driving distance I could go to if I had a leak, and I wanted a follow-up program to support me. I also decided it was more important for me to get my surgery soon (after waiting 18 months from referral to surgery) than to appeal, seek another doctor and see if I could pursue the DS at some indeterminate time in the future.

In the end I am happy I chose what I chose.

Ok, so it's a risk issue.  Not sure why it would be more risky. They are just moving different parts around. I will have to ponder that. Thanks for your answer. 

The DS is a more complicated surgery and takes longer to perform. Being under anesthesia for longer and higher degree of difficulty of the surgery give it a slightly higher complication rate, plus the DS tends to be more often performed on higher risk candidates, but were still talking less than 3% compared to the RNY's 1-2%. Post-op complications for the DS are equal in rate but different in type than the complications for the RNY. A surgeon can typically do 1 DS in a day, whereas they can do 3 RNY or VSG surgeries - what do you think is more cost effective?

You are bang-on about the perfect compromise of the DS, you eliminate the chunk of stomach where the hunger hormones come from, but still have enough stomach to eat reasonable and normal meals. Plus you get re-routing of the intestines which causes malabsorption that never goes away, so you have a life-long tool that helps you to avoid regain. You don't get the dumping or reactive hypoglycaemia because of the preservation of the pylorus, but you still get rid of co-morbids like diabetes at rates better than the RNY (except for GERD, which RNY is still slightly better for).

Some people are under the misapprehension that the DS will normally cause malnutrition and deficiencies - it doesn't. It has the same concerns as RNYers, you have to watch your vitamins, get labs, get sufficient protein and stay on top of iron, but most people never have serious issues. Those that do are the ones who did not receive proper information and counselling on how to eat and supplement post-DS (it is not the same as RNY) or *****fuse to take care of themselves properly. A study found that DS and RNY post-ops average the same number of bowel movements a day, for some reason the DS gets a bad rep for diarrhea, which can happen if you aren't eating properly but isn't an issue for compliant post-ops.

The bottom line is that this surgery is much more expensive to perform so the government will limit access to it in whatever way it can, especially as they have poured money into a system focused on RNY. Dr. Dent has gone on the record in appeal board hearings saying false things about the DS as justification for not offering it to Ottawa patients, to not even educate them about it. He was corrected at the hearing by Dr. Gagner and another top DS surgeon, yet continues to propagate misinformation - it's disgusting. It comes down to the government not wanting to pay for it and a lot of misinformation.

I believe people should push for the best surgery for THEM. Some RNYers prefer the small meals and risk of dumping to keep them on track. Others don't want the risk of malabsorption and can lose with restriction alone so the VSG is sufficient. Others, like myself, looked at the stats for my specific conditions and made a decision based on the studies out there that says DS has the best sustained weight loss and I'm the kind of person who likes to make decisions based on the stats :)

I encourage everyone to push for the surgery that is right for them. Right now, the odds of being approved in Ontario for DS are slim, virtually non-existent unless you can get a consult with Dr. Hong as he is the only Ontario surgeon who does the DS. Right now they consider DS for SMO patients (BMI over 50) who cannot have RNY, and as a revision for people who either lost insufficient weight or who had significant regain (BMI over 35). I believe that in time, OHIP will have no choice but to cover the patient's choice of surgery as long as it is not medically contra-indicated. That has become the standard of care for public and private insurance in the US, and in Quebec. If you qualify for bariatric surgery, you qualify for ALL the bariatric surgeries.

I meet with Dr. Hong in two weeks to ask for a DS. I have hundreds of studies I'm taking with me to present my case. I am a 42 BMI virgin surgery. I can't have RNY due to NSAIDs and don't want VSG as I'm convinced I need malabsorption to get rid of my pre-diabetes and prevent diabetes in the future, but most importantly, I want the DS. I just hope I can convince Dr. Hong - but I'll be honest I'm not holding my breath. That's why my husband and I are preparing to send me to Dr. Gagner in Montreal at a cost of $18,500 - that's how much I believe the DS is the right surgery for me.

Very well documented and stated.
I'm impressed.
It's sad when it all comes down to the almighty buck.

Best of luck with your appointment, I hope you get approved. Let us know.

J

Wow Pat, you have really done your homework!  It is sad that it is all about money but I am so grateful that the RNY is covered.  I kind of wish I had been a little better informed about DS, but I don't have a high enough BMI or serious co-morbidities and as a single woman would not be able to travel and spend that kind of money on the DS.  So RNY tomorrow it is!

Good luck with Dr Hong
Julie

I don't meet the current DS criteria either (virgin surgery, BMI of about 42), but I encourage you to still seek out what you want and force the medical professionals to justify why they won't give it to you. I expect that eventually a court challenge based on the most recent research will force a change in their policy, but I don't see it happening soon.

As I'm a Prosecutor, I've thought about whether I'm the person to bring such a challenge, but I don't think the momentum is there just yet. I want to watch the results of the Ontario program closely over the next couple of years and see whether it adapts at all to the lastest findings. I have a contact at a firm that handles class actions, so I'm just keeping a close eye out.

Sorry to say it but it's just wrong time wrong place issue. DS is a  fantastic surgery, the best IMHO, and I know what I'm talking about, lol. I'm a DSer who lost it all, lololol.

A few years ago, quite a few Ontario patients had serious complications, including a few deaths, following their wls surgery. There were seruios considerations, reviews, investigations, complains and, I even heard of legal actions, but all that is unofficial, unconfirmed info, partially speculation, partially come from subjective sources  These events affected Ontario's decision to chose RNY as golden standard. In the US and Quebec DS is a very valid option and many surgeons, actually prefer this surgery for all the valid reasons.

IMHO, my very peronal opinion - no other wls option for my family. I my hubby eventually eats his way up to BMI of 35+, he's getting DS with Gagner for his birthday. lol, and screw all Ontario Golden Standards.

Well I'm glad it worked out for you Nata!  May have been the better choice, but I don't think I would have gotten my choice. 

Julie