Are There Different Ways of Doing the VSG?

I was talking to a former client of mine today and he informed me that he had VSG a couple of months or so ago by a local surgeon (Wade Barker), one of the best, if not the most popular, WLS sugeons in my area ..   

 We were talking about amount of EWL after surgery with his VSG vs. my DS, and my client pointed out that he has already lost over 60 lbs.,, and is hoping to lose over 100 more.   He told me he is confident he will lose the rest of the weight if he continues to be as restricted in the amount of food he can eat, as he currently is by his sleeve to date.  I told him I hope so, but I have noticed in the last few months that I can now eat approximately twice the amount of food at one setting that I did @ abut two years out, and in the past few months have actually regained 25 lbs of my EWL.     I know that my sleeve has doubled in capacity of late for sure, because of a dining pracitce of mine at a certain Italian restaurant that I like to eat at:.  After my surgery and up until about 6 months ago, I could BARELY finish one of the pair of large veal parmigiana steaks they serve as an entree at the establishment, and usually took the other one home in a doggie bag,   .   However, when I ate there again for NYs I was stunned to find I easily downed BOTH steaks (along with 1/2 an order of "Italian (sausage & cheese) nachos", some salad, 1/2 a bowl of minestrone soup, some Italian bread and even a few bites of speghetti noodles.  

  My client responded to that news by pointing out that his surgeon supposedly does his VSG in a particular way, in which it sounds like he cuts away the front portion of the stomach and then "wraps" the skin back under and up the back, where the edges are then stapled together.       Supposedly, this particular configuration makes it much more difficult for the sleeve to "expand" in response to being filled with food, vs. other ways of designing it.  The client says Dr. Barker told him that the "weak point" of the stomach (which I guess means where the flesh is thinnest?)  is  toward the front and it is therefore in that area where it is most likely to stretch out when filled up.   He fashions the sleeve in such a manner to supposedly minimize the ability of the sleeve to change size over time.  

  Has anyone else heard anything like this?     I guess I have always assumed that their was only one way to do the VSG, being a rather simple procedure it would seem.  I wonder now, whether my surgeon didn't follow that procedure when doing the sleeve part of my DS and, if not, whether my VSG could be "re-done" in that configuration to keep it from expanding again.  This would amount to something akin to a "Stomaphyx for VSG".   

Well, while we look at the stretching of the sleeve as a good thing (at least for me so I could EAT my protein), it's not so good to someone who is depending on only it to get what they need.  It doesn't surprise me that they are working on ways to maintain that restriction longer.

As for eating two pieces of veal -- as long as you made more room for veal than you did for nachos and pasta, I don't see a problem with it.

The way I understand it and I am not a DR. If they are doing a DS or a two part DS they leave the stomach a little bigger knowing you'll need more food to get more nutrients and because of the malabsorption factor.

I have not heard if the "special" techinique you talked about

Paul, you are a couple of months further out than I am. I have posted replies to you throughout the years (eventhough you are an idiot priving into my private life than just ask questions pertaining to the DS and ignored you for that). I think replies that have been posted and given to you throughout the years goes in one ear and out the other for you, unless it is filled with drama or contraversies, in which I ignore.

I had a few friends on the Texas board private message me about you asking for revision surgeons in Texas. I didn't even bothered to reply to your thread because you made no sense. One reason, you know very well, if you have problems with your DS as you are saying and regaining weight, you should contact Dr. Stewart office for a consult that is not far from Dallas or seek a DS surgeon that knows about the DS and how it works and you KNOW is a DS specialist/expert and most important a DS surgeon or make an appt with a gastroenterologist who is familar and has knowledge of the DS. Asking the mainly RNY postop members that you know are on that board and have no knowledge of the DS or the physiology of it, to seek recommendation or answers from them when you are a DSer, seems illogical. As you can see they gave you RNY revision surgeons and for you to even want info on the 2 RNY revision surgeons you posted about, who have no experience or been proctored to know about the DS is absurb. As I said, replying to your thread you posted there would have been a waste of time because you are far out enough to know the answers, if you read the threads here on the DS board to know what you got to do if you are post seeking support, advice, reference to the DS or surgeons who do revised the DS.

Getting your DS to be revised is not easy to get, since, there are specific medical testings that needs to be done to rule out certain conditions and factors before the DS surgeon determines you need one. This includes a malabsorption controlled study, barium scan MRI and even evaluate your eating habits for 6 months in which you must follow and log your intake to see what is resulting in your regain. Save your money and post your food intake here and have the other DSers help you out and guide you with recommendations and from reading what you need to do to help continue your weight loss. You seriously do not have any DS complications.

The barium MRI test is done to check your VSG and DS plumbing and functionality. Stalls are very normal and a part of postop life. Regain for a DS is a direct cause by excessive carb intake and most DSer know this. DSers, and especially you know very well calories and fat and even some complex carbs will not cause tremendous weight gain. Have you input your food intake to any online sites to check your intake of carbs, especially simple carbs and especially from beverages and food that are not sugar free? If not, I recommend you should start there and also post here to the DS board to seek support, guidance and advice to help you with your DS lifestyle that you do not understand (even if you are 3 years out and causing you issues and not failure with your DS). A DSer can eat and alot, but it depends on what food or meal you are intaking and you should already know that protein is prevalent for us, then complex carbs and if room carbs. If you are still not full, eat more protein rich food. Leave the simple carbs to a minimum. Start making a spreadsheet like menu to what you are eating or input your intake for the day to site as fitday.com, dailyplate.com or you can also purchase a more personalize software. Be aware and get control to what you are eating and see how much you are intaking daily in regards to your complex and simple carbs, before concluding that your DS has failed you and especially your VSG portion. The switch itself is very powerful. If anything, have a malabsorption control test study done to see what your malabsorption level is. Not every DSer has the same malabsorption level. It is very close, but each of us do slightly differ. 


I know that my sleeve has doubled in capacity of late for sure, because of a dining pracitce of mine at a certain Italian restaurant that I like to eat at:. 

You do know most Italian based food are high carbs and many of the dishes uses breading, white flour, pasta, sugar and those Italian breads and dessert are high carb, especially simple carbs. Since you are STILL in what is considered the weight loss phase, even if you are almost 3 years out, take control of the amount of your carb intake and see what value you are absorbing daily. Calories and fat do not count or have to worry about. If you eat 4000 calories a day and that is alot to eat, it comes out to about 2000 calories a day for you due to you malabsorption courtesy of the DS intestinal bypass portion. Complex carbs are malabsorb on average 40%. Simple carbs does all stay within you (absorb at 100%), so keep that as low as possible and varies from person to person. Complex carbs are needed to stay healthy and never should go below 35gms. Healthy amount of complex carbs is 100-150gms of complex carbs. This means control your carb intake until you hit your personal weight goal, then add to help maintain your weight.

My personal opinion would be, for you to not visit these Italian restaurant for a month and see how that goes or at least not eat or avoid food that has breading, pasta, sugary and of course pushing away the bread, desserts and regular drinks and juice. By order of elimination of such things, you can determine where you stand with your weight and if there is any changes after a month. Also, lay off food that are known as high carb or high in simple carbs for a month.  Don't know which food is high carb, you are knowledgeable to google the nutritional values.


My client responded to that news by pointing out that his surgeon supposedly does his VSG in a particular way, in which it sounds like he cuts away the front portion of the stomach and then "wraps" the skin back under and up the back, where the edges are then stapled together.       Supposedly, this particular configuration makes it much more difficult for the sleeve to "expand" in response to being filled with food, vs. other ways of designing it.  The client says Dr. Barker told him that the "weak point" of the stomach (which I guess means where the flesh is thinnest?)  is  toward the front and it is therefore in that area where it is most likely to stretch out when filled up.   He fashions the sleeve in such a manner to supposedly minimize the ability of the sleeve to change size over time.

Has anyone else heard anything like this?    

I seriously recommend you contact Dr. Stewart and direct your concerns regarding this to see what he says or email Dr. Ganger or another DS surgeon you feel most comfortable to see what they have to say about it. Dr. Barker, although and excellent RNY surgeon and just started doing VSG recently as many RNY surgeons are jumping the bandwagon for this, does not compare to a any DS surgeons who has done the DS and is very familar with the VSG in relation to the DS configuration or even a VSG stand alone with more years and patient case in experience and expertise.


I wonder now, whether my surgeon didn't follow that procedure when doing the sleeve part of my DS and, if not, whether my VSG could be "re-done" in that configuration to keep it from expanding again. 

If you don't know what your surgeon performed on you, I recommend you contact him (which show you haven't) and ask him. Since you are questioning your surgeon and how he configured the VSG portion on you, I think you should also request a copy of your surgical report.

          I haven't seen you around lately, but thank goodness you are back now!


Paul -- focus on what she has told you, not her beautiful picture, but the content of her advice.  She isn't the first, nor I'm sure the last, that has spent a lot of time attempting to help you with your on going issues.  Maybe it is time you heed this advice and attempt to help yourself?

Sounds like a combination of a typical VSG and a Nissen Fundoplication to me. I have heard that there are some surgeons who are experimenting with VSG, especially to prevent or eliminate GERD. The Nissen has been known to stop the stretching process in normal stomachs without a VSG, so I'm not surprised that a few surgeons are using it as a stretch preventative in VSG's, although from the surgeons I've corresponded with, the patients still experience stretching, just not as much.

There are also some surgeons who are using different techniques in how they perform the VSG to try to prevent possible nerve issues and hopefully prevent duodenal reflux and over production of acid in the lower stomach and duodenum which can lead to Barrett's esophagus in a very small fraction of VSG (and DS) patients.

Just as an aside, there are many surgeons who have been trained in VSG (it's pretty darn simple as far as bariatric procedures go), but who have been tweaking theirs over time to best meet the needs of their patients. Some of them talk about it to other surgeons, and some don't. They don't usually talk to their patients about it though. Reading the white papers that some of these surgeons are putting out and hearing them speak is pretty interesting.

Paul, it's also unlikely that any surgeon could reconfigure your sleeve stomach in this hybrid manner. more of the stomach is needed, and in different areas than you now possess. It's the same reason why surgeons have their hands tied when a VSG or DS patients ends up with severe GERD - because the surgeon is unable to perform a Nissen once the VSG has been done.. just not enough of the fundus to do the job. Sorry, dude.

Also, as Val alluded to, regain in DS patients is most often and largely due to consumption of carbs. If you are eating veal parmesean the issue isn't the amount of veal, but the amount of breading that the veal has been fried or baked in. I had chicken parmesean last night and realized that I had more carbs in that 5oz chunk of chicken than I normally eat in an entire day! So, perhaps the issue for you is that you were in carb frenzy mode with the breading, nachos, minestrone soup (has pasta in it!) spaghetti and bread, and not really because your stomach is all that huge.. although that does seem like an awful lot to be eating at one sitting. And it IS possible to stretch the stomach out quite a lot, especially if you are chronically overeating.

 Wow  .  very informative, Ocean ..    And yes, I was wondering if the Nissen was akin to what this surgeon was doing during his VSGs ...  

 And you're right on about the carbs I guess and my bad habit with them      ..   Dang, if only they could come up with SOMETHING to cause a malabsorp of those little demons as well ..   then we would have THE "perfect WLS", sounds like  .        Until then, it's up to us .. 


  btw, congrats on reaching "Twoderland" ..   

Thank you, Paul.

Not sure carb malabsorption would be a good thing. Seeing as how the brain requires a certain number of carbs in order to work (carbs turn into specific kinds of sugar and fat molecules in the body which the brain uses to chemically pass information and to sheath the nerves with (one of the ingredients of myelin).

As much as I love carbs, too, and I have had NONE of the typical issues DS'ers have with them, it's pretty frightening thought to consider what could happen if someone wasn't compliant with a carb malabsorptive procedure. Coma, brain wasting and self-induced MS doesn't sound pleasant to me, someone who's already experienced widespread neuron death.

Have you considered honestly tracking your food on fitday or sparkpeople or dailyplate? Maybe joining OA or even getting some therapy to deal with your intense carb cravings? I found therapy to be hugely helpful and reduced a big chunk of what was making me "hungry" as well as the desire to put food in my mouth I knew wasn't a wise choice for me. Just a thought.

I wish you luck, Paul.

I have thought about OA ...  Another member just posted about her great experience with them, in another thread earlier today on OH ..  I have always been somewhat skeptical of how effective OA really was in the past, as eating is something we all need to do to survive, unlike taking drugs, alcohol, etc.     However, from what the member posted it seems like a lot of OA's tenets (e.g. "eating some sugar leads to eating more sugar") would be equally applicable and of benefit to post-ops, including DSers ..       Thanks for the suggestion .. !

You may want to give OA a shot, Paul. I did the OA program back in the mid-'90's and didn't do badly, but I really wasn't ready for the changes. My therapist and I have worked on much of the same stuff in session and I've done really well since I was mentally in a place to accept the input.

If you find the group atmosphere doesn't work for you, then try one on one therapy. A good therapist is worth more than his/her weight in gold! *smile*