Revise from sleeve only to RNY or Loop DS?

on 3/3/18 4:11 pm

For those of you who are revising to one or the other or have done so, what is/was your reasoning? I'm set up for a Loop DS (NO COMMENTS ABOUT "REAL"DSs PLEASE!) but find myself wondering if I should revise to a RNY. Thoughts/experiences? Thanks!

Donna L.
on 3/3/18 10:19 pm - Chicago, IL
Revision on 02/19/18

Well. It depends on a lot of factors. The new modification of the DS has promise and is not a bad alternative at all. Obesity is just a symptom of hormonal dysregulation, though, and that dysregulation is driven by behavior. People will get in internet battles over what surgery is better than which, but at the end of the day it's 1) making sure that behavior is controlled first and 2) controlling the body's hormonal dysregulation that sustains obesity. The former isn't really helped by surgery much, and the latter can be done with diet, fasting, or surgery, though any bypass procedure (RNY, loop, DS, etc) will have a better shot at ameliorating it and reversing insulin resistance.

This is because weight loss is caused after intestinal bypasses in part by malabsorption (duh), but also it is due to changes that any intestinal bypass causes in the cells of the body. RNY, DS, and the SADI/SIPS/loop/etc all cause profound alterations in hormone expression and how we react biochemically to food. They also alter the gut flora in ways that restrictive procedures do not. You have what are called enteroendocrine cells in the small intestine, and these get drastically changed. Even placing a physical barrier in the gut without bypassing can cause transformations in this regard.

I have friends in the ketogenic diet community who get like 60-80% of their total calories from fat, for instance. One friend has lost 400 pounds and kept it off without WLS - rare, but it happens. Thing is that fat malabsorption does not necessarily equal more weight loss, and the RNY has far less fat malabsorption than the SADI. Having the correct hormone balance in the body, having reduced insulin resistance, and having reduced consumption is the key formula.

Don't get me wrong... malabsorption helps, sure, but it does not do all the heavy lifting, necessarily. I've worked with DS clients who've regained 100+ (with Hess DS procedures from reputable surgeons) and I've worked with sleevers that have kept hundreds of pounds off after several years. A lot goes into the success of surgeries, and it's not just surgery choice. The DS or SADI/etc does provide the best insulation against behavior, however it comes at a price for eternal vigilance, and I am not sure the SADI/SIPS will have lower vitamin protocols long term. Either you pay attention to supplements and labs or you pay attention to what you eat to more carefully regulate hormones. Neither surgery lets you off easy, which is in part why I came to terms with the longer RNY I have, actually.

I'd say it comes down to the reason for revision. Either option can work well for weight loss - there is a reason the gastric bypass was very common, and that's because the majority of people who do get it lose and keep off a good chunk of their EWL%.

If you are revising due to GERD, the chances are higher it will be resolved with an RNY. You cannot develop bile reflux as easily with an RNY or DS, but with the SADI/SIPS you can, though this is quite rare.

You will have to eat less for some time with an RNY vs. a sleeve, however eventually meal size should be about the same, actually (a cup give or take). With either the SADI or RNY you'd still be prudent in following a low-carb diet regardless of procedure.

I do think it's true you can eat more with a DS or SADI than the RNY, however that's also not necessarily a good thing. In my case, I have severely disordered eating, and some foods will always be verboten, malabsorption or not. I also approach food from the perspective that surgery should not correct behavior. If I tend to overeat I should address why that is the case rather than getting surgery to accommodate my overeating. Of course, most WLS peeps do not have eating disorders....that is just my unique need and perspective.

I would write down what you want to get out of a revision and think about it. What are your six month goals? Year goals? Five year goals? What will an RNY do for you the SADI won't and vice-versa? What is your ultimate aim with revision - what is it correcting or fixing?

One caveat with the SIPS/SADI which I am sure you have heard is that there is no diagnostic code for it. Be sure to address with the surgeon whether insurance will cover complications after. Be informed and aware about the pitfalls of both procedures, and make an informed choice.

Not sure if this is helpful, however anyone is always welcome to ask me for any research they might wish. I have many sources for all the surgeries. Don't take my word for it or anyone else's word - determine what your needs are first, and then be meticulous in examining each option to decide for yourself.

I follow a ketogenic diet post-op. I also have a diagnosis of binge eating disorder. Feel free to ask me about either!

It is not that we have so little time but that we lose so much...the life we receive is not short but we make it so; we are not ill provided but use what we have wastefully. -- Seneca, On the Shortness of Life

on 3/4/18 5:50 am

Wow, how great to have a scientist on these boards! Thank you for the terrific post.

I trust my surgeon 99% and she's recommending the loop ds. I've read about some specific complications (found, I believe with "regular DS" subjects) that would be unacceptable to me if not treatable, e.g., frequent nausea, body odor, frequent, soft smelly poos and flatulance. Also, she's done hundreds of RNYs and has only been doing the loop for several years. She has her reasons re: why the SIPS/loop is superior to the "regular" ds and I believe her.

Donna L.
on 3/4/18 12:43 pm - Chicago, IL
Revision on 02/19/18

It sounds like you have a good relationship with your surgeon which is a wonderful thing :)

I'm not a scientist - my graduate degree is in clinical psychology, however I was in biochemistry before I changed my major. I also have a medical background so I'm accustomed that as well. I research everything because I prefer to be personally aware of why things work rather than just outcomes. Outcomes are desirable if positive, however they are not the only component, or even the most important necessarily, when evaluating surgical procedures. It's not as easy as just seeing what surgery absorbs more or less, or which surgery has the most/least weight loss. That's a gross simplification of WLS that doesn't do any procedure justice.

It really depends what "superior" and "the best" means. Weight loss isn't just about caloric deficit. I don't think the newer surgery is the same as a DS. Clinically, most people with a DS tend to tolerate it well from what I've seen, however you cannot predict how your own personal anatomy will react. Having said that, from what I have read and the many surgeons and patients I've conversed with, the SADI/SIPS is nearly equivalent in terms of results. Maybe there's a 5-10% variation at most depending on studies. The 10-year data for it is promising. And, that's the way of surgery and science in general - procedures evolve and new ones are developed.

I've seen people be successful with all surgeries. There are even people with sleeves on ketogenic/zero carb diets that don't calorie count and maintain close to 90% EWL. There are people even without weight loss surgery who do too that were 300, 400, 500 pounds.

What really matters is 1) choosing a surgery that you personally can live with - if you can't live with/dislike the "best" surgery that will do you zero good in the long run, 2) examining behavior and habit and the reasons we become obese and making sure they are addressed.

I follow a ketogenic diet post-op. I also have a diagnosis of binge eating disorder. Feel free to ask me about either!

It is not that we have so little time but that we lose so much...the life we receive is not short but we make it so; we are not ill provided but use what we have wastefully. -- Seneca, On the Shortness of Life