Guest guest Posted June 15, 2001 Report Share Posted June 15, 2001 Tom, do you mind if I forward this to Dr. Gagner in the form of a question? I'd like to know his thoughts on this. --- tlarussa@... wrote: > Hi all: > > Here's a question based on something I read on another list. > > I was told that a lot of our docs do not measure our small intestines > before making the division between the bilio and food limbs. In > essence, this person was saying, these docs follow a one-size-fits- > all policy of making either all bilio or all food limbs the same > length, regardless of how long a patient's small intestine is. > (Apparently it can vary by several feet.) > > Supposedly, this is particularly prevelant among the docs who do the > procedure by lap. (The one noted exception is Dr. Rabkin, who > does " lap assisted " specifically so he can measure the small > intestine and take out the appendix/gall bladder.) > > So, I'm wondering: > > 1. Is this true? > > 2. Is this info disclosed to patients before surgery? > > 3. Assuming it's true, how do those of you who have been to such > docs feel about it? That is, do you feel cheated, or is the extra > convenience and comfort of the pure-lap procedure so important that > you just don't care if the surgery is tailored to your body or not? > > Tom > > > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2001 Report Share Posted June 15, 2001 I would like to add to the questions about channel lengths. When docs do measure, how do they do it? Are the intestines removed from the body cavity to measure, are they measured inside the cavity, if so how? Karla. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2001 Report Share Posted June 15, 2001 In a message dated 6/15/01 4:35:15 AM, duodenalswitch writes: << Tom, do you mind if I forward this to Dr. Gagner in the form of a question? I'd like to know his thoughts on this. --- tlarussa@... wrote: > Hi all: > > Here's a question based on something I read on another list. > > I was told that a lot of our docs do not measure our small intestines > before making the division between the bilio and food limbs. In > essence, this person was saying, these docs follow a one-size-fits- > all policy of making either all bilio or all food limbs the same > length, regardless of how long a patient's small intestine is. > (Apparently it can vary by several feet.) > > Tom: This was one of the many questions I asked Dr Gagner as a pre-op. He explained that he does NOT think it is necessary (nor does he consider adjusting channel lengths necessary). He said that, in his experience, having the 100 cm common channel and the 'formula' he works with is perfect for most people. Yeah, it's a one size fits all kind of philosophy, but one that he stands by because he views it as being successful. He says that there are more possibilities for nutritional deficiencies, etc. with less channel length (especially long term) and that something like 80 cms will not be much of a difference at all (pretty much the same thing). I know that studies have been done on Scoparino's (spelling) 50 cm but I don't know if it has be proven that other lengths in between 50 and 100 are more effective and/or do not increase malnutrition risks.... His viewpoint doesn't seem to be really popular today with many surgeons offering a specific measurement and adjustment of the common channel for each patient. But, I can understand where he doesn't want to start messing around with the 'formula' that appears to have great success.... at least in his book. I asked not only as a general question but because I have IBS/spastic colon. I thought if my common channel were slightly longer I might have less prob lems. He stressed that an adjustment really wouldn't make much difference. It will be interesting to see what he says when this question is addressed to him again. all the best, lap ds with gallbladder removal January 25, 2001 four months post-op and still feelin' fab! pre-op: 307 lbs/bmi 45 now: 250 lbs (damn plateau has broken! YEAH!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 15, 2001 Report Share Posted June 15, 2001 Hi : > Tom: This was one of the many questions I asked Dr > Gagner as a pre-op. He explained that he does NOT > think it is necessary (nor does he consider adjusting > channel lengths necessary). He said that, in his > experience, having the 100 cm common channel and the > 'formula' he works with is perfect for most people. Thanks for the info. I think I should explain further, however, since I did not mean to refer to the length of the common channel, but of the ratio in length between the " Bilio-Pancreatic Loop " and the " Digestive Loop. " (Note: I'm using the terminology as it is presented on the Duodenalswitch.com website, at this address: http://www.duodenalswitch.com/Procedure/procedure.html> ) Let me try to restate my entire question. Let's assume a common channel length of 100cm, which is just about 40 inches, I think. Now, let's assume two different patients. Patient " A " (Able) has a total small intestine length of 15 feet, or 180 inches. After allowing 40 inches for the common channel, Able has 140 inches of small intestine left to be divided. Patient " B " (Baker) has a longer small intestine, with a total length of 20 feet, or 240 inches. After allowing the same 40 inches for the common channel, Baker has 200 inches of small intestine left to be divided. My question is, if the surgeon doesn't measure the total length of the small intestine, how does he decide how long to make the bilio- pancreatic and digestive loops? If the surgeion merely eyeballs it and cuts the small intestine in the middle, then Able gets a 70 inch digestive loop, while Baker gets a 100 inch digestive loop. Thus, Baker's digestive loop is nearly 43% longer than Able's digestive loop. Or perhaps the surgeon measures up so many inches from the large intestine, thus leaving Able and Baker with equal length digestive loops? What, if any, difference does this disparity (or similarity) of digestive channel length have on food absorption? Does small intestine simply absorb X calories per inch? Or do people with longer intestines absorb a smaller number of calories per inch, thus allowing them to absorb about the same number/percentage of total calories taken in? The implicit assumption of the person from whom I acquired this question is that this disparity in digestive loop (or food channel) length has some effect on the volume of calories a patient absorbs as a post-op. My question for Dr. Gagner, (or any other expert who cares to chime in), is whether this assumption is true or not. The information I have been given suggests that it does indeed make a difference. It also suggests that some doctors simply ignore this fact in the name of expediency -- to put it quite crassly, this person says that some surgeons are simply more interested in in cramming the greatest number of surgeries into a given time frame, and the individual differences/needs of each patient be damned. Please understand, I am not taking the position that this is true. It is merely something I have read which I would like to have explained to me further, if someone of appropriate knowledge could be contacted to do so. I hope I have made my question a bit more clear now? Tom Panniculectomy, Dr. Anthone, 11/10/2000 Open DS, Dr. Anthone, 03/30/2001 11/10/2000 . . . 384 03/30/2001 . . . 360 04/19/2001 . . . 338 04/22/2001 . . . 334.5 05/03/2001 . . . 328 05/14/2001 . . . 319 05/18/2001 . . . 316 06/03/2001 . . . 301 06/15/2001 . . . 299 85 Ugly Pounds, GONE FOREVER!!!!!!!!!!!!!!!! USC DS Support Group: http://groups.yahoo.com/group/ds_usc> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 16, 2001 Report Share Posted June 16, 2001 Tom, I'm no expert but this is why Dr Hess in Bowling Green Ohio (who came up with this surgery) measures and makes the common channel to the approiate length for each individual patient. No two people are alike and so he makes sure he tailors the common channel to the length their body requires. Angel --- tlarussa@... wrote: > > > Hi : > > > > Tom: This was one of the many questions I asked > Dr > > Gagner as a pre-op. He explained that he does NOT > > > think it is necessary (nor does he consider > adjusting > > channel lengths necessary). He said that, in his > > experience, having the 100 cm common channel and > the > > 'formula' he works with is perfect for most > people. > > Thanks for the info. I think I should explain > further, however, > since I did not mean to refer to the length of the > common channel, > but of the ratio in length between the > " Bilio-Pancreatic Loop " and > the " Digestive Loop. " (Note: I'm using the > terminology as it is > presented on the Duodenalswitch.com website, at this > address: > http://www.duodenalswitch.com/Procedure/procedure.html> > ) > > Let me try to restate my entire question. > > Let's assume a common channel length of 100cm, which > is just about 40 > inches, I think. > > Now, let's assume two different patients. > > Patient " A " (Able) has a total small intestine > length of 15 feet, or > 180 inches. After allowing 40 inches for the common > channel, Able > has 140 inches of small intestine left to be > divided. > > Patient " B " (Baker) has a longer small intestine, > with a total length > of 20 feet, or 240 inches. After allowing the same > 40 inches for the > common channel, Baker has 200 inches of small > intestine left to be > divided. > > My question is, if the surgeon doesn't measure the > total length of > the small intestine, how does he decide how long to > make the bilio- > pancreatic and digestive loops? > > If the surgeion merely eyeballs it and cuts the > small intestine in > the middle, then Able gets a 70 inch digestive loop, > while Baker gets > a 100 inch digestive loop. Thus, Baker's digestive > loop is nearly > 43% longer than Able's digestive loop. Or perhaps > the surgeon > measures up so many inches from the large intestine, > thus leaving > Able and Baker with equal length digestive loops? > > What, if any, difference does this disparity (or > similarity) of > digestive channel length have on food absorption? > > Does small intestine simply absorb X calories per > inch? Or do people > with longer intestines absorb a smaller number of > calories per inch, > thus allowing them to absorb about the same > number/percentage of > total calories taken in? > > The implicit assumption of the person from whom I > acquired this > question is that this disparity in digestive loop > (or food channel) > length has some effect on the volume of calories a > patient absorbs as > a post-op. My question for Dr. Gagner, (or any > other expert who > cares to chime in), is whether this assumption is > true or not. > > The information I have been given suggests that it > does indeed make a > difference. It also suggests that some doctors > simply ignore this > fact in the name of expediency -- to put it quite > crassly, this > person says that some surgeons are simply more > interested in in > cramming the greatest number of surgeries into a > given time frame, > and the individual differences/needs of each patient > be damned. > > Please understand, I am not taking the position that > this is true. > It is merely something I have read which I would > like to have > explained to me further, if someone of appropriate > knowledge could be > contacted to do so. > > I hope I have made my question a bit more clear now? > > > Tom > > Panniculectomy, Dr. Anthone, 11/10/2000 > Open DS, Dr. Anthone, 03/30/2001 > 11/10/2000 . . . 384 > 03/30/2001 . . . 360 > 04/19/2001 . . . 338 > 04/22/2001 . . . 334.5 > 05/03/2001 . . . 328 > 05/14/2001 . . . 319 > 05/18/2001 . . . 316 > 06/03/2001 . . . 301 > 06/15/2001 . . . 299 > 85 Ugly Pounds, GONE FOREVER!!!!!!!!!!!!!!!! > USC DS Support Group: > http://groups.yahoo.com/group/ds_usc> > > > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 16, 2001 Report Share Posted June 16, 2001 Tom, my understanding is that the Mt. Sinai-trained surgeons use predetermined limb lengths. The food limb is made to 250cm, of which 100cm is common channel. The remaining intestine is used as the biliary limb, regardless of total intestinal length. Dr. Rabkin has reported total intestinal lengths ranging from around 450cm to 950cm. Let's use those extremes to illustrate the predetermined measure vs. the proportional measure: MT. SINAI METHOD: ---------------- Total length: 450cm Food/common limb: 250cm Biliary limb: 200cm Total length: 950cm Food/common limb: 250cm Biliary limb: 700cm The biliary limb on these two patients are markedly different. What does that mean in real terms for the patient? This is the question to ask the docs. It seems that with a very short biliary limb, the digestive juices could reach the common channel in a much LESS dilute state to mix with the food. Could this mean more absorption? Smaller Less weight loss? More GI distress (diarrhea, gas, etc.)? By contrast, what if the biliary limb is exceedingly long? Could this mean that the digestive juices reach the common channel in a MORE dilute state that could reduce absorption and impact the rate of weight loss? More questions for the doc. If we compare the numbers above to the porportional method that keeps 60% biliary/40% food limb, the above-referenced patients get these lengths: 60/40 PROPORTIONAL METHOD: ------------------------- Total length: 450cm Food/common limb: 180cm Biliary limb: 270cm Total length: 950cm Food/common limb: 380cm Biliary limb: 570cm As you can see, this method yields limb lengths that are substantially different. The docs who use this method say that the proportional lengths give patients a similar expectation of results regardless of total intestinal length. Scopinaro used predetermined limb lengths for many of his patients for years before ultimately switching to a more individualized technique. This is mentioned in the DS website's Scopinaro article, specially in the CONCLUSION paragraphs: http://www.duodenalswitch.com/Procedure/1998BPD/1998bpd.html " The studies carried out in the last years have greatly enlarged our knowledge on the physiology of BPD, and this has enabled us to make a better use of the procedure, thus improving considerably its cost/benefit ratio. Biliopancreatic diversion is unanimously considered the most effective procedure for the surgical treatment of obesity. Like any other powerful weapon, it can be very dangerous if used improperly. Twenty years of careful investigation and clinical experience made it, in our hands, also a very safe remedy. It was a very long " learning curve " , consisting essentially of adapting more and more the operation to the patient's individual characteristics, so that the best weight loss results be reserved to the subjects who are at low risk of nutritional complications, accepting a smaller weight reduction in the less compliant patients in order to minimize the potential nutritional problems. Our criteria of assessment are based on our personal experience with our cohort of patients, and therefore they are largely subjective; on the other hand, to try to standardize them would be of little use when dealing with a different population. All surgeons willing to obtain the best results with BPD should follow our example, finding the criteria to be used to adapt the operation to the patients in their population according to their individual characteristics. The ductility of the procedure is such that, theoretically, for each individual patient the best combination of stomach volume and intestinal lengths could be identified. Obviously, the adaptation must be based on the profound knowledge of all the mechanisms of action of BPD, which are today sufficiently known to allow any good will surgeon to obtain the best results at the lowest price in all patients. " Rabkin also used predetermined limb lengths early in his DS series before switching to proportional. This is mentioned in Rabkin's published article on the Pacific Surgery website: http://www.pacificsurgery.com " In the initial patients, the common tract length was 75 cm, and enteric limb length was 200 cm. In 1996, the common tract length was extended to a minimum of 100 cm, and the Roux-en-Y segmentation was changed from a fixed to a proportionate basis utilizing the proximal 60% of small bowel as the biliary limb. " Finally, Dr. Rabkin address this question in an email to me awhile back. I'll copy it here: RE: Limb Length & Common Channel Length Dear , Thanks for forwarding the questions regarding why DS surgeons measure intestinal limb length. I believe it is quite important to measure the limb lengths in a reproducible manner, and I find that I when I do re-measure at various times (such as when repairing a hernia, etc.) the lengths as a rule prove to be consistent with what was noted in the original operative record. Standard lengths for the common limb, enteric limb and biliary limb that I use are based on my own experience and on the shared experience of Dr. Hess in Ohio and the group in Quebec City, Canada and were developed after each of us had carefully followed up of hundreds of our own patients over many years. The other groups evaluated the best limb lengths to use independently. That each of the three programs arrived at and presently use similar values implies to me that the current guidelines for limb length are not arbitrary. If such measurements had not been made and recorded there would have been no way to tailor the DS procedure to best accommodate the metabolic requirements of individual patients. The " 100 cm " and " 150 cm " measurements that Bridget quotes didn't materialize out of thin air! By way of background, my experience in Laparoscopic Surgery goes back to 1988/1989 when I (and subsequently other surgeons also) actually had to purchase the laparoscopic equipment personally and develop the laparoscopic cholecystectomy technique. This was some years before many hospitals and, for that matter, the majority of surgeons, got on the bandwagon. In 1989 I performed the first Laparoscopic Cholecystectomy north of Los Angeles and I continue to be involved with advanced laparoscopic surgery including endocrine and esophageal procedures. My private practice was opened in 1977 and bariatric surgery became an area of interest to me in 1979. I performed VBG, BPD and variations of RGB, prior to standardizing on the DS procedure in 1993. (Very infrequently, when indicated, we do offer RGB.) The LapDS technique evolved directly from more than 20 years of personal experience in bariatric surgery, including 8 years of experience with the DS as my primary procedure. I developed the Laparoscopic Duodenal Switch Procedure in collaboration with Gregg H. Jossart, MD, Director of the Minimally Invasive Surgery Program at California Pacific Medical Center since 1999. From the very beginning, the procedure specific laparoscopic techniques and the technical refinements which we incorporate on an ongoing basis were developed in our San Francisco facility, and not patterned from another program. Our LapDS series, which I believe is the largest, includes approximately 150 LapDS patients. I operate as the primary surgeon for all bariatric procedures, including the LapDS. Recent statistics are available on our website: www.pacificsurgery.com. I hope that this helps to answer the questions that were raised. Sincerely, A. Rabkin, MD, FACS -----End of Message----- Hope this helps! M. --- in Valrico, FL, age 38 Starting weight 299, now 156 Starting BMI 49.7, now 26.0 Lap DGB/DS by Dr. Rabkin 10-19-99 http://www.duodenalswitch.com Direct replies: mailto:melanie@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 16, 2001 Report Share Posted June 16, 2001 : WOW! Thanks for the awesome and comprehensive reply! YOU ROCK, GIRLFRIEND! (: Tom > Tom, my understanding is that the Mt. Sinai-trained surgeons use > predetermined limb lengths. The food limb is made to 250cm, of which > 100cm is common channel. The remaining intestine is used as the > biliary limb, regardless of total intestinal length. > > Dr. Rabkin has reported total intestinal lengths ranging from around > 450cm to 950cm. Let's use those extremes to illustrate the > predetermined measure vs. the proportional measure: > > MT. SINAI METHOD: > ---------------- > Total length: 450cm > Food/common limb: 250cm > Biliary limb: 200cm > > Total length: 950cm > Food/common limb: 250cm > Biliary limb: 700cm > > The biliary limb on these two patients are markedly different. What > does that mean in real terms for the patient? This is the question to > ask the docs. It seems that with a very short biliary limb, the > digestive juices could reach the common channel in a much LESS dilute > state to mix with the food. Could this mean more absorption? Smaller > Less weight loss? More GI distress (diarrhea, gas, etc.)? > > By contrast, what if the biliary limb is exceedingly long? Could this > mean that the digestive juices reach the common channel in a MORE > dilute state that could reduce absorption and impact the rate of > weight loss? More questions for the doc. > > If we compare the numbers above to the porportional method that keeps > 60% biliary/40% food limb, the above-referenced patients get these > lengths: > > 60/40 PROPORTIONAL METHOD: > ------------------------- > Total length: 450cm > Food/common limb: 180cm > Biliary limb: 270cm > > Total length: 950cm > Food/common limb: 380cm > Biliary limb: 570cm > > As you can see, this method yields limb lengths that are > substantially different. The docs who use this method say that the > proportional lengths give patients a similar expectation of results > regardless of total intestinal length. > > Scopinaro used predetermined limb lengths for many of his patients > for years before ultimately switching to a more individualized > technique. This is mentioned in the DS website's Scopinaro article, > specially in the CONCLUSION paragraphs: > > http://www.duodenalswitch.com/Procedure/1998BPD/1998bpd.html > > " The studies carried out in the last years have greatly enlarged > our knowledge on the physiology of BPD, and this has enabled us > to make a better use of the procedure, thus improving considerably > its cost/benefit ratio. > > Biliopancreatic diversion is unanimously considered the most > effective procedure for the surgical treatment of obesity. Like > any other powerful weapon, it can be very dangerous if used > improperly. Twenty years of careful investigation and clinical > experience made it, in our hands, also a very safe remedy. It was > a very long " learning curve " , consisting essentially of adapting > more and more the operation to the patient's individual > characteristics, so that the best weight loss results be reserved > to the subjects who are at low risk of nutritional complications, > accepting a smaller weight reduction in the less compliant patients > in order to minimize the potential nutritional problems. Our > criteria of assessment are based on our personal experience with > our cohort of patients, and therefore they are largely subjective; > on the other hand, to try to standardize them would be of little > use when dealing with a different population. All surgeons willing > to obtain the best results with BPD should follow our example, > finding the criteria to be used to adapt the operation to the > patients in their population according to their individual > characteristics. The ductility of the procedure is such that, > theoretically, for each individual patient the best combination of > stomach volume and intestinal lengths could be identified. > Obviously, the adaptation must be based on the profound knowledge > of all the mechanisms of action of BPD, which are today > sufficiently known to allow any good will surgeon to obtain the > best results at the lowest price in all patients. " > > Rabkin also used predetermined limb lengths early in his DS series > before switching to proportional. This is mentioned in Rabkin's > published article on the Pacific Surgery website: > > http://www.pacificsurgery.com > > " In the initial patients, the common tract length was 75 cm, and > enteric limb length was 200 cm. In 1996, the common tract length > was extended to a minimum of 100 cm, and the Roux-en-Y segmentation > was changed from a fixed to a proportionate basis utilizing the > proximal 60% of small bowel as the biliary limb. " > > Finally, Dr. Rabkin address this question in an email to me awhile > back. I'll copy it here: > > RE: Limb Length & Common Channel Length > > Dear , > > Thanks for forwarding the questions regarding why DS surgeons measure > intestinal limb length. I believe it is quite important to measure > the limb lengths in a reproducible manner, and I find that I when I > do re-measure at various times (such as when repairing a hernia, > etc.) the lengths as a rule prove to be consistent with what was > noted in the original operative record. > > Standard lengths for the common limb, enteric limb and biliary limb > that I use are based on my own experience and on the shared > experience of Dr. Hess in Ohio and the group in Quebec City, Canada > and were developed after each of us had carefully followed up of > hundreds of our own patients over many years. The other groups > evaluated the best limb lengths to use independently. That each of > the three programs arrived at and presently use similar values > implies to me that the current guidelines for limb length are not > arbitrary. If such measurements had not been made and recorded > there would have been no way to tailor the DS procedure to best > accommodate the metabolic requirements of individual patients. > The " 100 cm " and " 150 cm " measurements that Bridget quotes didn't > materialize out of thin air! > > By way of background, my experience in Laparoscopic Surgery goes > back to 1988/1989 when I (and subsequently other surgeons also) > actually had to purchase the laparoscopic equipment personally and > develop the laparoscopic cholecystectomy technique. This was some > years before many hospitals and, for that matter, the majority of > surgeons, got on the bandwagon. In 1989 I performed the first > Laparoscopic Cholecystectomy north of Los Angeles and I continue > to be involved with advanced laparoscopic surgery including > endocrine and esophageal procedures. > > My private practice was opened in 1977 and bariatric surgery became > an area of interest to me in 1979. I performed VBG, BPD and > variations of RGB, prior to standardizing on the DS procedure in > 1993. (Very infrequently, when indicated, we do offer RGB.) The > LapDS technique evolved directly from more than 20 years of personal > experience in bariatric surgery, including 8 years of experience > with the DS as my primary procedure. I developed the Laparoscopic > Duodenal Switch Procedure in collaboration with Gregg H. Jossart, > MD, Director of the Minimally Invasive Surgery Program at California > Pacific Medical Center since 1999. > > From the very beginning, the procedure specific laparoscopic > techniques and the technical refinements which we incorporate on an > ongoing basis were developed in our San Francisco facility, and not > patterned from another program. Our LapDS series, which I believe is > the largest, includes approximately 150 LapDS patients. I operate as > the primary surgeon for all bariatric procedures, including the > LapDS. Recent statistics are available on our website: > www.pacificsurgery.com. > > I hope that this helps to answer the questions that were raised. > > Sincerely, > > A. Rabkin, MD, FACS > > -----End of Message----- > > > Hope this helps! > > M. > > --- > in Valrico, FL, age 38 > Starting weight 299, now 156 > Starting BMI 49.7, now 26.0 > Lap DGB/DS by Dr. Rabkin 10-19-99 > http://www.duodenalswitch.com > > Direct replies: mailto:melanie@t... 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