Re: blue shield/blue cross

[Guest guest]

Heidi;

If you've already had an r-n-y, how is it possible to ever have the

DS?

I was under the impression that the pyloric valve is not left intact

during the r-n-y. Can you explain that please?

As to your insurance question: I think the problem boils down to

the CPT codes that are used.

Some surgeons are more savvy than others in giving the

insurance companies what they need in terms of CPT codes

and still getting what we need in terms of the appropriate

procedure.

My own surgeon is calling it the Distal Gastric Bypass (not the

Distal Roux-en-Y). There's actually about 16 words in the

description of the procedure.

An analogy for what they are doing would be to order a meal off a

menu by picking a-la-carte items instead of the entire

all-encompassing meal by simply one name. What ends up

seved to the table may be identical but it is ordered indiviually

and is rung up at the cash register as separate items. Every one

goes home happy, including the customer who gets what they

want.

gobo

DGB/ Dr.

July 9, 2001

[Guest guest]

Yes, revising your proximal RNY to a distal RNY makes sense.

in Seattle

----- Original Message -----

> Just wondering does blue shield/ blue cross normally cover a distal

> rny

I had an prox. rny in 99 lost 60lbs. and after 6 months

> started to gain. My diabetes is back again from the weight gain and

> meds you take to control the diabetes. I know I don't have the

> option to have a DS, due to my pouch and complexity of the surgery.

[Guest guest]

Heidi,

Given you diabetes, if your BMI is back over 35 than you should not

have any problems getting a distal RNY approved (assuming you don't

have WLS exclusions in your insurance contract).

I have been told that is theoretically possible to convert from

proximal RNY to DS, as the stomach (including pyloric valve) is not

removed in the RNY.

For those who are confused (as I was until I did a lot of study) the

RNY procedure uses the bulk of the stomach (including pyloric valve)

to carry the bile and acid. Only a small portion of the stomach

(near the esophagas) is kept as a pouch, and this is connected

proximally to the small intestine.

The key difference between a distal RNY and a BPD/DS procedure is

that in a distal RNY the stomach pouch is kept small with no pyloric

valve, and the bulk of the stomach is attached to the billio limb. In

the BPD/DS procedure about 3/4 of the stomach is compelatly removed,

and most of the rest of the stomachm (including the pyloric valve) is

in the alimentary path (food path) except for a small portion. The

billio path is formed essentially out of intestine only. The

duodenem is " switchd " from is function in the billo path to the

alimentary path (hence the name duodenal switch).

The net effect is the distal RNY will have the same malabsorpative

qualities as the BPD/DS procedure, but also have the extreme

restriction of the standard RNY procedure. Because the pyloric valve

is in the billo path (where it does no good), you will get dumping

just as in the proximal RNY procedure.

Wittgrove talks about the distal RNY procedure as having the worst

aspects of both the RNY and the DS.

So why do insurance companies approve the distal RNY and not the

BPD/DS. This will be the central core of my argument against the

insurance company - should I be denied the BPD/DS.

To convert a proximal RNY to a BPD/DS is possible and has been done,

but it is a very difficult surgery since it involves essentially

reversing the RNY procdure and then doing a BPD/DS. On the other

hand, converting a proximal RNY to a distal RNY is quite easy.

My father-in-law had this conversion and did loose an additional 100

lbs or so. Unfortunately he has regained about 40 of those pounds.

Pepsi seems to be the culprit (he drinks a lot of it!).

Hull

> Just wondering does blue shield/ blue cross normally cover a distal

> rny?? With all the ins. denial problems people are having, would

> this surgery be an option to think about, if they were to deny you

> of having a DS?. Ideally I can see where the DS is a good choice

and

> [popular. I had an prox. rny in 99 lost 60lbs. and after 6 months

> started to gain. My diabetes is back again from the weight gain

and

> meds you take to control the diabetes. I know I don't have the

> option to have a DS, due to my pouch and complexity of the

surgery.

> Emailed both Dr. Ren and Gagner who suggested a revision to a

distal

> gastric bypass. Right now I can eat pretty muchof anything and my

> pouch is not stretched, had an upper G.I.. But to continue to lose

> weight I will need the malabsorption part to help things along. I

> will evenually end up on insulin if the weight is not reduced, as

> well as all the other problems associated with diabetes. Thanks for

> your imput. Heidi

[Guest guest]

There is a fundamental anatomical and physiological error here. The

stomach has nothing to do with bile. Bile is produced in the liver

and stored in the gall bladder and exceted into the intestine.

Although it may be theoretically possible to reconstruct the stomach

and have it function and thus permit a revision from an RNY to a DS,

there are several problems that don't seem to have been overcome so

far.

First, the vagus nerve is often cut and left non functioning. This

means that the pyloric valve will most probably not work.

Second, reconstructing the stomach is a challenge. I am aware of

several requests made to surgeons to make this revision and it has

been refused each time. I would be very interested in hearing the

reposrt from any DS surgeon who had taken this on and thought it

might be successful.

The stomach produces substantially less acid following the

incapacitation the portion of vagus nerve involved in this. It is

one reason this is generally done-- to decrease acid prodiuction in

the stomach where there is no food to evoke the natural process of

pulverizing food.

One a person has an RNY there isn't much that can be done other than

to make it more or less distal. A proximal RNY revised to a distal

makes sense. Choosing a distal RNY instead of the DS make no sense

to me at all.

in Seattle

> I have been told that is theoretically possible to convert from

> proximal RNY to DS, as the stomach (including pyloric valve) is not

> removed in the RNY.

>

> For those who are confused (as I was until I did a lot of study)

the

> RNY procedure uses the bulk of the stomach (including pyloric

valve)

> to carry the bile and acid. Only a small portion of the stomach

> (near the esophagas) is kept as a pouch, and this is connected

> proximally to the small intestine.

>