Re: Average loss for proximals vs distals (was hungry, etc)

[Guest guest]

The surgeons at http://www.sabariatric.com, who do only proximal

procedures, consider a patient who gets and maintains weight loss of 50%

excess weight for 5 years to have a successful result.

The difference between proximaland distal lies in the lengths into which

the small intestine is resectioned during the surgery. The intestine is

divided into three functionally different pieces. One piece is attached

to the stoma on the gastric pouch. This is called the alimentary limb.

Just food passes through this section of the intestine. A second piece,

which contains the duodenum and upper jejunum, connects the stomach,

liver, gallbladder and pancreas into the intestine. Digestive juices

flow through this section. The stomach section of the intestine is

joined with the alimentary section to form a " Y " shape connection. The

third section is the common channel. This is the part of the intestine

below the " Y " junction through which both food and digestive juices

flow. It is here that nourishment is digested and absorbed. The

proximal RNY has the shortest alimentary limb and longest common

channel, hence the greatest nourishment absorption. The distal has a

much longer alimentary limb and much shorter common channel and markedly

less nourishment absorption. The practical effect of this difference is

that an individual with a proximal gastric bypass will absorb more of

the nourishment that passed through the common channel than will an

individual with distal short common channel. You can see drawings of

the difference between the operations in the Bariatric Surgical

Procedures section at http://www.bariatricsupplementsystem.com

This is the abstract of a study recently published on the effects of

lengthening the alimentary limb and shortening the common channel:

" Obes Surg 2002 Aug;12(4):540-5

The effect of Roux limb lengths on outcome after Roux-en-Y gastric

bypass: a prospective, randomized clinical trial.

Choban PS, Flancbaum L. Bariatric Treatment Center of Ohio, Ohio State

University, Columbus, OH, USA.

BACKGROUND: The effect of limb-length on weight loss after Roux-en-Y

gastric bypass (RYGBP) is controversial; hence, the optimal limb-lengths

have not been determined. This study evaluated the effect of different

limb-lengths on weight loss after RYGBP. METHODS: The study was a

prospective randomized clinical trial in which patients undergoing RYGBP

(110 F, 24 M; mean age 39.7) were randomized as follows: BMI < or = 50

(N = 69): A-75 cm (N = 35) vs B-150 cm alimentary limb (N = 34) and

C-150 cm (N = 33) vs D-250 cm alimentary limb (N = 31). All other

aspects of the operation were identical. Patients were followed at 2

weeks, 6 weeks, 6 months, 12 months, 18 months, 24 months and yearly

thereafter. RESULTS: There were no significant differences in age, sex,

race, initial BMI, or excess weight between patients assigned to groups

A vs B and C vs D. Postoperative nutritional intake was also similar

between groups. Within each weight category, there were no differences

in mean weight loss, change in BMI, and % excess weight lost (EWL) over

time. When the number of patients achieving 50% EWL was evaluated, there

was no difference between groups with a BMI < or = 50 kg/m2; however,

among patients with a BMI > 50 kg/m2, a significantly greater percentage

of those having a 250-cm limb achieved > 50% EWL at 18 months

postoperatively. This difference was lost at 24 and 36 months, possibly

due to the small sample size. CONCLUSIONS: In patients with a BMI < or =

50, there appears to be no advantage to longer limb-lengths. In patients

with BMI > 50, however, these data suggest that longer alimentary

limb-lengths may be associated with a higher percent of patients

achieving > 50% EWL. Longer follow-up studies of the effects of

limb-length on success of RYGBP are indicated. "

The study found that the short limb (proximal) procedure was just as

successful at achieving excess weight loss as the long limb (distal)

procedure if the patient had a Body Mass Index (BMI) of under 50 at the

time of the operation. If also found that those with a BMI greater than

50 had a more rapid excess weight loss during the first 18 months with

the long limb procedure, but that the extra weight loss evened out over

the 24-36 month time frame. The study suggests that in the long run the

distal procedure probably does not achieve any greater excess weight

loss than the proximal procedure. There were not enough patients to

justify this as a firm conclusion though.

This is what the Alvarado Clinic, the group who did Carnie 's

surgery has to say about the distal RNY, http://www.gastricbypass.com/

" Distal Gastric Bypass

" This procedure is offered by some, as a means of avoiding late weight

gain which may follow the restrictive operations. We prefer to perform

the restrictive operation to a higher standard, and to emphasize the

importance of appropriate eating afterward.

" The Gastric Bypass operation can be modified, to alter absorption of

food, be moving the Y-connection downstream ( " distally " ), effectively

shortening the bowel available for absorption of food. The weight loss

effect is then a combination of the very small stomach, which limits

intake of food, with malabsorption of the nutrients which are eaten,

reducing caloric intake even further. Patients have increased

frequency of bowel movements and increased fat in their stools (bowel

movements). The odor of bowel gas is very strong, which can cause

social problems or embarrassment. Calcium absorption may be impaired,

as well as absorption of vitamins, particularly those which are soluble

in fat (Vitamins A, D, and E). Vitamin supplements must be used daily,

and failure to follow the prescribed diet and supplement regimen can

lead to serious nutritional problems in a small percentage of patients.

We. and others, have noted an increased incidence of ulcers

post-operatively, in patients having this procedure.

" We have performed approximately 50 of these operations, as the primary

procedure, and have generally been disappointed in the results. Our

experience is that patients do not experience the feeling of

satisfaction with food, which is a prominent effect of the standard

Gastric Bypass, and that the risks of malnutritional complications is

significantly increased. Since our results with the standard Gastric

Bypass have been very gratifying, and the lifestyle of our patients is

very comfortable, we do not advise this procedure, except in special

circumstances - such as when a standard Gastric Bypass requires

revision. In a sense, this procedure combines the least-desirable

features of the Gastric Bypass with the most troublesome aspects of the

Biliopancreatic Diversion. We do not offer this procedure as primary

treatment. "

The folks at Alvarado seem to think that any short time extra excess

weight loss gained by having the shorter common channel is outweighed by

the higher level of nutrient malabsorption caused by the shorter common

channel.

Ray Hooks

For WLS nutrition info, visit

http://www.bariatricsupplementsystem.com

tuesdynite@... wrote:

>

> Does anyone else on the list have the 50-55% figure from somewhere for

> proximals to answer Cindy? This number comes from Dr. Kih Oh in Seattle. Since

he

> only does distals (I think), I doubt it would be from his own patient base.

And

> yes, one has to remember that averages are the mean, or centerline, of

> anything. The 75% figure quoted by Weight For Life in their pre-op seminars

for

> proximals is quoted as an average as well. My point is that perhaps proximals

are

> not always being given the correct data as pre-ops--not that it would

> necessarily change anyone's mind about having the surgery. Probably any MO

would still

> go for 50% rather than 75% simply bcuz it's a whole lot better than the status

> quo. My desire is to get the bariatric surgical community to tell us the

> truth and not sugar-coat anything and not omit any info just bcuz the

percentages

> are small (such as failed or stretched stoma). Actually, I'm not even sure IF

> the percentages on that are small. I just do not know.

>

> As far as obesityhelp.com / AMOS is concerned, did y'all read Ray's post

> about who owns it and who advertises on it? I guess that would explain why

they 1)

> don't want any posts on there about possible problems/ complications/

> failures and 2) why that site wouldn't be interested in any study like what

Cindy

> suggests. Personally I don't need a study to know that stretched stoma DOES

> happen. I have the scope results to prove it. And whether it happens to 60% or

0.6%

> doesn't mean a heckuva lot when it happens to YOU. As for the percentage of

> loss? I've lost to date (not quite 2 years out) exactly 50% of what I need to

> lose to be mid-point of normal BMI. Lost the major part of it in the first 6

> months. And in the past 2 months, have started to regain. That's why I think

it

> behooves the surgeons and their shills (such as WFL, the Wish Center, etc) to

> TELL every WLS candidate what CAN happen. If they've got statistics on the

> percentages, so much the better. But it ain't MY job to conduct such a study.

I'm

> not going in and re-arranging anyone's insides in such a manner that if a

> problem occurs, it cannot be fixed. Maybe someone else wants to undertake to

do

> the study? Cindy, what about you? You have the questions; maybe you can help

> find the answers....................

>

> Forgive me if I'm interpreting your post incorrectly. But I get the feeling

> that in your mind, I must be to blame, and even if I'm not, I must not have

the

> right info.

>

> Carol A

> -------------------------------------

>

> In a message dated 7/29/2003 10:32:25 AM Central Daylight Time,

> cindyjrubin@... writes:>

> >

> > Where does it say that its closer to 50-55% for proximals? Is this just one

> > docs opinion from his patient base? Where are you getting that from? Your

> > the only one I have heard espouse that figure... I guess that if you take

the

> > averages, perhaps, it may shake out that way. For instance, a lightweight

> > that only has to lose 100 or so, could lose 100 percent of excess weight,

and

> > perhaps even with regain, still have 75% or more permanent loss. But

someone

> > who started at 400 pounds, may lose 150 pounds, an awesome amount but it may

> > only be 50-60 percent of what they had to lose...does that make any sense?

> >

> > I know for me, so far at 17 mo post-op (and I won't feel comfortable until I

> > reach the 3-5 year mark), I have lost 84% of what the insurance tables say I

> > should weigh, but 97% of what I set out to lose (my own goal). Even with

> > some regain, I am and will stay way above the 55% and I am a proximal. I

think

> > what we need is a major study, and why shouldn't obesity help do one? For

> > instance, they have thousands and thousands of post-op posters. Why not

take

> > a poll and chart it somehow, showing % of weight lost at 1 year, 18 mo, 2

> > years, 3 years etc for proximal, distal RNy and DS, lap band etc..?? Or

even,

> > get the docs to submit their info...

> >

> > What are your thoughts on this?

> >

> > Tuesdynite@... wrote:

> >

> > >> In a message dated 7/27/2003 5:02:05 PM Central Daylight Time,

> >> cindyjrubin@... writes:

> >>

> >> >>> I'm wondering, what is the percent of those who have the RNY who have

> >>> stoma problems, andat what point in their journey-there are those who

> >>> start out with an enlarged stoma, but what percent have the relaxed

> >>> stomas and at what point do they occur, and do they occur to everyone

> >>> or just some, and what causes it-overeating?

> >>>

> >> -------------------------------------

> >

> >

>

>