RickM

The basic procedure upon which the RNY is based has been done for some 140 years for a variety of GI maladies, so it's mostly a matter of billing codes, and some minor variations in configuration, that make it a bariatric procedure vs. one for cancer, gastroparesis, etc., so insurance shouldn't be a factor if that is what is needed. As to whether the "RNY" is needed for your case is a judgement call; try to avoid self diagnosis and let the doctors make the recommendation as to what is appropriate to treat your particular case. GERD is a classic symptom of a hiatal hernia, and given that you didn't have any particular problem with it for some years post op indicates that it is the hernia and not the sleeve that is the primary problem. Again, let the experts weigh in on this. My preference when considering something like this would be to seek out an opinion from a bariatric practice that is associated with a regional cancer center, as they tend to treat a broader range of GI maladies than a general bariatric practice, and will probably have a wider range of options to consider. If you come across a surgeon who quickly determines that you have GERD and a sleeve, therefore you need a bypass, without looking at any imaging, I would tend to move on to someone else - they probably don't understand the sleeve as well as they should to make that determination. My philosophy is to try to avoid going to a bypass is possible, as it does present some diagnostic and treatment limitations down the line should they be needed as we get older. The blind stomach and duodenum that can't be readily imaged or manipulated endoscopically and medication limitations (of which NSAIDs are the largest class,) are the primary things that come to mind. They usually aren't big deals if that is what is needed, but I don't like giving up options unnecessarily. RNY patients can develop GERD later on, and occasionally (though rarely,) such a revision does not correct a GERD problem, so we're talking more of a statistical improvement rather than an outright cure. If that happens, then where does one go - the bypass is something of a one way street surgically (though is can technically be reversed)? So, my inclination is to go one step at a time and treat the hernia and then go from there is that doesn't correct the problem.

Some programs want their patients to avoid them as soon as possible - within the first few months - on the premise that they don't want their patients drinking calories and would rather they work with solid food instead. Most programs don't care, but there is some merit to the liquid vs. solid argument, at least for a time. Many, OTOH, as we see above, still use them long term, often as a convenience. I still use them - my own blend, as with most things - as an exercise recovery drink after the gym. My wife uses some of the powder in the regular smoothie that she makes (20 years post op) in which she also includes some of the added supplements that she still needs (for her DS,) So, if you can get away without them and still get the requisite protein, and object to drinking them, then great - you can do away with them. If you like them and they still provide some benefit or convenience, there's little reason not to continue using them.

Surgeons will have their preferences based upon their experience and background. When I had my VSG around 14 years ago, the sleeve was fairly new, but most surgeons included it in their practice, though most were not that experienced with it yet (and it often showed in the outcomes, with quite a few rapid revisions needed.) I travelled to SF to have my sleeve done as there wasn't anyone in the LA area where we lived that was very experience with them, but there were several good BPD/DS surgeons in the Bay area, and as the DS uses the sleeve as its basis, those are the guys most experienced with it - my surgeon had been doing them for around 20 years at the time. Note another difference is that we do see more revisions of the sleeve, in part because of that "infant mortality" problem of when most surgeons were still working up the learning curve on it, but also because it CAN be readily revised, whereas the RNY is difficult to revise, so it, or reversals, are not done commonly owing to the complexity. So, if one does wind up with, say, a GERD problem, which does happen occasionally with the RNY, too, then one is stuck with medicating it, or reversing it if things are that serious.

Bile reflux tended to be the biggie problem with the MGB back in the day. When my wife and I first started looking into WLS almost 25 years ago, the MGB was a proposed alternate to the incumbent bands and RNY but it never gained traction with the ASBS (precursor to today's ASMBS). In the meantime, both the BPD/DS and the VSG (and more recently the SIPS/SADI) have gained acceptance in the US bariatric (and insurance) industry. There are reportedly some techniques that have been developed to mitigate the bile problem, and there may be something to that, and why it may have been accepted elsewhere; but in the US, it's time has passed.

When my wife and I were first looking into WLS 20+ years ago, there were several newer procedures, including the MGB mini-bypass, DS duodenal switch and the VSG vertical sleeve gastrectomy, that were circling the periphery of bariatrics, which at the time was mostly lap bands and the RNY gastric bypass. These were the only procedures that were endorsed by the ASBS (American Society of Bariatric Surgeons) - the predecessor name for today's ASMBS. Since that time, the DS, VSG and newer SIPS/SADI/"Loop DS" that have gained endorsement from the ASMBS and general insurance coverage in the US. The MGB never made it past that hurdle here in the US, so isn't commonly done or covered by insurance. Bile reflux seems to be the major legacy problem that caused the profession to move away from it at the time. There are claims that some new techniques have been developed to minimize that problem, and maybe they do, but it's a hard sell to make it mainstream in the US. It has become more accepted in other countries. Overall, being in the States, I wouldn't be overly eager to go with the MGB as it is not commonly done here, so there are fewer MDs around who are familiar with its' care over the long term; the RNY, in contrast, has been done for around 140 years for reasons other than weight loss, so is a well known configuration in the medical world, as are the problems one may encounter over the years. If you have an unusual configuration like an MGB or BPD/DS, it can be harder to isolate any health problems one may have years down the road owing to the general unfamiliarity with the procedure -at least the DS has significantly better weight loss and diabetes results than the other procedures to make that a worthwhile consideration. If you live in a country where the MGB is commonly done, then it would be a worthwhile consideration, but the US has too many other mainstream procedures commonly available and accepted that do as well or better than the MGB that it doesn't make much sense here.

The DS docs I'm most familiar with are out here in California - John Rabkin in SF, his older brother did my wife's DS about 20 years ago and he did my VSG 13 years ago, so we are quite familiar with their program and satisfied with the results and service. There is also Ara Keshishian in the LA area who is also quite good - he adopted Rabkins local LA support group as the Rabkins moved to SF, and we have been impressed with his knowledge in the many discussions that we have had as a group (dssurgery.com). Both cater well to travelling patients as DS surgeons are still few and far between. If I was on the east coast, I would check out Mitchell Roslin in NYC; though he seems to be most heavily promoting the SADI/"loop DS" these days, he still seems to be a firm advocate of the legacy Hess DS for those who need that.

I had my sleeve done by Dr. John Rabkin at St. Mary's (he also works out of California Pacific.) I was in LA at the time, but the Rabkins had more experience with the sleeve than anyone down there (they had been doing them as part of the DS for around twenty years then.) Other names to look into are Dr. Gregg Jossart and Dr. Paul Cirangle. Jossart did his DS residency with the Rabkins and Cirangle seems to have specialized with the sleeve. I like that all three are DS qualified, even if one is not particularly interested in that procedure, since owing to its technical challenges, only the better qualified surgeons perform it routinely. And, as it is based upon the sleeve, it means that the DS guys tend to have more sleeve experience than others. Also, while they are all fully capable of doing bypasses, they generally don't do them as a default, reserving them only for those patients have a particular need for it. If one has any liver related comorbidities (not uncommon in the obese population,) Rabkin would be the choice as he is also a liver guy, doing biliopancreatic transplants in his "spare" time. The other thing that I liked with the Rabkins is that their whole process is pretty straightforward - no extensive pre-op diets (other than the usual day before thing,) and a fairly rapid post op progression, as tolerated. Good luck in getting through all of this!