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Can someone please enlighten me.



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7 hours ago, damonlg said:

I am curious that so many people are going from Sleeve to bypass. What is the reasoning behind this. Do you not have the option to go straight to the bypass. Can someone enlighten me.

Concerned it’s a just using us patients to make more money for the doctors by getting 2 operations from us?

I don't know how many are "many" (there is something called "adverse selection" that is common in online forums, where negatives outnumber positives because everyone with a complaint will post about it, but those with nothing to complain about are largely silent, so things tend to seem worse than they are,) but it does happen for a few reasons.

The sleeve is predisposed do reflux problems due to its geometry and physiology. The volume of the stomach is reduced much more than the acid producing potential, so it takes a while for the body to adapt, and sometimes it doesn't. Also, the sleeve is considered to be a "high pressure" system in that the stomach is often closed off by the pyloric valve at the bottom, so excess gas, fluids or solids have no place to go other than back up; the bypass is a "low pressure" system as there is no pyloric valve in the system, so excess gas can vent down into the intestines. In contrast, the RNY due to its geometry and physiology is predisposed to dumping, marginal ulcers, reactive hypoglycemia and bile reflux. With either procedure, this does not mean that everyone will experience these problems, just that this is the natural result of the anatomical changes that have been made.

Another compounding factor with the sleeve is the relative experience level of the profession - in the US, the sleeve has been routinely approved by insurance for about the past 6-8 years, while the bypass has been routine for around 40 years. This means that there has been some revisions needed due to inexperience in some of those early sleeves - the surgeons may have been well experienced doing bypasses and bands, but a new procedure, even a straightforward one such as the sleeve, brings along its own subtleties and nuances that take practice to master. Resultant shaping issues can promote or exacerbate the reflux problem. In the US, most bariatric surgeons are now far enough up the learning curve that most are now making routinely making functionally competent sleeves (one should always seek out a surgeon who has several hundred of whatever procedure one is interested in under his belt.) However, now the problem is, as it has been since early on, is that many are not very experienced in correcting any problems that may crop up with a sleeve, so the natural inclination is to stick within their comfort zone and revise to a bypass when a problem occurs, rather than correct the sleeve. So yes, the OP is correct in some respects that there are some unnecessary revisions being done, though not necessarily just for the sake of charging for two procedures. As time marches on and the industry gets more experience with sleeves, I would expect that the revision rate will decline as both the sleeves will be made better overall, and the surgeons learn how to repair them when necessary rather than revise them, much as the bypass has matured over time and some of its predisposed problems are less common as they have learned how to mitigate them to the extent they can (bile reflux isn't too common anymore as they have worked out techniques to minimize its occurrence, for instance.)

Another factor that may skew the impressions some is that the bypass is a difficult procedure to revise - it is something of a dead end surgically speaking. If poor weight loss performance or regain is experienced, there is little point in reversing it and revising it to a sleeve as they are both so similar in performance that there isn't much to be gained. There are minor tweaks that are offered - tightening of the stoma or intalling a band over the bypass - but overall results are generally pretty poor. Revising it to a DS, which can offer improved weight loss and regain resistance, as well as diabetes remission, is a very complex procedure that only a handful of surgeons are capable of performing. So, we don't see a lot of bypasses revised for that reason, though sometimes they are reversed if there are significant complications that can't otherwise be resolved, though that isn't a trivial option, either.

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My doctor does sleeve-to-bypass revisions for those who have GERD or those who don't lose weight with the sleeve.

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I chose the sleeve because it is less invasive (45 min surgery), less risk, fewer nutritional deficiencies. Some articles I read say the weight loss is a little less, although I also read that over time it is about the same as bypass. And no dumping, or at leas a lot less. I haven't had any. Made me feel a tiny bit better at my 2 year follow up when my Surgeon asked all these questions to see if I was having any issues. I told him he did not have to worry about me taking my Vitamins and Calcium because I had read an article about wls patients loosing their teeth from not taking their vitamins. He looked at me and said that would be the least of your worries. Apparently he was more concerned about neurological issues. Afraid to look into what those can be. But I have to wonder if the malabsorbptive nature of bypass and other more invasive surgeries increases the risk for neurological diseases.

Also, I had terrible GERD before surgery. Tested for Pylori and was negative. 27 months out now and I can say my GERD has been 100% under control. I can control it with diet and might take a tums once every month or two. Diabetes is ibetter improved with bypass, so that is also a concern for some people.

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I wanted the sleeve when I first began this process, it is less invasive and seemed a safer choice for me. After a lot of research and talking to many experienced people I changed my mind and asked my surgeon for bypass. He was fine with either choice and agreed that a bypass will probably be better for me as I have a lot of mobility issues. The decision is entirely mine and insurance approved my surgery for the 24th of July!!!

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I was originally wanted the sleeve but per the doctor the RNY/gastric bypass was better choice for me because I suffer from severe reflux/GERD.

My Doctor personally stated the gastric bypass is reversible.

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I agree with the posts about not losing the weight and GERD. My doctor and I decided on the sleeve as I’ve never had GERD. A little over 2 months post surgery and I still don’t experience it.
I do hear a lot about the bypass being better for diabetes, but I stopped all my diabetes medications two days after starting my pre-op diet, and I’m already down to normal levels for A1c and haven’t restarted any of the meds.
Personally, the sleeve was my number one choice because it’s less invasive and had fewer complications like dumping. I am losing at a slower rate than the bypass people who had their surgeries around the same time, but I’m still down 43 pounds in 66 days and 99 pounds since I started the WLS journey.
I was initially wary because the sleeve is a newer procedure. Turns out the first record I found of it was in 1988. Sure, it’s been perfected and changed over the years, but it’s always been one of the steps of DS. So it’s actually been around quite a while.
I found a great surgeon who is very well known for WLS and the rest is history.
Also, I don’t believe the majority of sleeve patients end up revising, but since you see the posts of the people who do, it seems like a bigger majority than it is. After all, no one really makes posts about nothing changing 😂

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On 07/14/2018 at 06:33, RickM said:





I don't know how many are "many" (there is something called "adverse selection" that is common in online forums, where negatives outnumber positives because everyone with a complaint will post about it, but those with nothing to complain about are largely silent, so things tend to seem worse than they are,) but it does happen for a few reasons.




The sleeve is predisposed do reflux problems due to its geometry and physiology. The volume of the stomach is reduced much more than the acid producing potential, so it takes a while for the body to adapt, and sometimes it doesn't. Also, the sleeve is considered to be a "high pressure" system in that the stomach is often closed off by the pyloric valve at the bottom, so excess gas, fluids or solids have no place to go other than back up; the bypass is a "low pressure" system as there is no pyloric valve in the system, so excess gas can vent down into the intestines. In contrast, the RNY due to its geometry and physiology is predisposed to dumping, marginal ulcers, reactive hypoglycemia and bile reflux. With either procedure, this does not mean that everyone will experience these problems, just that this is the natural result of the anatomical changes that have been made.




Another compounding factor with the sleeve is the relative experience level of the profession - in the US, the sleeve has been routinely approved by insurance for about the past 6-8 years, while the bypass has been routine for around 40 years. This means that there has been some revisions needed due to inexperience in some of those early sleeves - the surgeons may have been well experienced doing bypasses and bands, but a new procedure, even a straightforward one such as the sleeve, brings along its own subtleties and nuances that take practice to master. Resultant shaping issues can promote or exacerbate the reflux problem. In the US, most bariatric surgeons are now far enough up the learning curve that most are now making routinely making functionally competent sleeves (one should always seek out a surgeon who has several hundred of whatever procedure one is interested in under his belt.) However, now the problem is, as it has been since early on, is that many are not very experienced in correcting any problems that may crop up with a sleeve, so the natural inclination is to stick within their comfort zone and revise to a bypass when a problem occurs, rather than correct the sleeve. So yes, the OP is correct in some respects that there are some unnecessary revisions being done, though not necessarily just for the sake of charging for two procedures. As time marches on and the industry gets more experience with sleeves, I would expect that the revision rate will decline as both the sleeves will be made better overall, and the surgeons learn how to repair them when necessary rather than revise them, much as the bypass has matured over time and some of its predisposed problems are less common as they have learned how to mitigate them to the extent they can (bile reflux isn't too common anymore as they have worked out techniques to minimize its occurrence, for instance.)




Another factor that may skew the impressions some is that the bypass is a difficult procedure to revise - it is something of a dead end surgically speaking. If poor weight loss performance or regain is experienced, there is little point in reversing it and revising it to a sleeve as they are both so similar in performance that there isn't much to be gained. There are minor tweaks that are offered - tightening of the stoma or intalling a band over the bypass - but overall results are generally pretty poor. Revising it to a DS, which can offer improved weight loss and regain resistance, as well as diabetes remission, is a very complex procedure that only a handful of surgeons are capable of performing. So, we don't see a lot of bypasses revised for that reason, though sometimes they are reversed if there are significant complications that can't otherwise be resolved, though that isn't a trivial option, either.


Thanks Rick. That was very insightful. I am glad so many people are posting and discussing things. This is a life changing bit of surgery and the more knowledge we have the better.


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I went bypass; it’s been around a lot longer so doctors know and have studied the long term effects. I didn’t feel as confident about the sleeve, it seemed as many of you said “the trendier option”

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It’s usually for reflux issues or it could also be that they still have not reached their goal weight or have regained. The reflux is totally out of their control, the other stuff is partially about being mentally prepared and consistent.

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I have seen post about people revising to bypass because of GERD and other issues. My surgeon only preforms the sleeve. He does 3-5 surgeries a day, 6 days a week and has been doing it since 2006. I have acid reflux from time to time (very minor) and so my biggest concern was having to eventually revise to bypass. After talking to my surgeon and his staff, he can count on one hand out of the thousands he has operated on, how many have had a revision. He actually stated that because of the new diet plan, many people who have GERD actually see it go away.

The sleeve is actually not that new. While doing some research, the bypass used to actually be done in steps. The surgeon would go in and do a sleeve, then once that healed, would do the bypass. Once people started seeing great results with just the sleeve, it continued to gain popularity.

A lot of people choose bypass because they want to loose a lot, fast. Even though I am overweight, I don’t have any health issues yet. I am young (28) and don’t have to loose all my weight at once. The sleeve might make me loose slower than the bypass, but will also allow my body to struggle less to keep up. If you read success stories, you will find many who have had the sleeve have done just as well, if not better than the bypass.

Best of luck in which ever option you choose.

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