I see that a lot of people are okayed to have eggs in the purée stage, but my nutritionist has specifically said no eggs until the soft stage. Any thoughts on why?

3 hours ago, Zom B said:

Hey Rick, do you happen to know why your Dr/program rarely does RNY any more? I’m on the West coast and my team calls it “the golden standard” But I do wonder if that’s because trends tend to start on the East coast and slowly make their way up ver here.

I think that, as with most practices that I have seen that offer the DS, they have little need to do the RNY anymore - they find that, overall, the DS works better and for those patients who don't need as strong a tool, the VSG (which is the stomach half of the DS) works just as well. However, there are situations where the RNY is the appropriate procedure for some patients, so most still offer it when needed.

Most practices don't offer the DS because it's more technically challenging than the RNY or VSG and most surgeons have to take time out from their practices to go back to school (usually a residency with another practice) to learn how to do it, get some guided practice on it and get up to speed on the differences in after care. Most who are currently doing them got into it 15-20 years or more ago when they were dissatisfied with the results of the existing bariatric procedures, which at the time was primarily the RNY and lap bands.

On 12/17/2019 at 2:18 PM, mediocreoblongata said:

I see that a lot of people are okayed to have eggs in the purée stage, but my nutritionist has specifically said no eggs until the soft stage. Any thoughts on why?

I am allowed eggs and pouch seems to tolerate sometimes i just eat the juice outta the yolk of fried egg. I agree with the person who adds things to eat them fluffy. I like egg substitute w laughing cow cheddar

2 hours ago, RickM said:

I think that, as with most practices that I have seen that offer the DS, they have little need to do the RNY anymore - they find that, overall, the DS works better and for those patients who don't need as strong a tool, the VSG (which is the stomach half of the DS) works just as well. However, there are situations where the RNY is the appropriate procedure for some patients, so most still offer it when needed.

Most practices don't offer the DS because it's more technically challenging than the RNY or VSG and most surgeons have to take time out from their practices to go back to school (usually a residency with another practice) to learn how to do it, get some guided practice on it and get up to speed on the differences in after care. Most who are currently doing them got into it 15-20 years or more ago when they were dissatisfied with the results of the existing bariatric procedures, which at the time was primarily the RNY and lap bands.

Most practices offer rny because its the gold standard not as complex and has a lower death rate. I dont know what country you are in but here in america gastric bypass is standard but sleeve is more popular this year statistically

20 hours ago, tarotcardreader said:

Most practices offer rny because its the gold standard not as complex and has a lower death rate. I dont know what country you are in but here in america gastric bypass is standard but sleeve is more popular this year statistically

"Gold standard" is a marketing term used in selling a procedure (cynically, it has been said that it applies to the surgeons themselves, as that is where they make the most "gold") and as such is basically meaningless.

Here in the States, there are four mainstream procedures that are routinely performed, and approved by the ASMBS and the US insurance industry - lap bands, RNY, VSG and DS.

The bands are falling out of favor owing to their high longterm complication rate and low effectiveness, but there is still a lot of marketing push for them by their manufacturers.

The RNY has been around for forty years or so, based upon procedures that had been first developed 100 years before to treat gastric cancer and other gastric maladies (Billroth II). It was an improvement over the existing malabsorptive procedures such as the JIB (jejuno ileal bypass) but it still had the longstanding tradeoffs of its basic configuration - bile reflux, marginal ulcers (aka, the "NSAID problem"), dumping syndrome and moderate nutritional deficiencies. Bile reflux has largely been eliminated in the RNY WLS procedure via tailored limb lengths, but the others remain as common side effects and are largely controlled by diet or medication restrictions and supplements. It is overall a very good and mature procedure that works well with tolerable side effects, but it is far from perfect, which is why there is been an ongoing effort in the industry to find a replacement (this is how progress is made.)

The duodenal switch (DS) was developed in the mid to late 1980's, which combined a moderate level of malabsorption with a moderate level of restriction (compared to the RNY which is more highly restrictive and minimally malabsorptive) that takes care of the RNY's problems with bile reflux, dumping/reactive hypoglycemia and marginal ulcers. In exchange, it is more technically challenging for the surgeon (which is why most don't offer it) and is a little more fussy on its' supplement regimen. On the plus side, it is more effective in treating diabetes, somewhat more effective on overall average weight loss, and much better at resisting regain. It should certainly be on the radar for anyone in the high BMI ranges and/or with a history of yoyo dieting. The main thing that has held the DS back from being more popular is its complexity, which often doesn't fit in with either surgeon's skill sets or business models (can't do as many procedures in a day.)

The VSG came out of the DS as it is the first phase when the DS is done in two steps. Typically the VSG stomach is made smaller, about half the size, than the DS sleeve. It overall yields similar weight loss and regain characteristics to the RNY but without the dumping/reactive hypoglycemia or marginal ulcer predispositions and is also quicker and easier for the surgeon to perform, which is why it has been gaining popularity. The primary downside is the predisposition toward acid reflux owing to the stomach volume being reduced much more than the acid producing potential, to which the body doesn't always adapt.

Nothing is perfect, and they all have a place for different circumstances. Getting beyond marketing fluff, hey are all the "gold standard" when used appropriately.

The next new thing that is working its way through the industry is the SIPS/SADI (sometimes called the "loop" or simplified DS) that shows some good promise of having effectiveness somewhere between the RNY and the DS, with surgical complexity on the order of the RNY (it is being promoted as being "almost as good as the DS" while being more "accessible" - simpler so more surgeons can do it. It is still usually considered by most insurance to be investigational, and has yet to gain approval by the ASMBS, but there's a good chance that it may become that RNY replacement that the industry has been looking for.

47 minutes ago, RickM said:

"Gold standard" is a marketing term used in selling a procedure (cynically, it has been said that it applies to the surgeons themselves, as that is where they make the most "gold") and as such is basically meaningless.

Here in the States, there are four mainstream procedures that are routinely performed, and approved by the ASMBS and the US insurance industry - lap bands, RNY, VSG and DS.

The bands are falling out of favor owing to their high longterm complication rate and low effectiveness, but there is still a lot of marketing push for them by their manufacturers.

The RNY has been around for forty years or so, based upon procedures that had been first developed 100 years before to treat gastric cancer and other gastric maladies (Billroth II). It was an improvement over the existing malabsorptive procedures such as the JIB (jejuno ileal bypass) but it still had the longstanding tradeoffs of its basic configuration - bile reflux, marginal ulcers (aka, the "NSAID problem"), dumping syndrome and moderate nutritional deficiencies. Bile reflux has largely been eliminated in the RNY WLS procedure via tailored limb lengths, but the others remain as common side effects and are largely controlled by diet or medication restrictions and supplements. It is overall a very good and mature procedure that works well with tolerable side effects, but it is far from perfect, which is why there is been an ongoing effort in the industry to find a replacement (this is how progress is made.)

The duodenal switch (DS) was developed in the mid to late 1980's, which combined a moderate level of malabsorption with a moderate level of restriction (compared to the RNY which is more highly restrictive and minimally malabsorptive) that takes care of the RNY's problems with bile reflux, dumping/reactive hypoglycemia and marginal ulcers. In exchange, it is more technically challenging for the surgeon (which is why most don't offer it) and is a little more fussy on its' supplement regimen. On the plus side, it is more effective in treating diabetes, somewhat more effective on overall average weight loss, and much better at resisting regain. It should certainly be on the radar for anyone in the high BMI ranges and/or with a history of yoyo dieting. The main thing that has held the DS back from being more popular is its complexity, which often doesn't fit in with either surgeon's skill sets or business models (can't do as many procedures in a day.)

The VSG came out of the DS as it is the first phase when the DS is done in two steps. Typically the VSG stomach is made smaller, about half the size, than the DS sleeve. It overall yields similar weight loss and regain characteristics to the RNY but without the dumping/reactive hypoglycemia or marginal ulcer predispositions and is also quicker and easier for the surgeon to perform, which is why it has been gaining popularity. The primary downside is the predisposition toward acid reflux owing to the stomach volume being reduced much more than the acid producing potential, to which the body doesn't always adapt.

Nothing is perfect, and they all have a place for different circumstances. Getting beyond marketing fluff, hey are all the "gold standard" when used appropriately.

The next new thing that is working its way through the industry is the SIPS/SADI (sometimes called the "loop" or simplified DS) that shows some good promise of having effectiveness somewhere between the RNY and the DS, with surgical complexity on the order of the RNY (it is being promoted as being "almost as good as the DS" while being more "accessible" - simpler so more surgeons can do it. It is still usually considered by most insurance to be investigational, and has yet to gain approval by the ASMBS, but there's a good chance that it may become that RNY replacement that the industry has been looking for.

The gb is considered the gold standard scientifically because we have the most statistical data for it making it Be a bit less “experimental” when coming to side effects and weight kept off.

Edited September 15, 20205 yr by tarotcardreader

1 hour ago, RickM said:

"Gold standard" is a marketing term used in selling a procedure (cynically, it has been said that it applies to the surgeons themselves, as that is where they make the most "gold") and as such is basically meaningless.

Here in the States, there are four mainstream procedures that are routinely performed, and approved by the ASMBS and the US insurance industry - lap bands, RNY, VSG and DS.

The bands are falling out of favor owing to their high longterm complication rate and low effectiveness, but there is still a lot of marketing push for them by their manufacturers.

The RNY has been around for forty years or so, based upon procedures that had been first developed 100 years before to treat gastric cancer and other gastric maladies (Billroth II). It was an improvement over the existing malabsorptive procedures such as the JIB (jejuno ileal bypass) but it still had the longstanding tradeoffs of its basic configuration - bile reflux, marginal ulcers (aka, the "NSAID problem"), dumping syndrome and moderate nutritional deficiencies. Bile reflux has largely been eliminated in the RNY WLS procedure via tailored limb lengths, but the others remain as common side effects and are largely controlled by diet or medication restrictions and supplements. It is overall a very good and mature procedure that works well with tolerable side effects, but it is far from perfect, which is why there is been an ongoing effort in the industry to find a replacement (this is how progress is made.)

The duodenal switch (DS) was developed in the mid to late 1980's, which combined a moderate level of malabsorption with a moderate level of restriction (compared to the RNY which is more highly restrictive and minimally malabsorptive) that takes care of the RNY's problems with bile reflux, dumping/reactive hypoglycemia and marginal ulcers. In exchange, it is more technically challenging for the surgeon (which is why most don't offer it) and is a little more fussy on its' supplement regimen. On the plus side, it is more effective in treating diabetes, somewhat more effective on overall average weight loss, and much better at resisting regain. It should certainly be on the radar for anyone in the high BMI ranges and/or with a history of yoyo dieting. The main thing that has held the DS back from being more popular is its complexity, which often doesn't fit in with either surgeon's skill sets or business models (can't do as many procedures in a day.)

The VSG came out of the DS as it is the first phase when the DS is done in two steps. Typically the VSG stomach is made smaller, about half the size, than the DS sleeve. It overall yields similar weight loss and regain characteristics to the RNY but without the dumping/reactive hypoglycemia or marginal ulcer predispositions and is also quicker and easier for the surgeon to perform, which is why it has been gaining popularity. The primary downside is the predisposition toward acid reflux owing to the stomach volume being reduced much more than the acid producing potential, to which the body doesn't always adapt.

Nothing is perfect, and they all have a place for different circumstances. Getting beyond marketing fluff, hey are all the "gold standard" when used appropriately.

The next new thing that is working its way through the industry is the SIPS/SADI (sometimes called the "loop" or simplified DS) that shows some good promise of having effectiveness somewhere between the RNY and the DS, with surgical complexity on the order of the RNY (it is being promoted as being "almost as good as the DS" while being more "accessible" - simpler so more surgeons can do it. It is still usually considered by most insurance to be investigational, and has yet to gain approval by the ASMBS, but there's a good chance that it may become that RNY replacement that the industry has been looking for.

Wow. Thank you for taking the time. An amazing read. I’m in Seattle and wanted a sleeve but my acid test and gerd numbers were too high according to my team. I informed them that I only began experiencing heartburn/reflux after my abdomen got larger and tight plus I have a small frame, 5’0. They refused, it was bypass or nothing. If I can get my belated dumping under control I believe I will be on track to hit my goals and can start exercising soon. That is, when the West Coast smoke dissipates. Thanks Rick