Question:
Why such variation?
I am considering RNY surgery and want to ask about something I find very disturbing. Every site and every question I see has a huge variation between responses to the same questions. Yet, at the same time, I read "trust in and do what your surgeon says". The variations I see are based on habit/opinion variations from surgeon to surgeon, not because "each person is different". It seems kind of dumb to trust when they can't agree. I would really like to see some response from some of the medical community on this one, too. If the RNY has been done & successful for decades, why aren't there established standards? Why no statistics beyond the 2 to 5 year range? If they've done so many of these, why do quoted complications statistics vary so much from surgeon to surgeon? If they are quoting only their own, is there any one out there compiling them into a national database? Why do opinions about RNY vary as to whether it is restrictive/malabsorptive/both and for how long those qualities are expected to last (avg) after surgery? Why do the immediate post-op diets vary so much (liquid/soft/intro of food types/foods banned)? Why does pre-screening and post-op support vary so significantly? Help. — Lizzie G. (posted on March 1, 2000)
February 29, 2000
Lizzie,
You have a bunch of tough questions here. Obviously, there is a great deal
of variation between surgeons as to how they handle this surgery. One
thing I can answer for you is why there aren't many statistics beyond the
2-5 year range. Surgeons lose track of some patients after surgery, and
after five years, fewer than 20% of patients maintain contact with their
surgeon. People move away, surgeon's retire, or people just don't get
around to going to the doctor because maybe they feel fine, or maybe
(heaven forbid) they have gained weight or stopped following doctor's
orders and they are ashamed to let the surgeon know. With so few patients
following up after five years, the statistics would not be reliable, so
they are not usually reported. The only place I have seen that has
maintained patient data for over ten years is the International Bariatric
Surgery Registry. http://www.surgery.uiowa.edu/ibsr/ibsrbroc.html and
IBSR newsletters http://srn.surgery.uiowa.edu/ibsr/
I hope these things help you a little, but in a way we really do take a
leap of faith when we have this surgery. Statistics won't tell you what
your individual outcome will be, and you don't really know if your
individual doctor's approach is "the best", but you really need
to trust your surgeon and follow his orders as best you can. If it gets to
a point where your surgeon's approach is just not working for you, then
look around for alternatives. Good Luck!
— Lynn K.
March 1, 2000
The short answer is: because this isn't cookie-cutter surgery. There's so
much varying info about the RNY because the RNY has so many variations. The
size of the pouch can vary, and is in fact generally smaller today than it
was 10 years ago. The amount of bypassed intestine can be radically
different from one person to the next, either proximal, medial or distal.
This determines the degree of malabsorption. In a proximal RNY, most of the
weight loss is caused by the reduction in stomach size, making it a
primarily restrictive operation, but with some malabsorption. Some people
have had trouble maintaining weight loss after this surgery, but many
others do fine with it. A distal RNY involves a large bypass, with a great
degree of malabsorption, especially of fats. This makes it easier to
maintain weight loss, but patients need to be more vigilant about following
their prescribed vitamin regimen. The medial RNY is somewhere in the
middle. I've not given any numbers to define proximal, medial and distal
because, again, there is so much variation in actual length. Some surgeons
use a set number for each patient, others use a percentage of the patients
intestinal length as their guide. But these are minor differences.
Proximal, medial or distal will be the major consideration with the RNY.
The most important thing to remember when talking to people about their RNY
is to find out which type they had, and put their experience in the correct
context. Unfortunately, not everyone knows what type of bypass they have.
You asked why there aren't established standards for the RNY. I'm not sure
what you mean. Every surgery has some accepted, standard procedural steps,
but each surgeon will have his or her own individual techniques. That's how
improvements come about. What counts is safety and efficacy, and you'd have
to check the results for the surgeons you're considering. NIH released a
consensus report in 1991 that has some stats for results and complications,
but they don't cover all of the surgery options. I personally question the
value of their numbers on complications such as staple line breakdown,
because of the advances in stapling techniques and equipment. WLS has come
a long way in the past 9 years, and continues to improve. With so many
variations in technique, any large compilation of stats would be a
monumental undertaking.
As to why post-op diets vary so widely, it comes down to what a given
surgeon prefers. I chose to have a BPD/DS and was on a soft diet for 3
weeks post-op. Most other BPD/DS surgeons allow their patients to eat
solids immediately, while one completely prohibits food for the first two
weeks. End results are the same, though. Within a month we're eating
whatever we want. The thing to focus on is the procedure and it's expected
results and most common side effects, because no one can predict with
certainty what any given patient will experience. Think in generalities and
expected differences, and use those to evaluate the various surgical
options.
I know this doesn't answer all of your questions, but I hope it helps just
a bit, and I apologize for the length. Best of luck to you, whichever
option you choose.
— Duffy H.
March 1, 2000
Hi Lizzie: You pose some excellent questions, and you've gotten some
excellent answers. Here's my .02 worth. Each doctor has differences in
the way he performs a procedure, and his own reasons for performing it that
way. Differences in individual patients create situations where doctors
have to make decisions, based on their knowledge and their
opinions/preferences, on what is best for a particular situation. This is
the reason for the wide variations among surgeons when performing a certain
procedure. If you polled 15 surgeons doing 'open proximal RNY' you would
find 15 different surgical plans. That is why it is so important for
patients to do the research, and ask questions. Find a surgeon who has the
same philosophy that you do when it comes to patient care. Make sure that
he or she is someone you can talk to and who will answer your questions in
a way you can understand. Ask him why he does things a certain way if you
have conflicting information from your research, and bring up alternatives
if you think they are reasonable or if you have questions about them. If
your surgeon acts impatient with you, becomes angry or defensive at your
questions, then perhaps you need to find another one. Keep looking, there
ARE surgeons out there who are clinically skilled AND caring. I found one,
you can too! Now a quick word about studies and statistics! You can find
a study or statistics out there to prove or disprove anything. They all
have an agenda, so be careful. Not that there is no value in them, just
take it with a grain of salt, and reference back to WHO did the study and
WHY. God bless! Jaye Carl, RN, open proximal RNY 7-29-99, 94 pounds gone
forever!
— Jaye C.
March 23, 2000
As an RN with 5 yrs experience as a staff nurse in a post-op
unit and 2 yrs experience as a Case Manager dealing with insurance
companies for reimbursement - here is my two cents worth:
The primary differences in type of procedure, pre- and post-
requirements are surgeon preference. He/she probably bases it
on personal experiences and training. The second reason for
some of the differences is insurance requirements. This is
especially seen in the pre- requirements. Different insurance
companies require different things at different times and according
to who you talk to on what day and what kind of mood they are
in when you call. As stated in a previous posting, statistics
are hard to keep because patients don't keep up with the surgeons
and other various reasons. Personally, I decided on the
mini gastric bypass by Dr Robert Rutledge in Durham, NC, for
my WLS for several reasons - the main one being that he does
it laproscopically (very recently did his first one where the
patient went home on the same day of surgery!!) and he has been
performing this procedure for several years and this is the
only surgery that he does now. He has them lined up at the
door waiting on his services, too!! Mine is scheduled for
April 17, 2000.
— Cheryl R.
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