Roux-en-y

[sandg]

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I was hoping some of you surgeons could chime in about this.

Do you find most of your patients undergoing gastric bypass have exhausted all other options and truly understand the implications (permanently changed diet, etc.)? Or does the public view the surgery as a magic wand that instantly removes excess weight? Does there need to be more education and longterm attention paid to the obesity problem so that the stage at which bypass is needed is never reached?

I heard (yes, word-of-mouth and without a reference) that insurance companies are about to drastically change how much of the cost of roux-en-y they'll pay for. Thus, I was wondering if this had anything to do with the last two questions above.

Thanks all.

 

[DoctorDoom]

Roux-en-Y is pobably falling into disfavor with the lap gastric banding being rather commonplace. Insurance compensation for obesity surgery certainly does play a role in promoting the procedure, but is not the main reason that Roux-en-Y is falling into disfavor.

I won't get into the need for behavioral modifcation and such for fear of my own biases.

 

[dr.evil]

Our surgeons are quite adamant about never doing the lap bands. There is a good amount of data talking about the reoperation rate for these bands and how easy it is for these people to "beat the band". We have a very arduous program prior to a person receiving bypass. This includes the need for a patient to have tried and failed at 2 or more diets, a strict psychological evaluation, thorough nutritional evaluation and education, a thorough explanation of the risks and having the patient repeating back the risks so the patients knows, as well as needing to lose some weight prior to the surgery to show initiative.

I'm not sure which type of surgery is best but we have had extraordinary results with the RNYGB.

 

[DoctorDoom]

Our surgeons are quite adamant about never doing the lap bands. There is a good amount of data talking about the reoperation rate for these bands and how easy it is for these people to "beat the band". We have a very arduous program prior to a person receiving bypass. This includes the need for a patient to have tried and failed at 2 or more diets, a strict psychological evaluation, thorough nutritional evaluation and education, a thorough explanation of the risks and having the patient repeating back the risks so the patients knows, as well as needing to lose some weight prior to the surgery to show initiative.

I'm not sure which type of surgery is best but we have had extraordinary results with the RNYGB.

That's interesting, and goes to show the differences between institutions and the protean nature of surgical practice in the age of accelerating technological development. I assume you have a longstanding bariatric program at your institution, as at my medical school. For a dedicated practice group and experienced nurses and care coordinators the complication rate is quite low and sustained success rate for R-n-Y is high. The learning curve for the classic R-n-Y bypass is, however, pretty steep. People definitely beat the band but it is by far the most common obesity surgery now, especially with the technical ease of lap banding. One of the vascular attendings from my former residency institution just quit vascular to perform gastric bands exclusively; not data, but a representative anecdote. Suffice it to say that gastric banding is not becoming so popular solely based on it being the "best" surgery.

 

[dr.evil]

Suffice it to say that gastric banding is not becoming so popular solely based on it being the "best" surgery.

I'm in total agreement with you. The lap bands are definitely coming on strong as they are so easy to do compared to a RNYGB.

I had an attending talking about carotid stents/coronary stents etc. versus surgery and his quote was quite good:

"Sometimes it's better to perform a less invasive, less effective procedure on someone than a more invasive, more effective procedure."

For some, that is difficult to accept but the medicine community has been doing it for quite some time.

 

[Winged Scapula]

dr evil and I have the same experience. The ONLY operation we do here is the Roux-en-Y (either open or lap) because our surgeons believe it to be the superior procedure and have very low complication rates due to their experience. We also have a long (takes nearly a year to complete) multi-disciplinary program which patients must complete before coming to the OR. That said, there are people who really don't understand the lifestyle modification it requires.

My understanding from our surgeons is that insurance companies aren't balking more at paying these days because of problems with the patients but rather because of the high complication rates nation-wide

 

[droliver]

There is a good amount of data talking about the reoperation rate for these bands and how easy it is for these people to "beat the band". .

The data points for this have been all over the board in re. to efficacy. The largest series of these from Europe and Australia were dramatically more successful then the early series done here stateside. A lot of the laparoscopic surgeons pin the blame for this on the technical deficiencies of many of the surgeons who led the early trials (many of them well-known baraitric surgeons who had very little prior laparoscopic skills) and several technical modifications to prevent slippage.

If you've taken care of large #'s of these patients you will have an appreciation of just how morbid an operation gastric bypass is both peri-operative & down the road. All you have to do is talk to the partners of the bariatric surgeons who have to cross-cover their patients about what a nightmare this group is.

While clearly the gatric bypass (which is actually one of some 4-5 distinct operative varients) is the most effective & time-tested procedure, it certainly introduces an increased morbidity and mortality. A lot of surgeons and patients have voted with their feet (and pocketbooks) and decided the tradeoff of an easily reversible procedure without disruption of the GI continuity is good enough & are willing to accept more treatment failures.