VSG surgery consultation questions

[Ruby11 7]

What are the most important questions to ASK on VSG surgery consultation?

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[RickM 1,747]

How many VSG's have they done (it should be several hundred to be comfortable that they know all the in's and out's of the procedure.)

Do they impose a liquid pre-op diet (other than the usual day before thing,) - I would be disinclined to deal with a surgeon who does as it implies that they still aren't comfortable doing the procedure; the most experienced guys out there don't do any at all as they want the patient as strong and healthy as possible come surgerytime, and fasting for weeks before doesn't do it.

[Ruby11 7]

The 2 weeks pre-op liquid diet is not a must to reduce the size of the liver b4 surgery?

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[Ruby11 7]

How many VSG's have they done (it should be several hundred to be comfortable that they know all the in's and out's of the procedure.)

Do they impose a liquid pre-op diet (other than the usual day before thing,) - I would be disinclined to deal with a surgeon who does as it implies that they still aren't comfortable doing the procedure; the most experienced guys out there don't do any at all as they want the patient as strong and healthy as possible come surgerytime, and fasting for weeks before doesn't do it.

The 2 week pre-op liquid diet is not a must to reduce the size of the liver b4 surgery?

[RickM 1,747]

The building consensus amongst the surgeons is that no amount of short term dieting will make a marked difference in the size of a fatty liver; what it can do is reduce a slime coat that forms on the surface of a fatty liver, which can make it somewhat easier to handle during surgery. Some surgeons need that extra help while others have developed the tools/skills to negate that need. What is needed to make such changes as can be done is a low carb diet leading up to surgery. Typically what most surgeons who do this recommend is a couple of Protein shakes a day, and a lean meat/green veg meal or two. The shakes aren't really necessary other than as a bridge to get the patient used to using them post-op (which is a good idea, whether one has a pre-op diet requirement or not - explore the different products ahead of time so you don't get stuck with something that you can't stand when you have no alternative post-op.) What the pure liquid diet that some surgeons impose is any body's guess - it's the low carb and restricted calories that is the functional aspect of the diet, not the liquid consistency. Some surgeons make their patients buy a specific product through their office as an additional revenue source.

The stomach only needs a few hours to empty to be ready for surgery (which is why the minimal requirement is usually no foods or liquids after midnight before surgery, though most push that back some and make it liquids only the day before in case they need to switch to a bypass during the operation.) Some surgeons vary their diet requirement based upon the patient's BMI or liver tests, which shows that they are at least considering the patients' condition rather than just a one-size-fits-all approach. This is certainly better than putting everyone on a liquid fast whether they need it or not.

Most of the surgeons that I am familiar with who specialize in the duodenal switch (which is a sleeve plus an intestinal rerouting which includes some rather fiddly work directly underneath the liver) don't require any extensive pre-op dieting, which leads me to conclude that they have developed tools and skills that negate the need for such diets. They have typically been doing sleeves for 10-20 years or more vs. five or so for the average bariatric surgeon, who typically has been doing them part time along with bypasses and bands. Those DS guys are the type of surgeon I prefer to have on my side.

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I wouldn't make an assumption that a doctor is less experienced bc of a pre-op diet. For many it would be the policy of the practice or hospital. And wanting every advantage possible is not a negative.

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[Ruby11 7]

Thank you

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[RickM 1,747]

I wouldn't make an assumption that a doctor is less experienced bc of a pre-op diet. For many it would be the policy of the practice or hospital. And wanting every advantage possible is not a negative.

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A pre-op diet unto itself is not such a big deal, though I certainly question those who do the fully liquid diets as those don't seem to offer any benefit over a simple low carb diet, but do present potential negatives to the patient. If they have other reasons why they may want to do such a diet, other than selling a product through their practice, I have not seen them expressed - it's always the 'shrink the liver' thing. If it is the policy of the practice or hospital, I would question the seniors involved in establishing their policies; if a hospital recruits a respected surgeon to practice in their facility, it is the surgeon who establishes such policies, one way or another.

It is really tough evaluating these guys - the surgeons themselves have a hard time at it unless they actually see their colleagues at work in the OR, or have occasion to see their work after the fact (not a good sign if another surgeon has to revise their work!) Some guys may be good at settling claims before they become official, so their record remains clean even if their skills may be marginal, others may have a clean record because they never do anything challenging while another may be more skilled and experienced but have some bad marks on his record because he takes on challenging cases and may have lost one or two. Which is better? Who are you most comfortable with? Patient reviews only scratch the surface (we aren't awake during surgery, and most of us aren't qualified to evaluate them if we were) only touching on tangential issues like bedside manner and office staff and rarely on long term outcomes - which is the most important thing. We need to look for indicators where ever we can.

My preference is to look for DS qualified surgeons (those who actually perform them routinely, not just list them on their CV and then sell you something else,) for the reason enumerated in the post above, but also owing to the DS being a technically challenging procedure (that does use the sleeve,) such that those who adopt it as a primary procedure tend to come from the top half of the class. They also tend to have broader experience, as most started out doing bypasses and moved to the DS in search of a more effective procedure, so they don't have a problem recommending an RNY if that is really in the patient's best interest; with most other bariatric surgeon, if they recommend a bypass over the sleeve (or wanting to revise a sleeve to a bypass,) there is always a question as to whether they are looking at the patient's interests, or what is most comfortable for them to perform.

Given that the DS has maybe a 5% market share, at best, this leaves another 45% or so of other surgeons who are also in the top half of the class that I have excluded. I don't know how to evaluate them, other than the basic number of specific procedures under their belt, and that isn't particularly helpful if you don't live near one of them, or can't travel to them. My surgeon is about six hours away from me, even though living in southern California there are bariatric surgeons on almost every street corner (though there are a couple of others I have found in the area since then that I would go to, though they came more from networking than from the usual vetting methods.)

It is certainly an imperfect selection process, but it beats randomly picking whoever is local that's in the insurance network.

[KristenLe 5,979]

@@rickm I have to correct you - it is not always the surgeon who establishes policies especially if they are part of a large group or hospital.