There is one statistic under represented and it's popping up more and more. I was origiginally scheduled for a RNY and flamed by many of those same people on OH but I hung in there. I kept reading. But I read more than just the DS board, I read the Main board, and all the other ones I could.
My original surgeon would not do a DS on me as I am a LW (pulled into his office at 35.2 BMI) and he said he only did 50 and above. What I did not know was his partner did do LW's. Had I known, I would have started with him first.
But after a couple of months of lurking and doing my own research, I came to the conclusion I needed a new surgeon. One willing to handle a LW DS. So I went hunting.
Now there were two reasons I did that. One, I have to have celebrex for spinal arthritis. Right now I am coping but miserable. Normally on celebrex, my pain level is a 2/3, right now, it's 4+. A RNY would rule that out. And I was already taking the alternatives with the celebrex. My insurance company approved the surgery but not my out of state surgeon so I had to find an in state surgeon...turns out the only one willing to do a LW was my original surgeon's partner. I was working on my third appeal to the insurance company when they agreed to let me switch.
Second reason is Reactive Hypoglycemia. I have type II diabetes and have RH within it already. I did not need to aggrevate the situation with adding that to my plate. And more and more threads were popping up on OH about that issue.
After doing research on many aspects of both, the DS is better not just for resolving diabetes but for keeping it away from your door down the road. I spent much time over on the RNY board and time after time, I saw threads about hypoglycemia. So I looked it up on my favorite diabetes format, the endocrinologists that TREAT diabetes.
Here is what I found:
Endocrine News http://www.endo-society.org/endo_news/2009/upload/Endocrine-News-February-2009-part-I-of-IV.pdf
Patients who undergo Roux-en-Y gastric bypass surgery (RYGBP) experience many benefits such as dramatic weight loss and type 2 diabetes remission. Yet, they also face a risk for developing severe postprandial hypoglycemia due to gastric dumping.
Researchers have observed elevated levels of the incretin glucagon-like peptide 1(GLP-1) postsurgery, which has been linked to increased β-cell proliferation and differentiation. A research team led by Josep Vidal, M.D., Ph.D., at the Hospital
Clínic Universitari in Barcelona, Spain, investigated whether a rise in this hormone could over time cause this severe setback.
The team divided 24 women into three groups according to time after RYGBP (9–15 mo, 21–30 mo, and > 30 mo). Controls were 8 additional normal weight and 8 morbidly obese women. The subjects fasted overnight and ate a standardized test meal the following day. Blood samples to measure GLP-1, immunoreactive insulin, plasma glucose, and glucagon were taken beforeeating and 10, 30, 60, 90, and 120 minutes after the meal. The patients also underwent an intravenous glucose tolerance test to look for insulin secretion and insulin sensitivity and used a continuous glucose monitoring system to record their postprandial glucose profiles.
In an upcoming article in The Journal of Clinical Endocrinology & Metabolism,* the researchers report that although GLP-1 rose steadily after RYGBP, it did not eventually cause inappropriate insulin secretion. Additionally, their data did not reflect a link between asymptomatic postprandial hypoglycemia in the RYGBP-operated women and an unsuitable relationship between β-cell function and insulin sensitivity. The researchers called for further studies to examine why some patients develop severe postprandial hypoglycemia.
While that article says there wasn’t enough evidence at this time, it did give me pause in that they are even considering the issue.
Then there was a blog article from the EndocrineToday that intrigued me:
Hypoglycemia after Roux-en-Y surgery for weight reduction
Posted by Michael Kleerekoper, MD, MACE April 7, 2009 11:26 AM
Endocrine Today Blog http://www.endocrinetoday.com/blogs.aspx
Seven years ago, my patient had a Roux-en-Y procedure to fight her obesity, and the result was just what she wanted — substantial weight reduction and “no more diabetes” as she reported with a huge smile. Her weight had been stable for a few years, and she was comfortable with it. Four months before her office visit, and for reasons she could not explain, she felt the need to go on a weight-reduction diet during which she lost 12 lb. Two months before she was referred to me, she began to experience episodic hypoglycemia. In her early post-surgery period, she had experienced very typical “dumping syndrome” symptoms, but they had finally cleared and the recent episodes of hypoglycemia seemed quite different.
At 10 p.m. one evening, she felt weak and her capillary blood glucose was 50 mg/dL. This was several hours after dinner. Over the next several weeks, she had a CBG of 53 at 7:45 p.m., 59 at 10:30 p.m., 45 at 3:30 p.m., and most worryingly to her, she woke at 1 a.m. one night feeling very unwell and disoriented, and her CBG was 45 mg/dL. She never experienced fasting hypoglycemia.
Physical examination was essentially normal aside from a suggestion of hyper-pigmentation of her abdominal scar and palmar creases. Pulse and blood pressure were normal as were visual fields and the thyroid examination. Her laboratory findings were also all normal, including electrolytes, fasting blood glucose of (89), insulin, C-peptide, cortisol and adrenocorticotropic hormone.
The history had many characteristics of the dumping syndrome, but several pieces of information did not quite fit. Dumping syndrome is not uncommon in the early months after a Roux-en-Y procedure, but patients generally adapt well by taking frequent very small meals, and over time, the syndrome seems to resolve. Additionally, why did the hypoglycemia occur only several hours after a meal and not sooner? She tried several approaches to changing her eating habits, but these episodes persisted.
I discussed this case with my colleague Dr. Anu Puttagunta, who had cared for a patient with much the same history. This late (post-weight-reduction surgery ) and delayed (post-meal) hypoglycemia has been reported,1, 2 but the mechanism remains elusive as far as I could tell from my reading. The articles reported that some patients did respond to frequent small meals that had little carbohydrate while others only responded when the diet change was accompanied by acarbose.
In some patients, it appears that acarbose alone was sufficient. Dr. Puttagunta’s patient did well with diet modification plus acarbose, so I have begun that same therapy on my patient. She had found those same articles on her own, had modified her diet and had no subsequent episodes of hypoglycemia, but that was not reassuring to her because they were so episodic. When adding the acarbose it was important to remind her to take the tablet (I started with 25 mg three times per day) as soon as she takes her first bite of food. I will report her progress after a few months.
1: Kellogg TA. Surg Obes Relat Dis. 2008;4:492-499. PMID: 18656831.
2: Moreira RO. Obes Surg. 2008;18:1618-1621. PMID: 18566871.
But was was the final straw that pushed me into the DS camp were the guidelines published for the Endocrine Society in March 2009.
Evaluation and Management of Adult Hypoglycemic Disorders: http://www.endo-society.org/guidelines/final/upload/FINAL-Standalone-Hypo-Guideline.pdf
An Endocrine Society Clinical Practice Guideline
First published in the Journal of Clinical Endocrinology & Metabolism, March 2009, 94(3): 709-728
Hypoglycemia can occur as a result of hyperinsulinism in the absence of previous gastric surgery or after Roux-en-Y gastric bypass for obesity. (pg8)
Some persons who have undergone Roux-en-Y gastric bypass for obesity have endogenous hyperinsulinemic hypoglycemia most often due to pancreatic islet nesidioblastosis, but occasionally due to an insulinoma (48–50). With nesidioblastosis, spells of neuroglycopenia usually occur in the postprandial period and develop many months after bariatric surgery. Spells of neuroglycopenia that occur in the fasting state soon after bariatric surgery are more likely due to a preexisting insulinoma (51). The predominance of women with post-gastric-bypass hypoglycemia may reflect the gender imbalance of bariatric surgery. The precise mechanisms of hypoglycemia remain to be determined (52–54). The incidence of this disorder is unknown, but at the Mayo Clinic the number of cases exceeds, by a considerable degree, that of insulinoma. Partial pancreatectomy is recommended for nesidioblastosis in patients who do not respond to dietary or medical (e.g. an a-glucosidase inhibitor, diazoxide, octreotide) treatments. (pg11)
I checked the document for any mention of the DS and there weren’t any but there were the two references to the RNY.
I have reactive hypoglycemia within my diabetes already. I don’t need a surgery that will make that worse.
All the browbeating, “yelling”, sniping, etc in my other posts discussing my options and TRYING to figure out what to do for ME, did not carry the weight as much as those articles and clinical guidelines did.
My insurance company approved the surgery but not my out of state surgeon so I had to find an in state surgeon...turns out the only one willing to do a LW was my original surgeon's partner. I was working on my third appeal to the insurance company when they agreed to let me switch.