IFSO -Paris, France 2009

Recently I had the chance to journey to Paris, France for the IFSO International Federation for the Surgery of Obesity. The conference is held annually in a different city (world-wide).

This years’ conference focused mainly on topics relating to AGB success, VSG - Bougie size and outcomes, DS Duodenal Switch procedure.

As to not bore my readers I want to summarize the prevailing thoughts presented by the conference.

Regarding AGB - Adjustable gastric banding;

-The overall consensus was the band works in both <60 and >60 BMI however, the long-term outcomes become questionable around year 7. The conference doctors mentioned that while the per case outcomes are based and/or skewed by the BMI the resulting long-term outcomes didn’t support the AGB as long-term surgery solution for obesity rather it was mentioned in more than one setting as a secondary ‘revision’ or in addition to RNY (Dr. Mal Fobi) Over the surgeons agree that the AGB is a safe procedure that provides nominal outcomes (success <50% of EWL -excess weight loss) However, in contrast the definition of a successful surgery was presented as any surgery that produces >50% EWL over time. (7 or more years)

Considerable differences were demonstrated among the presenters leaving one to formulate their own conclusion that the AGB has applications but in some case may or may not be the primary surgery of choice for some patients. This would of course be determined by the surgeon and patient.

Regarding VSG - vertical gastric sleeve

The VSG was presented with considerable favor by 99% of all the presenters. In short the VSG is a stage (1) procedure in the Duodenal Switch operation. However, the procedure itself can be, as was asserted by many presenters, be a primary procedure in and of itself.

The VSG is performed by creating a long cylinder type pouch using the current stomach as a guide. A “bougie” is used to create the correct cylinder pouch. The bougie is very similar in look to a piece of PVC pipe and is used in effect as a stencil for the pouch size. Bougie size used was commiserate to BMI and the aggressiveness of the surgeon.

The data presented demonstrated that VSG results over-time offered equal or greater success (again the same ration >50% EWL) than the RNY procedure. Additionally because the VSG is not a malabsorptive procedure the vitamin deficiencies, dumping, and other issues related to malabsorption are not present. The outcomes presented showed that at or around year three post VSG the patients had met or exceed the success of the RNY (without malabsorptive restriction). This leads the lay-person to conclude that the VSG may become the primary choice for surgeons in the U.S. over the next three to five years as training and insurance companies catch up to the international momentum. Indeed, recently VSG was coded for insurance approval and is being performed under insurance approval in the U.S. at this time.

Duodenal Switch

Of all the surgery types presented certainly the DS is the most radical of all surgeries. The procedure is the most radical of the major surgery types AGB, RNY, VSG. In times past the DS was red flagged by many U.S. surgeons as ‘too aggressive’ or ‘too risky’. Thus, the surgery has had a small but dedicated fan base. The surgery is being performed in only a handful of U.S. cities.

The outcomes presented in patient with BMI >50 seemed strikingly good (maintained weight loss over time) however, as would be expected the surgery produces a varied array of malabsorptive issues if the patient is malcompliant in daily nutrient supplements. Overall the DS can be viewed as a favorable surgery choice for any patient of a super morbidly obese classification. Now that the surgery data is in its ten year it can be expected that additional surgeons will begin to perform the DS surgery in the U.S. The majority of the presenters demonstrated that DS is an effective treatment for obesity but should be performed with strong understanding of after-care compliance.

I hope you gleaned from the IFSO information. No part of this is an endorsement or one or other type of surgery however, a simple “reporting” of the conference. I have not drawn many conclusions from the information given because I am not a medical professional but I have learned what the international community feels about the major surgery types.

From my point of view:

While I am not a surgeon or medical professional I am a patient of whom has already had several surgeries in an attempt to control obesity. My surgery resume:

• RNY 2002
• Hernia repair 2003
• Plastic Surgery I 2004
• Plastic Surgery II 2005
• Stomaphyx. 2007

I began my journey at 626 losing >200 lbs in the first six months. Peaking my weight loss at 385 lbs I found myself at 241 lbs in January of 2005. Since then I have struggled to keep every lb off. My pouch was dilated and measured in 2007 and found to be 200+ cc’s. This is gargantuan compared to pouches of today. In 2002 when I consulted with my surgeon I had no idea of DS, VSG, AGB etc. I only knew about RNY because that was the ‘gold standard’ at the time. Like any procedure the technique and outcomes are perfected over time. I find myself now nearly eight years out form surgery having regained about 120 of the lost 385. That places me very near to the ’success’ and ‘failure’ break-even point. I am hovering at 52% of EWL (success?) it depends on if you measure where I came from, where I have been, or where I want to be?

I choose daily to consider my surgery a success and my new life a testimony to that success. However, many people may view my journey with a bit of skepticism because they remember me at 241 and not 366. To those persons I would say you have entered the ‘play’ at Act III of a five act play. The excitement that built in Act II (being 241 lbs) has let down in Act III and now the conclusion looms. If you are just joining my play in progress you might see my before pictures of 626 and not realize the up and down struggle I have been facing. You view point might be “wow…you look great”. But, because my mind and body remembers the 241 with a longing sense of awe I might not agree with your assessment. But, I have to NOT see that 241 because it creates a negative self image for me. I have to view the 626 and remember just how far the journey has brought me.

So what happen in Act V? How will this play close? I do not know. I wish I had known about VSG in 2002. I wish I had a cure for this disease. But, I choose each day to fight rather than give up. I am considering surgery #5 (revision). I do not know if I can force myself to endure it but as a thinking and logical person I have to concede that losing another 100lbs would prolong my life 10 to 15 years. Thus, I sit her today writing this blog for others and myself.

Thanks for joining my play….come in the next act starts soon.