Wednesday, July 18, 2007

More Information about the DS

Here is some more information on the DS. Regardless of being self-pay or covered by proactive for the surgery that will BEST benefit you.

It is a sad truth that there is a lot of misinformation being circulated about the duodenal switch (DS) procedure. Even more sadly, much of it comes from RNY surgeons and their patients, who have various degrees of vested interest in promoting their surgery (or in certain cases, dissing WLS altogether). I would hope that each and every potential WLS patient who is researching what to do about treating his or her morbid obesity has access to the FACTS before making the decision about which surgery to have.
For a number of years, insurance approval has been the vehicle by which access to the DS procedure has been limited -- most of the largest insurers, including Blue Cross, Blue Shield, Aetna and Cigna, have cited misleading information and each others' policies to claim that the DS is "experimenal," "investigational" or "unsafe and inadequately studied." However, the papers cited by these insurance companies to support this allegation are often not even related to the correct procedure.
When the DS was introduced, it was an improvement over the Biliopancreatic Diversion procedure, or BPD -- unfortunately, this led to the procedure being called the BPD/DS, which is a misnomer. While the intestinal part of the BPD is essentially the same as the DS, the stomach part is VERY different. The problems with the BPD are much more like a distal RNY than the currently practiced DS, as the BPD involves removing much of the lower part of the stomach, including the parts that absorb vitamin B12 and iron, and the pyloric valve, and BPD issues include potentially serious malnutrition issues. What insurance companies often do is to cite papers discussing the very real problems with the BPD (which is rarely performed anymore) against the DS, which is quite inappropriate. In addition, they completely ignore the growing body of scientific evidence that is approaching 20 years of study on the DS and the wonderful results that have been established.
Over the past several years, and due in no small part to the steady pressure exerted by patients demanding the DS procedure, there have been numerous inroads made into educating both the insurance companies and the external reviewers who end up ruling on the appeals of die-hard DS wannabees. The tide appears to finally be turning, as one after another insurance company is beginning to acknowledge the beneficial effects and safety of the DS. Blue Cross of California has recently changed their official policy to permit the DS, and it seems from recent legal challenges that Blue Shield will not be far behind. The national Blue Cross/Blue Shield Technology Evaluation Center assessment of the DS is currently being reviewed as well, and there is a good possibility that they will reclassify the status of the DS. The most recent CPT Code book for 2005 has given the DS a new, Category I, code number, indicating that it is now a generally recognized procedure and not still being evaluated for safety and efficacy.
In addition to the many published articles that have come out recently praising the DS procedure (available on request), there is now an almost astonishing new source of analysis and validation of the procedure -- the external reviewers of the Center for Health Dispute Resolution of Maximus. This organization has been contracted to perform external reviews for 25 states, Federal government employees and Medicare/Medicaid appeals. They now appear to be taking the position that essentially ANY patient (including those with a BMI under 50) should qualify for the DS, and that insurers are improperly refusing to acknowledge this. One of the most available sources of information about this sea change is the published decisions of the California Department of Managed Health Care, which is the agency to whom California HMO participants appeal denials of coverage.
Needless to say, organizations such as CHDR are inclined to be very conservative, since they are hired by politically influenced state agencies -- as you can imagine, it is likely that the insurance companies will have SOME input to how such state reviews are conducted. In addition, these organizations are also performing PRIVATE external medical reviews for insurance companies which are able to chose who will perform the external reviews of their own decisions. So it is in my opinion a significant fact that CHDR is now supporting the DS and overturning almost every denial that comes their way, at least in California (which is the only source of published opinions I have found -- I will be happy to provide the link to it on request, because putting it here will make this posting difficult to read, since it will stretch out the entire posting and all posts in response sideways to accommodate the entire link). (*Leslie's Edit: This is the link: )
Here are some quoted comments on the DS in these published decisions by CHDR, which has NO vested interest whatsoever in seeing this procedure being more commonly performed, other than their own intellectual honesty:
* Techniques in duodenal switch have been available since the 1980s. There is now sufficient data to show that duodenal switch has a superior long-term outcome when compared to gastric bypass.* In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. * Long-term studies of the duodenal switch procedure demonstrate equal effectiveness with less need for a highly restrictive diet than with gastric bypass.* There is a significant risk of marginal ulceration with the standard gastric bypass that does not appear to be present in the duodenal switch procedure. * The data strongly supports the high failure rate of Roux-en-y gastric bypass in patients who are super morbidly obese.* Review of the medical literature indicates revisional weight loss surgeries have a high complication rate. A patient who has failed a restrictive operation (Lap-Band) is more likely to fail another restrictive operation longer-term unless a malabsorptive element is added. The study cited above reported high incidence of protein and nutritional deficiency after revision of gastric bypass to distal gastric bypass. Furthermore, a patient with a BMI of 48 may have a high failure rate after a restrictive procedure. A more suitable option may be a hybrid procedure such as duodenal switch.* The duodenal switch procedure has a track record greater than 15 years. The anticipated complications associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch.* At the 2003 American Society of Bariatric Surgeons meeting held in Boston, Massachusetts, scientific papers were presented, which indicated there is growing evidence that protein malnutrition is a much larger problem post gastric bypass than was initially suspected.* Techniques in duodenal switch have been available since the 1980s. With duodenal switch, patients lose weight in the range of 69% to 80%.* Complications have been reported to be comparable to other operations. Multiple vitamin deficiencies, mineral deficiencies, bacterial overgrowth issues seem all to be comparable and less than other alternative surgeries. Hundreds of duodenal switch operations have been performed on patients in California and they appear to have a good track record of positive results.
In addition to this clarifying information about the safety and efficacy, I also want to make people understand that the "socially unacceptable" side effects of the DS surgery are often exaggerated in the extreme by those who don't have actual information from real patients to be making such statements. Again, sometimes this is confabulation of the problems associated with the BPD to apply to the DS, which is inappropriate. Sometimes, it is purely to steer patients from a surgery the surgeon doesn't perform (the DS) to one they do (the RNY or LapBand). Here is my experience, which I have substantially in common with most DSers:
* I have a bowel movement every morning as soon as I wake up. Sometimes, I have another one after breakfast, IF I am still at home. Sometimes, I have another one shortly before bedtime. I NEVER have to go poop outside my house (except when I'm traveling, of course, and then only at the hotel). I do not have diarrhea, uncontrollable need to poop, or anything like that. In fact, my post-op issues with IBS have significantly improved, and my bathroom habits are BETTER than they were pre-op. It smells somewhat worse then it did pre-op, but not that much worse, and a quick spray of Ozium takes care of any lingering smell.* I fart, and it stinks, IF AND ONLY IF I have eaten some of the foods that disagree with me, such as white bread, most pasta, onions, beans and broccoli. This will happen 4-6 hours after eating such foods, so I can still eat them if I know I will not be around people (other than my family) when it kicks in. I can also take Gas-X and smell-reducing agents such as Beano, Devrom or Innermint with the meal to ameliorate the gas. It is entirely dealable with, and not really worse than it was pre-op with my IBS issues. The gas WAS more of a problem in the first 2-3 months after surgery, but it has gotten a LOT better since then, both because I have learned how to manage my diet and because my body has accommodated. Plus, I take a probiotic every day to help maintain my internal flora.* I take the following vitamins at 15 months out, and my one year labs were perfect: One prenatal vitamin, and 4 calcium citrate pills. That's it. No malnutrition or protein or vitamin deficiencies. I don't even need to supplement the fat soluble vitamins A, D, E or K.* I don't diet anymore. I eat what I want, starting with protein. I can eat about 2/3 of what I used to eat and I feel full -- comfortably -- when I'm done.* I don't barf, ever, even if I overeat (which I'm less inclined to do, though sometimes I eat reflexively while watching TV). At worst, I get a little uncomfortable, and I immediately stop. No nausea, ever, either.
There's more, but you get the picture? The so-called "socially unacceptable problems" that you probably have heard about the DS are for the most part, scare tactics, a myth and I daresay a LIE.
Other facts that should be understood (from a preprint of an ongoing study by Hess et al.):
* The DS is a CURE for type II diabetes. In Europe, the intestinal part of the DS is being performed on people who are not obese to cure type II diabetes. There is data going out over 10 years now demonstrating the cure rate is 98%.* The average excess weight loss at ten years is 76%. * 94% of 10 year out patients are in the satisfactory category (50% or more excess weight loss). * There are no foreign materials used. * The pylorus is retained and controls the stomach emptying. * There is no small stoma that could dilate causing failure, allowing the patient to eat normal meals. * There is no dumping syndrome.* If the patient takes vitamins and minerals as instructed, as well as eats sufficient protein as instructed, which is easily accomplished eating normal food and without “protein shakes” or other supplementation, they will have little or no malnutrition issues. * The average lab results on a ten year cohort are all within the normal range.* Long-term studies have shown little or no serious or irremediable nutritional squellae, contrary to frequently expressed – but unsubstantiated – concerns. * It is certainly no longer considered an experimental or investigational procedure, either by the American Society for Bariatric Surgery (ASBS) or by the surgeons who perform it.
It is still true that there are not that many surgeons offering the DS as compared with the RNY. It is a more difficult procedure to learn and to perform properly, as the tissue of the duodenum is harder to stitch. You ONLY want an experienced surgeon performing this procedure on you (but that's true for ANY surgery). Many insurance companies are still balking at covering it, but if pressed, they often will cave in, and more of them are now accepting it. But you must ask yourself, which surgery can I live with for the rest of my life -- which will give me the BEST quality of life, as well as ability to maintain my hard-earned weight loss without constant dieting? For me, there was only one answer, and that was the DS. (Written by and posted with permission by Diana Cox)
Good luck to everyone in making the best and most informed choice you can.
A short and easy description of the DS procedure
Duodenal Switch
This procedure modestly restricts food intake while radically limiting the absorption of calories, especially the obesity causing calories from fat, complex carbohydrates, and starches. Approximately 3/4 of the stomach is removed, but the natural outlet of the stomach, the pylorus, is left in, allowing the stomach pouch to function more naturally. As the stomach pouch stretches out in the first year after surgery, patients are moderately limited in the amount of food they can eat, reduced to about 2/3 of what they could eat before surgery. However, patients are not limited in the types of food they are able to eat, tolerating meats and whole vegetables without difficulty.
The food is rerouted through a radically altered intestine, limiting the amount of food that is absorbed, which is what results in weight loss, despite the patient eating freely. The intestine is essentially reduced to less than half of its length and the digestive juices (the biliopancreatic secretions) mix with the food at only the last 10% of the intestine.
Patients undergoing duodenal switch eat normally and have bowel habit changes characterized by frequent (2-4 per day) soft stools and a propensity for gas. Both of which are generally malodorous unless a stool deodorant (such as Devrom) is taken.
The stomach is trimmed to a 4-6 ounce volume, preserving its natural inlet and outlet ( the pylorus). Trimming the stomach results in a temporary restrictive effect on eating for several months, which then reverts to normal, and decreases the incidence of ulcer formation as well.
The small intestine that the stomach normally empties into (the duodenum) is "switched" to the downstream portion of the small intestine (the digestive limb-D). The outflow from the duodenum, carrying the digestive juices and enzymes (but no food) becomes the bilio-pancreatic limb (C) utilizing approximately 60% of the small intestines length.
The digestive limb takes up approximately 40% of the small bowel length, and most of this length is upstream from where the biliopancreatic limb deposits its juices to allow for the absorption of fats, starches, and complex carbohydrates.
The common limb, being the portion of intestine where both food and biliopancreatic outflow meet, is made up of the most downstream 100 cm of small intestine and is the only portion where absorption of dietary starches, fats, and complex carbohydrates occurs. The capacity for absorption reaches a maximum within several months after surgery and cannot be over eaten, resulting in long term sustained weight loss..
The gallbladder and appendix are removed.__________________________________________________________________________
Swiped from BT, just too good not to add here....
Both the DS and the RNY have two parts to the surgery - what is done to the stomach (restrictive part) and what is done to the intestines (malabsorptive part). In the RNY, they section off the majority of the stomach which remains in the body, but unused (thus the term gastric bypass). Because this area is 'blind' - not accessible via oral medication or endoscopy, RNY'ers are advised to avoid NSAIDS or non-steroidal anti-imflammatory drugs such as aspirin or ibuprofen due to the potential for ulcers. DS'ers don't have this problem because there is no blind portion - the unused part of the stomach is removed instead, so we can take OTC drugs. For people with *other* problems, such as lupus or migraines or a family history of ulcers, this can be an important factor in their decision. The remaining portion (nicknamed The Pouch) is anywhere from 1-3 oz. (About the size of a large egg). This then feeds directly into a newly restructured part of the intestine with no valve regulating how quickly food moves from the stomach into the intestine. Instead of a valve, there's simply a hole - kind of like a doorway - which leads into the intestines. This is called a stoma. The stoma is not flexible, so it cannot expand if you try to put something through it that is too big. This is why RNY'ers are told to chew their food VERY well, and are advised AGAINST having fluid with meals, because just like a sink drain, solid stuff will go down easier if you 'flush' it down with water. Because there is no regulation there, three-fourths of all RNY patients suffer a syndrome called Dumping. For some people, dumping just makes them feel a little bad. Others vomit. Still others have a more severe reaction that feels more like a bad case of the flu, and a rare but potentially dangerous reaction can be like a diabetic attack. Dumping Syndrome can be both a positive and a negative factor - if you immediately suffer a REALLY bad reaction to eating sweets, you're going to learn (the hard way) to avoid foods that aren't good for you. It's called Aversion Therapy, and if you learn better from the stick than you do from the carrot, this will keep you on the straight and narrow. In the DS, they literally do a gastrectomy, removing the outer curvature of the stomach (making it physically smaller), but leaving the actual functionality of the stomach intact as it was before surgery. The remaining portion of the stomach is kind of "banana" shaped, and you start with about 3-5oz stomach - a little larger than the RNY, but still MUCH smaller than it is now. You have multiple places in your body where you have a sphincter type muscle - the one everyone is familiar with is your anus, at the 'bottom' (pun intended) of your intestines. Well, you have a similar 'ring of muscle' at the pit of your stomach called the pyloric valve. Because this valve remains in use, DS patients do not have any dumping because the pyloric valve is still regulating how often food moves into the intestines as it does for you right now. In both surgeries, the stomach/pouch will expand over time to about twice it's post-surgery size. This leaves long-term RNY'ers with about 3-5oz and long-term DS'ers with about 10-12oz. Then we move into the lower portion of the surgery, which is essentially the same for both with a few small, but significant differences. The small intestine has three sections/phases - called the jujuneum, the illeum and the duodenum. (Forgive my spelling if it's wrong - it *is* 4:30 in the morning)Right now, it is one continuous line. What they do is cut it in two and reattach them in a Y formation. One branch of the Y comes down from the liver with the digestive juices. The other portion comes down from the stomach (DS) or the pouch (RNY) with food. The two them come together into what is called the common channel which then has both digestive juices and food. It is in the common channel that most digestion takes place. (Some digestion takes place all throughout the whole digestive system, starting from saliva in the mouth, all the way to the colon)The primary differences between the two in the lower part are this:1) In the RNY, the common channel is generally longer - perhaps 275cm. In the DS, it's generally shorter - about 100cm. Everyone absorbs carbs like a non-WLS patient, but we malabsorb for protein, fat and calories - DS more than RNY, again due to the shorter common channel. The 'big' problem this causes the DS'ers is too much fat can cause bad-smelling gas and/or diarrhea - and it's the one thing everyone who has every heard of the DS has heard of. However, for MOST people, this isn't a huge problem, is easily controlled with products like Beano, and watching what they eat. 2) The Duodenum is bypassed in the RNY, and it is functional in the DS. What makes that important is that this is where protein, calcium, iron and vitamin B12 are absorbed. So even though the DS has a greater malabsorptive factor (the shorter common channel), it actually has more normal nutritional absorption than the RNY because the duodenum is still involved in the digestive process.Now - BOTH types have to watch what they eat, and be aware that they are susceptible to nutritional deficiencies. For the most part, these can be controlled with diet, but if your diet is out of control, you can do *severe* damage to your health if you ignore this. DS patients specifically need to make sure they take calcium & protein, and the fat soluable vitamins. RNY patients need to make sure they get protein, calcium, iron & B12. (Some need B12 shots, but not all). A person who has never had surgery needs about 60g of protein a day. RNY need about 80g. I've seen recommendations for DS patients of 90-120g. Everyone should take a multi-vitamin, and get exercise, with or without WLS surgery. A low-carb, high protein diet is recommended to make sure you get in your protein, and you'll find LOTS of suggestions on what to eat on every board - both food, protein shake and supplement-wise.


Terry in NC said...

Thank you for beginning this ambitious and informative blog!

There is both accurate and inaccurate information in this post. This is the part that is wrong: the post states in a couple of places that the Duodenal Switch causes malabsorption of carbohydrates. It doesn't! You will still absorb all of the carbohydrates you eat just as if you had never had the surgery. The absorption of fats and proteins are what is affected (as the latter part of the post correctly identifies). This is a critical point, because people who have had this surgery will need lots more protein than before.

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