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Why not the Duodenal Switch?


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#1 fattyfattyboomstix

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Posted 02 June 2010 - 06:33 AM

Still reseaching on best surgery for me and I came across the Duodenal Switch. To me, it seems to be a combination of vertical sleeve (alowing more nutrients into the body) and RNY (retrictive and malabsorptive). I'm wondering if there's a reason more people do not choose this option?
Here's some info I found on this procedure:
The BPD/DS combines restrictive and malabsorptive elements to achieve and maintain the best reported long-term percentage of excess weight loss among modern weight-loss surgery procedures.

The Restrictive Component
The BPD/DS procedure includes a partial gastrectomy, which reduces the stomach along the greater curvature, effectively restricting its capacity while maintaining its normal functionality.

Unlike the unmodified BPD and RNY, which both employ a gastric pouch and bypass the pyloric valve, the DS procedure keeps the pyloric valve intact. This eliminates the possibility of dumping syndrome, marginal ulcers, stoma closures and blockages, all of which can occur after other gastric bypass procedures.

In addition, unlike the unmodified BPD and RNY procedures, the DS procedure keeps a portion of the duodenum in the food stream. The preservation of the pylorus/duodenum pathway means that food is digested normally (to an optimally absorbable consistency) in the stomach before being excreted by the pylorus into the small intestine. As a result, the DS procedure enables more-normal absorption of many nutrients (including protein, calcium, iron and vitamin B12) than is seen after other gastric bypass procedures.

The Malabsorptive Component
The malabsorptive component of the BPD/DS procedure rearranges the small intestine to separate the flow of food from the flow of bile and pancreatic juices. This inhibits the absorption of calories and some nutrients. Further down the digestive tract, these divided intestinal paths are rejoined; food and digestive juices begin to mix, and limited fat absorption occurs in the common tract as the food continues on its path toward the large intestine.


#2 ansley

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Posted 02 June 2010 - 06:38 AM

Yeah its good but most Doctors/insurances wont pay for it unless you have a very high BMI. At least that is what I heard at the seminar!

#3 watfam4

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Posted 02 June 2010 - 07:27 AM

Malapsorption is higher with this procedure. It is usually only given to those with very high BMI. Also, diarrhea is a common issue after the DS.

IMO, the best procedure is the one that gets you to a "healthy" weight with the least amount of changes to your insides. Not the procedure that makes you loose the weight the fastest. Gastric surgery is not a quick fix...it is for the rest of your life.

I had the RNY and have lost 250 lbs. (starting BMI of 62) and I think it was the best procedure for me at the time. However, I have dealt with deficiencies in Calcium, Vitamin D, and Iron (and health issues related to these deficiencies). I am now religious about my vitamin intake (3 times a day, 7 days a week) and will need to be FOREVER if I wish to remain healthy. If there was another procedure available for me that would have allowed me to get to a healthy weight without the malapsorption issues, I would have gladly done it. (my $0.02)
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#4 fattyfattyboomstix

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Posted 09 June 2010 - 01:43 PM

Sorry for the late response. I've been investigating. It seems to me that while the complications associated with malabsorption are higher with the DS surgery, everything I've read indicates it has longer term success overall and so long as you watch vitamins, take your protein and do your regular lab work, you should be ok.
I am really after the longer term solution that has the least number of complications and highest quality of life (ie: I can eat an ok sized meal containing most things). I have seen people saying the RNY has caused them to stop eating certain foods all together because they can't tolerate them. The DS seems to allow you to eat most things, but if you do eat certain foods (broccoli for example) you may have gas problems. With DS you can chew normally, eat steak and other regular foods. Obviously every person is different with what they can and cannot eat. Given that I'm self pay, I'm trying to determine the best choice for me first time.
Did anybody else consider this surgery but decide against it for some reason?

#5 ansley

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Posted 09 June 2010 - 01:46 PM

My surgeon would only suggest it if the patient had a very very high BMI. If not he considered it dangerous. So basically it wasnt offered to me. Did you find a Dr that will do this surgery?

#6 fattyfattyboomstix

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Posted 09 June 2010 - 02:00 PM

Yes, there's many around that still do it. There's a top surgeon in Mexico. A couple in Texas and other places. The prices in Mexico range from $10,000 to around $14000 for my BMI, higher and it costs more I believe.
I'm seriously considering it for the long term aspect and the overall quality of life. No final decisions yet though.
When I had my original consultation with a surgeon here in Seattle, it was never discussed as an option. I suspect because he knew it would not be covered by insurance. I am just curious about how many people end up with RNY simply because DS is not covered by insurance, as opposed to whether RNY is the best surgery for them in their case. Of course, I know most need to rely on their insurance, but in my case since it won't be covered, I am free to shop around.

#7 AirForceW1fe

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Posted 09 June 2010 - 02:03 PM

Sorry for the late response. I've been investigating. It seems to me that while the complications associated with malabsorption are higher with the DS surgery, everything I've read indicates it has longer term success overall and so long as you watch vitamins, take your protein and do your regular lab work, you should be ok.
I am really after the longer term solution that has the least number of complications and highest quality of life (ie: I can eat an ok sized meal containing most things). I have seen people saying the RNY has caused them to stop eating certain foods all together because they can't tolerate them. The DS seems to allow you to eat most things, but if you do eat certain foods (broccoli for example) you may have gas problems. With DS you can chew normally, eat steak and other regular foods. Obviously every person is different with what they can and cannot eat. Given that I'm self pay, I'm trying to determine the best choice for me first time.
Did anybody else consider this surgery but decide against it for some reason?



Just so you know, self pay or not DS is such a drastic surgery that it is normally reserved for the super morbidly obese category. In fact I would consider a surgeon that would perform it on someone not in that category to be irresponsible. I looked into it when I first started looking into surgery and quickly decided along with advice from 3 surgeons that I met with that it was not for me. They would not perform on me even if I had wanted it.

It seems to me that while the complications associated with malabsorption are higher with the DS surgery, everything I've read indicates it has longer term success overall and so long as you watch vitamins, take your protein and do your regular lab work, you should be ok.

Nothing could be further from the truth with this statement, even for Gastric Bypass. We have many people on these forums alone that in spite of being diligent with their supplements have developed severe deficiencies and complications. Please do not go into either of these surgeries thinking that taking those steps ensure you won't have any issues. It's simply not true.

Just something you may want to keep in mind.
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#8 fattyfattyboomstix

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Posted 09 June 2010 - 02:05 PM

Thanks for the information. How do people ensure they are getting enough of the vitamins and protein then to ensure their success with their WLS (whichever option they go with)?

#9 fattyfattyboomstix

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Posted 09 June 2010 - 02:09 PM

It seems also (of course I'm still researching so please understand I don't know everything), that the biggest complication for DS surgery is the malabsorption. They don't have the same issues of ulcers, strictures, hernias and so on. Thoughts?

#10 mrwe

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Posted 09 June 2010 - 03:15 PM

When I asked my Dr. about why he doesn't offer the DS, he said this one sentence with such clarity that it shook me, "Because if something goes wrong, I can't fix it" Sold me, right then and there.
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#11 AirForceW1fe

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Posted 09 June 2010 - 04:01 PM

Thanks for the information. How do people ensure they are getting enough of the vitamins and protein then to ensure their success with their WLS (whichever option they go with)?


You just have to take the 200% of recommended daily allowances and hope for the best. Eat as nutritiously as you can and get labs done every 6 months. This will help your chances to lessen complications but it's by no means a guarantee.
Surgery Date- 7/14/09

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#12 fattyfattyboomstix

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Posted 10 June 2010 - 07:08 AM

In response to the comment about not being able to "fix" things if a problem occurs with DS such as malnutrition or even not losing enough weight. The DS surgery can be revised:

Duodenal Switch (DS) Revision Surgery

Approximately 2-5% of Duodenal Switch patients may be candidates for revision weight loss surgery. As we become more adept at understanding the balance between weight loss and malnutrition, the number of patients requiring revision surgery after duodenal switch will likely decrease, but never be eliminated completely. The most common reasons for the revising Duodenal Switch include the following:

excessive weight loss
inadequate weight loss
nutritional deficiencies caused by malabsorption
Some of the clearest issues requiring surgical correction after Duodenal Switch are nutritional deficiencies caused by malabsorption and excessive weight loss, both of which often occur simultaneously. As with most things, timing plays a significant role in success. As time goes on, the malabsorptive effect of Duodenal Switch decreases as the intestine becomes increasingly efficient at absorbing protein and other nutrients. Therefore, revising the Duodenal Switch should not be done too early in patients who experience malabsorptive complications, rather, conservative therapy should be attempted prior to revision surgery, allowing sufficient time for the absorptive abilities of the intestine to increase. If enough time is not allowed and revision surgery is performed too early, patients risk regaining excessive weight after the intestine has increased its absorptive abilities.

Treating malabsorptive complications resulting from Duodenal Switch most often require adding intestinal length or elongation. Elongations of the common limb are possible utilizing the biliopancreatic limb, to attain specific results. A relatively common elongation procedure requires elongation of the alimentary and common limbs, providing additional surface area for protein, starch and fat absorption. Increased fat absorption abilities in turn increases ones ability to absorb fat soluble vitamins such as vitamin-D. Treating excessive weight loss and protein malnutrition with revision procedures after Duodenal Switch, simultaneously increase a patients ability to absorb fat soluble vitamins.

The easiest revision procedure that increases both alimentary and common limb length involves a single connection to the small intestine; this is also known as entero-enterostomy and by some, the "kissing-X." The "neuro-endocrine brake" effect, generally enables patients to maintain some level of weight loss. The neuro-endocrine brake effect is also responsible for weight loss after Ileal Trasposition surgery.

Instances where calcium and iron malabsorption occur following Duodenal Switch, Ileal Transposition may be used as a means of intestinal elongation to treat these conditions. When Ileal Transposition is used in these cases, unlike a conventional Ileal Transposition, the Ileal Transposition can be done at the level of the duodenum, without having to re-connect the duodenum; after Duodenal Switch this is not an easy task. High Duodenal Ileal Transposition may only utilize a segment of the alimentary limb to perform the transposition. The rest of the alimentary limb is used for a "Parallel Ileal Transposition" at the level of the biliopancreatic limb. The Parallel Ileal Transposition joins the flow of food that resulted from the High Duodenal Ileal Transposition performed above. This restores calcium and iron absorption without entirely reversing the Duodenal Switch procedure.

There are some occasions where patients experience inadequate weight loss or weight regain after initial weight loss with Duodenal Switch. With the assumption that non-surgical weight loss attempts have been made and failed, there are two theoretical approaches to solve this problem,

reduce the stomach size
shorten the length of the common limb
While the results of these two revisions vary, reductions in stomach size seem to generate superior results over shortening the length of the common limb in North America.

#13 watfam4

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Posted 10 June 2010 - 07:28 AM

I would hamper to say that the majority of the 2%-%5 are those who were borderline for needing this drastic form of bypass in the first place.

And if you consider what the odds are for having complications during ONE gastric surgery, know that they are doubled for having two. GBS should be the very last option to loosing weight, and only then if it is absolutely going to add years to your life. Considerations for having revision surgery should not even be an option going in IMO.
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#14 ansley

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Posted 10 June 2010 - 11:01 AM

I would be weary of a doctor that will do a surgery you are too small to have. It sounds like a great concept to lose and not stop losing...but in reality it isnt.

#15 fattyfattyboomstix

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Posted 10 June 2010 - 12:45 PM

Jim, about considering the option for surgery revision, I was prompted to look this up after somebody else posted about this being a concern. I would never go into surgery expecting to fail in some way or other. It is very good to know where things stand though. I have always been highly compliant when I diet and I view this concern as a real compliance one too.

Most (almost all) of the candidates I have spoken with/ reviewed myself, had a BMI very close to mine (39-40). Yes, there are many who have extremely high BMI's too and I'm so glad there's a surgery out there that helps them. Overall, in my BMI range, it seems like people lose around 100 pounds and then stabilize. I could easily stand to lose 100 pounds. There's no comment about them madly stuffing themselves full of food to keep their weight on. If anything, they have learned to really use their DS as a tool since they can see the scale go up every time they consume a large amount of carbs or sugary foods in general.

The surgeons take many things into consideration when making the decision about the most appropriate surgery type. The surgeons I have spoken with are very interested in how long I have been obese and the family history of obesity, among other things. (I know you all know this from your own experience). There are still many surgeons in the US that offer this surgery. I can't afford their prices though.

Anyway, I do appreciate all of the input I have received about this topic. It really is an important decision that I need to get right, first time.

#16 ansley

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Posted 10 June 2010 - 12:49 PM

absolutely! Let us know what you decide! Good luck and we're thinking about you!

#17 cinwa

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Posted 10 June 2010 - 03:06 PM

I can't really add anything to what's already been said.

One thing I would recommend is that if you choose to get your WLS surgery done in Mexico or even out of state, you find a surgeon who's willing to provide you with post-op care BEFORE you have your surgery.

And that is particularly important if you decide to go with the DS because there aren't that many surgeon's offering the switch as an option compared to other forms of WLS.

Additionally, as your insurance won't cover the cost of a DS, if you choose that option and and self-pay, does that mean that you'd have to pay for all post-op care including complications?

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#18 shiver

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Posted 10 June 2010 - 07:47 PM

Additionally, as your insurance won't cover the cost of a DS, if you choose that option and and self-pay, does that mean that you'd have to pay for all post-op care including complications?


I don't know about her insurance. But with the surgeon I recommended to her (that a friend of mine and her family has used) does cover post-op appointments. But care for complications are extra.
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My Goal: 135 made on 2/8/11
On to: Dr. Goal: 120
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#19 fattyfattyboomstix

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Posted 10 June 2010 - 08:29 PM

Thanks for these tips.
About the complications, many surgeons in Mexico now offer complication insurance that you can take out (no matter what surgery I go for), that can cover me for several months after surgery, but not never ending! So yes, I would need to find someone local. I'm unsure about my insurance cover regarding this. I'm not sure how to discuss it with them without sounding the "alarm bells" on them and them placing a permanent record on my file when nothing's final yet..
Shiver - the surgeon you suggested doesn't do the duodenal switch. They may have done it in the past, but not anymore. Thank you very much for the thought though. It's always great to get personal recommendations. Apparently it's the most complex of the procedures and since many insurers will not cover it, surgeons are just stopping doing it and going with the RNY.

#20 ansley

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Posted 15 June 2010 - 06:17 AM

Did you decide which surgery you are getting yet? Enquiring minds want to know!