Duodenal Switch vs Roux-en-Y

LucilleBB
on 9/29/08 7:33 pm - St. Cloud, MN
Anyone care to give me some pros and cons that are easy to understand for each? I'm leaning towards the RnY, but am interested in hearing about both. Thanks!

Eggface
on 9/29/08 7:42 pm - Sunny Southern, CA
Here is a link that will lead you to all of our OH Surgery type forums. There are wonderful people on each forum that have had the various surgeries and can tell you the pluses and minuses they have found as post-ops.

http://www.obesityhelp.com/forums/

There is NO ONE SURGERY FITS ALL. It's definitely an individual choice. You can really select the "tool" that most fits you and your lifestyle.

I wish you the best in your fact finding,
~Michelle

Weight Loss Surgery Friendly Recipes & Rambling
 
www.theworldaccordingtoeggface.com 

LucilleBB
on 9/29/08 7:56 pm - St. Cloud, MN
Thanks, yes, I knew about these places. Just thought a quick answer on here would be good too. I appreciate your help!

Tammy_in_PA
on 9/29/08 8:30 pm - New Castle, PA
You'll get a lot more quick answers about the Ds if you post this on the DS forum...they are always ready and willing to give people insight into the surgery.
 Best Wishes,
Tammy                              

 

Entered Onederland 01-03-2010
Century Club  01-29-2010
Goal    06-29-2010
Batwingsman
on 9/29/08 8:53 pm, edited 9/29/08 8:53 pm - Garland, TX
 Check out the website www.duodenalswitch.com for a comparison of the two in detail ..   More specifically:

    http://www.duodenalswitch.com/procedure/ds_vs__rny/ds_vs__rn y.html

  And good luck whichever you choose .. 

Frank talk about the DS / "All I ever wanted to be was thin, like that Rolling Stones dude ... " 

 HW/461  LW/251 GW190 CW/322 (yep, a DS failure - it happens  :-(    )

MsBatt
on 9/29/08 8:54 pm
I chose the DS, because it just made more sense to me.

I liked still having a fully-functional stomach, no stoma (or the problems associated with a stoma, like strictures, marginal ulcers, and the possibility of a stretched stoma), no dumping, no danger of getting food 'stuck', and no 'blind pouch'.

I knew I'd always need to be able to take NSAIDs.

I wanted to be able to drink with meals, and to be able to chug-a-lug a big ol' glass of water when I was hot and thirsty.

Diabetes runs in both sides of my family, and since the DS has the best 'cure rate' for diabetes, I figured it would do the best job of protecting me against ever becomng diabetic.

High cholesterol also runs in my family, and the DS targets fat absorption. Since I've been absorbing only 20% of the fat I eat, my cholerterol numbers are WONDERFUL!

I knew myself well enough to know that I am NOT good at dieting. I felt that with the RNY, I'd just be signing up for a life-long low-fat, low-carb diet, and I knew I couldn't stick to that. With the DS, I eat a high-protein, high-fat, 'normal' carb diet, and I have enough malabsorption to allow me to eat enough to be emotionally satisfied as well as physically satisfied.

I'm better at "doing" than at "not doing". In other words, it's a lot easier for me to actively DO something like taking vitamins and supplements than it is for me to resist, or "not do" things like eat what I want when I want it. (Gee, if I could have done THAT, I wouldn't have needed WLS. *grin*)

And---I'd read studies that convinced me that the DS was my best hope of KEEPING the weight off, long-term.
Leslie
on 9/29/08 9:30 pm
I chose the DS for the wonderful post-op life and the malabsorption to help me KEEP the weight off! I've been maintaining my 160 lb weight loss for about 8 months and it's been effortless!! I love my DS.

My profile has several studies compaing the DS and the RNY and lots of pictures of how I can eat now! It's pretty amazing!

This is a nice comparisson chart from www.dssurgery.com

Best of luck to you with your decision and
keep doing your research!


Type of Operation RNY, Gastric Bypass,Roux-en-Y, LAP, RNY Duodenal Switch, BPD-DS,Distal Gastric Bypass with DS VBG Lap Band
Modality of Weight Loss Restrictive 1-3 ounce stomach Restrictive and Malabsorptive Restrictive Restrictive 1-3 ounce stomach (15cc)
Description A very small pouch of fundus connected to a limb of small bowel. Pyloric Valve bypassed. Sleeve gastrectomy, with ~8ounce pouch. Pyloric valve functional. The bilio-pancreatic secretions are kept separated from food to limit absorption except the last ~75cm of small bowel. A silastic ring is used to create a small pouch of stomach. An adjustable silicone constricting band is place completely around the very top part of the stomach creating a very small pouch.
Long term success Average. 60-70% Peak results 18-24 months [8],[9],[10],[11]>30% regained >15% or lost <50% [12] Above Average. 70-80% excess weight loss reported over long term follow up.[3],[4],[5],[6],[7] Poor. Only 26% of patients maintain >50% of excess weight
[12]
No long term studies yet available. At best should be similar to VBG.
Complications
Non Surgical
68.8% “continued” problem with vomiting, 42.7% plugging of the gastric pouch outlet.[13] 12% stenosis & 12% ulceration, with over all stomac complication in 20%.[14] Up to 76% of Patients develop Dumping Syndrome, with no association between severity of Dumping Syndrome and weight loss.[15] Fat soluble vitamin deficiency- Rarely seen with adequate dietary supplements, in addition to a normal healthy diet. Protein malabsorption- again with healthy well balanced diet far less common than seen in VBG or RNY patients with stenosis or who only consume high sugar/calorie drinks. 21% Vomit more that once a week.

14% have heartburn.[1]

Binging and purging very common secondary to pain.

89% of patients have at least one side effect.
Nausea and Vomiting 51%
Heart Burn 34%
Need for re-operation or removal as high as 25% [17]
Opinion “Gold standard” with frequent complications and hospital visits for patients 8. Technically a difficult operation to perform. Division of the post pyloric duodenum is a difficult step and could be dangerous in an inexperienced hand. Poor long term results with VBG[2] Actually not a new idea and was abandoned years ago. Some top surgeons in the field feel its resurgence will give bariatric surgery a bad reputation [18]
Summary A restrictive procedure rendering a patient to a very limited diet, with significant complications. Long term results acceptable. The best surgical solution available for treatment of Morbid obesity. Allows a patient to lead a normal life with normal dietary intake of meals in smaller volume, without the side effect of dumping syndrome, continued vomiting, plugging, etc. A restrictive operation with poor long term track record and numerous complications. Restrictive procedure with no long term studies. Preliminary results disappointing.[19]
Long Term Dietary Modification Significant dietary restriction. The unhealthiest diet after any weight loss surgery. Meat intolerance in majority of Pt.[16]Patients resort to high calorie drinks because can not tolerate “regular” meals Most balanced diets tolerated well with no adverse effects. Patients tolerate “normal” diet. Extremely poor diet- Patients are not able to consume any solids since it plugs the opening at the silastic ring.

 

The same as VBG
Nutritional Supplement

Individual patients requirements may differ. May also differ among physicians.
Multivitamin, Iron, B12, Calcium for life Multivitamin and Calcium for life. Multi vitamin, Iron, Calcium For life The same as VBG

 

[1] Balsiger BM, Poggio JL, Mai J, Kelly KA, Sarr MG, Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity, Gastrointestinal Surgery 2000 Nov-Dec;4(6):598-605.

[2] McLean LD, Rhode BM, Sampalis J, Forse KA Results of the surgical treatment of obesity. Am J Surgery 1993;165:155 - 59.

[3] Scopinaro N; Adami GF; Marinari GM; Gianetta E; Traverso E; Friedman D; Camerini G; Baschieri G; Simonelli A, Biliopancreatic diversion, World J Surgery 1998 Sep;22(9):936-46.

[4] Hess DS; Hess DW, Biliopancreatic diversion with a duodenal switch, Obesity Surgery 1998 Jun;8(3):267-82.

[5] Baltasar A; Bou R; Bengochea M; Arlandis F; Escriva C; Mir J; Martinez R; Perez N, Duodenal switch: an effective therapy for morbid obesity--intermediate results, Obesity Surgery 2001 Feb;11(1):54-8.

[6] Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M; Biron S, Biliopancreatic diversion with duodenal switch, World J Surgery 1998 Sep;22(9):947-54.

[7] Marceau P; Hould FS; Potvin M; Lebel S; Biron S, Biliopancreatic diversion (duodenal switch procedure), European J Gastroenterology Hepatology 1999 Feb;11(2):99-103.

[8] Balsiger BM et all, Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity. Mayo Clinic proc. 2000 Jul; 75(7):669-72.

[9] Oh CH, Kim HJ, Oh S, Weight loss following transected gastric bypass with proximal Roux-en-Y, Obesity Surgery 1997 Apr;7(2):142.

[10] Reinhold Rb, Late results of gastric bypass surgery for morbid obesity, J Am College Nutritio***** Aug;13(4):326-31.

[11] Avinoah E et all, [Long-term weight changes after Roux-en-Y gastric bypass for morbid obesity]. Harefuah 1993 Feb 15; 124(4):185-7,248.

[12] Brolin RE et all, Lipid Risk profile and weight stability after gastric restrictive operations for morbid obesity, J Gastrointestinal Surgery 2000 Sep-Oct;4(5):464-9.

[13] Mitchell JE, Lancaster KL, Burgard MA, Howell M, Krahn DD, Crosby RD, Wonderlich SA, Gonsell BA, Long –term Follow up of patients’ Status after Gastric Bypass, Obesity Surgery, August 2001,11(4) 464-468.

[14] Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe L.,Stomal complications of gastric bypass: incidence and outcome of therapy, Am J Gastroenterology 1992 Sep;87(9):1165-9.

[15] Mallory GN, Macgregor AM, Rand CS, The Influence of Dumping on Weight Loss After Gastric Restrictive Surgery for Morbid Obesity. Obesity Surgery 1996 Dec;6(6):474-478.

[16] Avinoah E, Ovanat A, Charuzi I., Nutritional status seven years after Roux-en-Y gastric bypass surgery. Surgery 1992 Feb; 111(2):137-42

[17] U.S. Food and Drug Administration, FDA Talk Paper T01-26, June 5, 2001

[18] NIH, Working Group on Bariatric Surgery, Executive Summary, May 8-9, 2002

[19] Doherty C, Maher JW, Heitshusen DS., “Long term data indicate a progressive loss in efficacy of adjustable silicone gastric banding for the surgical treatment of morbid obesity”, Surgery, 2002, Oct.;132(4):724-8









4 Years Post Op: At Goal And STILL Loving My DS!  
340/180/180  ~  5'11"  ~   I lost 160 lbs!!  
LBL & Hernia Repair: Done! Arm Lift: Done! Next Up: Thighs & Boobs!
Get the facts about Duodenal Switch at
DSFacts.com

scrapper5
on 9/29/08 9:43 pm - Burnsville, MN
You have already gotten some great information here.  I just thought that I would add in why I chose the DS over the RNY. 

I had failed at dieting, at every diet and I wanted a surgery that I was going to be able to live like a normal person.  I did not want to have to diet the rest of my life.  I wanted a few rules to follow and then go.  The DS provided that for me.  You need to eat a high protein, a little higher fat (which means full flavor), and limit the amount of carbs.  I knew I could do it.  This surgery made so much sense to me.  A normal functioning stomach, just smaller and three simple rules.  Easy.  Then the other items were to make sure to take supplements for life and have labs taken for life.  I knew I could do that as well.  It was a no brainer.

If this sounds like something you can do then it is the surgery for you.

Jennifer
 

 
carolinern
on 9/30/08 3:11 am - Toledo, OH
RNY on 04/16/08 with
Hi there,

I chose the RNY over DS because of the deficiences associated with DS.  I felt like the malabsorption issue was so much greater with the DS.  I also felt like anemia would be a much larger problem with the DS.  The RNY is a simpler surgery, is a great tool to help you loose the weight.  I was also afraid of the diarrhea the comes with DS because of the malabsorption.  You do have lots of restrictions with the RNY, but I thought that would be a small price to pay to be healthier.  Which ever you choose, you have to choose what is right for you.  Both surgeries can have great outcomes!!!  Good luck to you in your decision
MY JOURNEY BEGINS...

Anne S.
on 9/30/08 3:36 am
Please feel free to take a look at my profile. There's a comparison chart there. . . and lots of other information for newbies looking for info.

Good luck in your research.

:)
anne

Learning about the DS? An excellent resource is www.dsfacts.com
For scientific studies about the DS and more, "friend" me, and then click on my profile. Best of luck on your journey.

(deactivated member)
on 9/30/08 5:06 am - Woodbridge, VA
I think the most important thing is to decide what you can and can't live with for the rest of your life. Some people hope to experience "dumping syndrome" from the RNY (this does not happen with the DS) so they are "forced" to eat healthier (but not all RNYers experience dumping). If you want to dump, you'll have a better chance with the RNY.

With both procedures, you'll focus on "protein first" in your post-op way of eating. IMO, this is easier with the DS because you do not have to limit fat intake since you only absorb about 20% of the fat you eat, whereas some RNYers dump if they eat too much fat, I believe.

With both procedures, you'll also be on a lifelong supplementation regimen. This will likely include more supplements for the DS than the RNY.

With BOTH procedures (and this is a fact most people try to push only to the DS), you may experience diarrhea/gas issues post-op, and your stool and gas may smell different/worse than before surgery. There are, however, ways to deal with and even prevent it in most cases. Often, it is dietary choices that have this affect (many people find an increase in simple carbs results in worse BMs/gas). You can also take probiotics to help maintain a good balance of good/bad bacteria in your gut. And, when all else fails, there are some very discrete toilet bowl/air fresheners/neutralizers that work wonders.

I am chosing the DS for all of the above reasons (I don't want to dump, less restriction on fat intake, I can commit to required supplements, and, umm, my gas and poop don't exactly smell like roses before the surgery!). I am also chosing the DS because I have type 2 diabetes, and the DS indisputably has the best rate of remission for diabetes. It also has the BEST statistics for maintaining your weight loss long term (in studies as far out as 15 years from surgery). I'm young, so I want to KEEP my weight off! While we're on statistics, the DS also has the best chance at losing more of your excess weight. Long term studies show RNYers should expect to keep off an average of about 65% of their excess weight, whereas DSers can expect to keep off an average of 80%.

Finally, when an RNY fails a patient, they often seek a revision to the DS. The DS is basically the Big Kahuna of WLS. A surgeon in my area who performs all types of WLS (RNY, DS, band, sleeve, etc.) refers to the DS as the "bazooka" of WLS
LeaAnn
on 9/30/08 11:37 am - Huntsville, AL
DS on 11/28/05 with
When I began looking into WLS and was researching the RNY I was told that the POUCH would stretch over time and I would be able to eat more food. I wanted to know how this would be supportive of keeping the weight off long term. I was told that after a year of eating right that I should be in the habit and stay in that habit. Huh!? I know myself, I love to eat like everyone else, and I will slide back into old habits if I'm able! I clung to that slightly malabsorptive aspect of the RNY thinking that would perhaps help me keep some weight off. Then I read my RNY surgery pamphlet which stated I could expect to keep 50%-65% of my weight off long term. ?!?! I was doing more reading and research trying to see how people fared after doing this to themselves, and that's how I stumbled onto the DS.


The small stomach that is left intact with the DS will stretch back to a normal (but smaller) sized stomach with time. Opponents of the DS argue that the removal of the stomach is a bad thing. In fact, it is not a bad thing--the blind pouch left off to the side with the RNY is a bad thing. This blind pouch is inaccessible to endoscopy evaluation, thus you cannot be diagnosed in the future with problems such as ulcers or tumors, etc. This is why RNYers cannot take NSAIDs because of the potential for ulcer formation in the blind pouch. DS patients can take NSAIDS with no problem.

It is the malabsorptive portion of the DS that results in the superior long-term excess weight lost (around 85%). More of the intestines are bypassed in the DS than the RNY resulting in more malABSORBTION of calories, but NOT more malNURTRITION because of the superior digestion of a fully functional stomach instead of a man-made pouch.

Although the size of the stomach is reduced with this procedure, the
pyloric valve of the stomach, which controls the emptying of food
from the stomach into the intestines, remains in tact. With the RNY
there is a man-made pouch which allows food to pass freely through
the man-made "stoma" from the pouch into the intestines
resulting in dumping syndrome (a potentially-dangerous, sudden jump
in blood-sugar level caused by undigested food entering the
intestines), stomal ulcers, and vitamin deficiency due to poor
digestion. The malabsorption component of the Duodenal Switch as
relates to CALORIES from fat is GREATER than with the RNY because
more of the intestine is bypassed. The DS retains a normal,
functioning stomach with access to all the digestive juices, etc.,
rather than a man-made pouch.

Long-term excess weight lost and kept off is better with the DS.
After the “honeymoon” period of the first year or two of rapid weight
loss ends, 20% (or 1 in 5) of post-op RNY patients gain back 50% or more of
the excess weight lost. The DS combines both restrictive and
malabsorptive elements to achieve and maintain the best reported
percentage of excess weight loss, 80-85% with little or no regain.

The DS surgery without gastric reduction has been
performed on non-obese, diabetic patients since 1997 and is
increasing in popularity in Europe as an IMMEDIATE CURE for type II
diabetes. Latest studies on this technique report a 98% rate of cure.
This is attributed in theory to the malabsorption component of the
DS. The RNY does not cure diabetes. It only puts it in remission, and
the disease oftentimes comes back in two or three years--even if the
patient maintains most of their weight loss. It seems even a small
weight gain long-term (which is the norm) will cause diabetes
relapse.

Here's a list of careful studies which demonstrate the efficacy and safety of the DS procedure:

· Results of Ten Years or More Post-DS by Dr. Douglas S. Hess (128-138) (preprint which was recently published as "The Biliopancreatic Diversion with the Duodenal Switch: Results Beyond 10 Years," Hess, Douglas S.; Hess, Douglas W.; Oakley, Richard S.; Obesity Surgery, March 2005, vol. 15, no. 3, pp. 408-416(9) which concludes, “...it can be seen that the DS procedure is a safe and extremely effective procedure for weight loss, in fact more effective long-term than the more commonly used Roux-en-Y gastric bypass surgery. It is essentially a cure for Type II diabetes. Other long-term studies have shown little or no serious or irremediable nutritional sequellae, contrary to frequently expressed—but unsubstantiated—concerns. It has been successfully performed in our practice for over ten years, and for several years longer in other practices, and has in our opinion become, if not the “gold standard,” the “platinum standard” for bariatric surgery. 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” .


· The Duodenal Switch Operation for the Treatment of Morbid Obesity by Gary J. Anthone, MD; Reginald V. N. Lord, MD; Tom R. DeMeester, MD; Peter F. Crookes, MD (188-189). This study included 701 patients who underwent longitudinal gastrectomy with duodenal switch operation. The mean loss of excess body weight exceeded 65% at five or more years. Perioperative mortality was 1.4% and morbidity was 2.9%. The study concludes, “the ...duodenal switch is a safe and effective primary procedure for the treatment of morbid obesity. It has the advantage of allowing acceptable alimentation with a minimum of side effects while producing and maintaining significant weight loss. These results are achieved without developing significant dietary restrictions or clinical metabolic or nutritional complications” .

· Duodenal Switch: an Effective Therapy for Morbid Obesity—Intermediate Results (190-194): Published in 2001 in Obesity Surgery, this article reflects the intermediate results of Dr. Baltasar’s DS study which has been ongoing and reported for several years. Dr. A. Baltasar is chief of Surgical Service; Surgical Staff; Surgical Resident; at Virgen de los Lirios Hospital, Alcoy, Alicante, Spain: 125 patients were in the study from 1994 to 2000. No patients were lost to follow-up. Dr. Baltasar reports the DS as “the most effective operation to lose weight” (193). He cites a major benefit of the surgery as patient quality of life in that patients can eat virtually all foods and do not suffer the major restriction of the restrictive Roux-en-Y gastric bypass procedure. The weight loss has been consistent with the other studies.

· Biliopancreatic Diversion with a Duodenal Switch (195-216). In 1998, Dr. Hess of Bowling Green, Ohio, published a 10-year follow-up report on the first 440 patients to undergo his BPD/DS proceudre in Obesity Surgery, the leading journal addressing issues related to surgical treatment of morbid obesityh. Generally considered the “father” of the DS operation, having integrated the Scopinary BPD with Dr. DeMeester’s DS procedure, Hess reported his results on 440 patients. The paper outlines many advantages to the DS procedure and states, “this method of surgery has been the most successful for patient weight loss that we have used so far” (216).

· 1998 Scopinaro Report (217-236): The BPD procedure (without the duodenal switch), on which the BPD/DS is based, was first performed in 1976 by Dr. Nicola Scopinaro of Italy. In 1998, Dr. Scopinaro published a 21-year follow-up report on a series of 2241 BPD patients. This report concludes that the BPD is “the most effective procedure for the surgical treatment of obesity” (233).

· Biliopancreatic Diversion with a New Type of Gastrectomy (172): In 1993, Dr. Picard Marceau of Laval, Canada, published a report on the benefits of the BDP/DS procedure over the unmodified BPD. This report confirms that the DS procedure eliminates or greatly minimizes most negative side effects of the original BPD (172).

· Nutritional Markers following Duodenal Switch for Morbid Obesity (567-574): This study was published in the 2004 Jan:14(1):84-90 issue of Obesity Surgery and concludes the the DS “is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated” (568). This study was submitted to dispute the claim made in BC/BS’s policy that “BPD with or without Duodenal Switch has malabsorptive properties and eventual metabolic complications have been demonstrated” (547). This assertion is simply not true any more for the DS than for the RNY which BC/BS readily covers.

· Comparison of Nutritional Deficiencies after Rouxen-Y Gastric Bypass and after Biliopancreatic Diversion with Roux-en-Y Gastric Bypass (Abstract of a study published in Obesity Surgery in August 2002) (576): This study concludes that there is no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P=0.0294). This study was submitted as this was the only DS-related study listed as a reference (263) by the Anthem Blue Cross Blue Shield policy (253-269), which deems there is sufficient evidence to support the BPB/DS (254).


Among the advances of the DS procedure is the absence of dumping syndrome (a potentially-dangerous, sudden jump in blood-sugar level caused by undigested food entering the intestines through a man-made opening), stomal ulcers, and vitamin deficiency commonly seen with the Roux-en-Y (RNY), the compulsory procedure covered by BC/BS of AL (165, 170-237, 267, 559). With the DS, the patient retains their naturally functioning stomach (although the volume is reduced) along with the pyloric valve or natural exit from the stomach to the intestines rather than a problematic, man-made “pouch” as with the RNY (165). Other advantages of the DS are better sustained long-term excess weight loss, a 98 percent cure (181, 183) rate for type II diabetics and ability to take NSAIDs, non-steroidal anti-inflammatory medications. Another advantage still is that the entire stomach and duodenum can be visualized by endoscopy, unlike the RNY which divides the stomach into an upper and lower pouch, the lower of which cannot be visualized endoscopically (165).

Among the advances of the DS procedure are the following:

· Rarity of dumping syndrome (a potentially-dangerous, sudden jump in blood-sugar level caused by undigested food entering the intestines through a man-made opening), commonly seen with the Roux-en-Y (RNY).

· NO stomal ulcers commonly seen with the Roux-en-Y (RNY).

· The DS patient retains their naturally functioning stomach (although the volume is reduced) along with the pyloric valve or natural exit from the stomach to the intestines rather than a problematic, man-made “pouch” as with the RNY.

· Better sustained long-term excess weight loss and, unlike the RNY, a low failure rate.

· A 98 percent cure rate for type II diabetes.

· The ability to take NSAIDs, non-steroidal anti-inflammatory medications.

· The entire stomach and duodenum can be visualized by endoscopy, unlike the RNY which divides the stomach into an upper and lower pouch, the lower of which cannot be visualized via endoscope.

· DS surgery results in little to no nutritional or metabolic complications as long as the supplementation regime (required for any weight loss surgery) is followed carefully.

· DS surgery results in a superior quality of life to RNY in that patients are able to enjoy eating a normal, balanced diet with no specific food restrictions.

· NO stomal plugging and less vomiting.

LucilleBB
on 9/30/08 1:11 pm - St. Cloud, MN
Wow! You have been very helpful with a lot of information! I appreciate it greatly!