Ok seriously I gotta ask in all seriousness, if the DS is soo superior why is it then that it is such a hard procedure to obtain. I mean he leading minds in professional medicine dont seem to agree with you. Insurance companys , whose interests is value for making you as healthy as possible dont agree. The vast majority of WLS patients dont agree either. Do the math , it doesnt add up for you. Tell me who exactly besides a bunch of blowhards on here maintains that DS is a "far superior procedure" ???  Where did you go medical school Diane? At which hospital did you do your residency ?
What university did you gather all of your statistical data ( which amounts to a hill of beans when it comes to statistics: ask a statistician)  A bunch of self-superior minded  jackasses running around putting down anyone who didnt get a DS.


And my answer:

Post Date: 8/16/08 5:23 pm

You are so full of yourself -- and so full of shit, which is the same thing actually -- that I should just ignore you.  However, like that idiot Jade, every time the taunts start, it is a TEACHING opportunity for the newbies, as well as the sad postops who -- like you -- will probably find their surgeries failing and in need of a revision.  At which point you will come crawling back to us for help.

First of all, you question my credentials to speak on scientific and medical issues.  I have a PhD in biochemistry and molecular biology from UCLA Medical School, where I TAUGHT biochemistry to medical and dental students.  I am also a lawyer, a biotech patent attorney actually, and Chief Patent Counsel for a biotech company.  I deal with bleeding-edge science day in and day out, including molecular biology, biochemisty and immunology.  So yeah, I DO know a little bit about science and medicine, as well as statistics.

I am also a support group leader for my surgeon's practice.  And I provide advice and guidance for people navigating the insurance approval process -- predominantly for the DS, but also for other procedures and reconstuctive surgery.

So, what are YOUR credentials, and what have YOU done lately for the WLS community?

Why, if the DS is so superior (and yes, yes it IS), isn't it more available?  I'm going to treat that question as a serious one, even though you probably are unable to comprehend the answer, as it involves complex issues of economics and psychology.

1)  By the time the DS procedure was developed and perfected, from 1988 to the mid 90s, the RNY was entrenched.  Thousands of general surgeons had taken weekend courses and hung out their shingles, offering RNY-mill operations -- doing 4-6 surgeries/day, with little or no follow up.  A money-making machine.  The insurance companies got in on the act as desperate people demanded that bariatric surgery be covered, and drove the reimbursement rate down by leveraging the thousands of RNY surgeons against each other.  If the surgeons wanted to get a steady stream of patients sent to them by the insurance companies, they had to contract with the insurance companies and their shitty reimbursement rates.

2)  The DS is a FAR more difficult surgery to learn.  The duodenal anastomosis is a very tricky procedure -- the tissue of the duodenum is difficult to stitch.  It cannot be learned in a weekend -- it requires being proctored by a VERY experienced surgeon.  And most of the RNY hacks don't want to take time off from their high-throughput lucrative RNY mill practices to learn a new procedure when they've got plenty of RNY fish to fillet. 

Also, there isn't to my knowledge a DS surgeon who does more than 2 DSs per day, and many spend lots of hours providing follow on care for their patients, because they CARE about them, and are providing not only follow on care but also collecting statistics to publish and provide scientific evidence of the superiority of the procedure for future patients to use to fight their insurance companies.  These honorable practices have resulted in NUMEROUS insurance companies changing their policies over the last several years -- some of which policy changes I am proud to say I have had some small part in -- including BC of CA, Cigna, Aetna and Medicare.

Because of this economic disincentive, not many of the DS surgeons contract with insurance companies.  They don't have to, in order to get their FULL fee, to which they are entitled.  If they accepted the paltry rate of reimbursement the insurance companies offer for the DS (i.e., what they are willing to pay for the RNY), they would not be in business very long.  In fact, many of the DS surgeons who DO contract with insurance companies have instituted manditory non-insurance-reimbursable "program fees" amounting to several thousand of dollars that the patients have to come up with before surgery, just to make the surgery marginally profitable to the surgeon.  This is a practice I find despictable, even if I understand why they do it.

3)  "Insurance companys , whose interests is value for making you as healthy as possible ..."  Oh PLEASE tell me you meant this as a joke, and you are not that naive or stupid.  Nah, nevermind, you ARE that stupid (and illiterate besides -- what you wrote is practically indecipherable, misspelled and ungrammatical).

News flash for you: Insurance companies are in business to make money for their executive management and shareholders, you idiot.  Their managers are paid and retained on their ability to spend less in any given immediate time period than they collect in premiums.  They have data showing that the average insured person changes insurance companies (through job move, job loss, or choice) about once every three years.  The longer the insurance company puts off having to pay any amount of money, the more money they make in THAT time period.  And the higher the chance that the sick person will LEAVE before they have to pay a claim.  They don't CARE what is more cost effective in the long run -- they care about what is the cheapest in the current quarter.  Period.  They don't CARE about making you healthy -- they are hoping you change insurers or DIE before they have to pay a big claim in THIS quarter.  Period.

I'm sure this is all information you are too stupid to understand, but it's really not for you -- it's for the others who might be reading this.  Now get back to your trailer and mind your own garden.  You have no business here -- until you need information about your revision.

*******

Of course, he had no answer for this post!

That Diana Cox should write a WLS book. She wrote this, too:

Bad outcomes with Lapband:

Obes Surg. 2008 Mar;18(3):251-5. Epub 2008 Jan 24. Links

 

11-year experience with laparoscopic adjustable gastric banding for morbid obesity--what happened to the first 123 patients?

Tolonen P, Victorzon M, Mäkelä J.

Department of Gastrointestinal Surgery, Vasa Central Hospital, Hietalahdenkatu 2-4, 65280 Vaasa, Finland.

BACKGROUND: Few long-term studies regarding the outcome of laparoscopic adjustable gastric banding for morbid obesity have so far been published. We report our 11-year experience with the technique by looking closely at the first 123 patients that have at least 5 years (mean 86 months) of follow-up. METHODS: Data have been collected prospectively among 280 patients operated since March 1996. Until March 2002 (minimum 5-year follow-up), 123 patients have been operated laparoscopically with the Swedish band. We report major late complications, reoperations, excess weight losses (EWL) and failure rates among these patients, with a mean (range) follow-up time of 86 months (60-132). EWL < 25% or major reoperation was considered as a failure. EWL > 50% was considered a success. RESULTS: Mean (range) age of the patients (male/female ratio 31:92) was 43 years (21-44). Mean (range) preoperative weight was 130 kg (92-191). Mean (range) preoperative body mass index was 49.28 kg/m2 (35.01-66.60). Patients lost to follow-up was nearly 20% at 5 years and 30% at 8 years. Major late complications (including band erosions 3.3%, slippage 6.5%, leakage 9.8%) leading to major reoperation occurred in 30 patients (24.4%). Nearly 40% of the reoperations was performed during the third year after the operation. The mean EWL at 7 years was 56% in patients with the band in place, but 46% in all patients. The failure rates increased from about 15% during years 1 to 3 to nearly 40% during years 8 and 9. The success rate declined from nearly 60% at 3 years to 35% at 8 and 9 years.
CONCLUSIONS:  Complications requiring reoperations are common during the third year after the operation, and almost 25% of the patients will need at least one reoperation. Mean EWL in all patients does not exceed 50% in 7 years or 40% in 9 years and failure rates increase with time, up to 40% at 9 years.


"Bad" outcomes with DS:

Obes Surg. 2007 Nov;17(11):1421-30. Links

Duodenal switch: long-term results.

Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S.

Department of Surgery, Laval University, Laval Hospital, Québec, Canada. picard.marceau@chg.ulaval.ca

BACKGROUND: This report summarizes our 15-year experience with duodenal switch (DS) as a primary procedure on 1,423 patients from 1992 to 2005. METHODS: Within the last 2 years, follow-up of these patients, including clinical biochemistry evaluation by us or by their local physician is 97%. RESULTS: Survival rate was 92% after DS. The risk of death (Excess Hazard Ratio (EHR)) was 1.2, almost that of the general population. After a mean of 7.3 years (range 2-15), 92% of patients with an initial BMI < or = 50 kg/m2 obtained a BMI < 35 and 83% of those with an initial BMI > 50 obtained a BMI < 40. Diabetes was cured (i.e. medication was discontinued) in 92% and medication decreased in the others. The use of the CPAP apparatus was discontinued in 90%, medication for asthma was decreased in 88%, and the prevalence of a cardiac risk index > 5 was decreased by 86%. Patients' satisfaction in regard to weight loss was graded 3.6 on a basis of 5, and 95% of patients were satisfied with the overall results. Operative mortality was 1% which is comparable with gastric bypass surgery. The need for revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%). Failure to lose > 25% of initial excess weight was 1.3%. Revision for failure to lose sufficient weight was needed in only 1.5%. Severe anemia, deficiency in vitamins or bone damage were exceptional, easily treatable, preventable and no permanent damage was documented. CONCLUSION: In the long-term, DS was very efficient in terms of cure rate for morbid obesity and its comorbidities. In terms of risk/benefit, DS was very sucessful with an appropriate system of follow-up.

More details from the Marceau paper:

At last evaluation, among 1,356 living patients (990 women, 366 men), mean weight loss was 55.4 ± 23.0 kg (range 3-186) and the percent initial excess weight loss (%IEWL) using the Metropolitan tables was 73.0 ± 19.0 (range 5-138).  The loss in terms of BMI was 20.3 ± 7.8 kg/m² (range 1-62).  Weight loss could also be expressed in terms of success or cure rate.  Success, defined as a loss >50% IEW, was 82%.  Failure, defined as losing <25% IEW, was only 1%.  Success, defined as reaching a BMI of ≤40 kg/m², was 91% or, for attaining a BMI <35 kg/m², was 76%.


SO, a comparison of long-term results with LapBand and DS:

____________LapBand______DS
% EWL: .........<40%.............76%
Success: .........35% .............82%
Failure: ...........40% ............. 1%

Geez, you don't need a PhD to figure out THIS math. 

Fruits comprise simple carbs (primarily fructose, which is a monosaccharide and doesn't have to be digested at all) and so are fully absorbed in the small intestine, and fiber, which is indigestible by both our guts and our bacterial symbionts.

Flour products contain starches, which are made up of long chains of monosaccharides -- thus, polysaccharides -- which are only partially digestible by our rearranged guts with the diminished contact with digestive enzymes.  This results in some of the starch ending up in the COLON where it is digested by our bacterial symbionts to produce gas.  The more whole grain-y the complex carbs we put in our guts, the higher the fiber (indigestible) to starch ratio, and the less likely to cause issues.

Other things that cause gas are SPECIFIC starches that are indigestible in our guts, but which our colon bacteria are happy to process, such as raffinose and inulin (the offensive starches in beans, broccoli, etc.) and retrograded starch, caused by cooking and then cooling of amylose, the primary starch in while flour products, which process produces a form of amylose that is indigestible in our small intestine, but can be digested by our colon bacteria.  This of course is a worse problem for DSers, who digest starches even less well than others.  See, e.g., http://journals.cambridge.org/download.php?file=%2FBJN%2FBJN 64_02%2FS0007114590001349a.pdf&code=79a7aa518b1eeec5a8274c4f dfabca59

See also:  http://www.answers.com/topic/flatulence-1

Flatulence-producing foods are typically high in certain polysaccharides (especially oligosaccharides such as inulin) and include beans, lentils, dairy products, onions, garlic, scallions, leeks, radishes, sweet potatoes, cashews, Jerusalem artichokes, oats, wheat, yeast in breads, and other vegetables. Cauliflower, Broccoli, cabbage and other cruciferous vegetables that belong to the Brassica family are commonly reputed to not only increase flatulence, but to increase the pungency of the flatus. In beans, endogenous gases seem to arise from complex oligosaccharide (carbohydrates) that are particularly resistant to digestion by mammals, but which are readily digestible by microorganisms that inhabit the digestive tract. These oligosaccharides pass through the upper intestine largely unchanged, and when they reach the lower intestine, bacteria feed on them, producing copious amounts of flatus.^[5] In the case of those with lactose intolerance, intestinal bacteria feeding on lactose can give rise to excessive gas production when milk or lactose-containing substances have been consumed.

http://www.obesityhelp.com/forums/rantsandraves/a,messageboard/board_id,8418/cat_id,7617/topic_id,3547920/action,replies/

I revisit it periodically and I've got loads of funny pics stored there.

Post Date: 7/30/08 4:09 pm
I've tried to keep my explanations simple for the general audience, but carbohydrates are more complicated than I present them. (Frankly, I'll be happy when it sinks in with the general public that most foods have a combination of different types of carbs and you can't just define something like fruit as "a complex carb".)

Basically, there are three types of carbs: sugars, starch, and cellulose (indigestible plant fiber). And yes, they are all digested (or not) slightly differently depending on the complexity of the carb's molecular structure. The more complex a carb is, the harder it is for your digestive system to break it down to be absorbed.

Monosaccharides like fructose and glucose digest very rapidly. Disaccahrides like sucrose and lactose digest rapidly, but slower than monosaccharides. Polysaccharides like starch take longer to digest. And cellulose, indigestible plant fiber, can't be digested at all.

The whole process of digestion is designed to break down disaccharides and polysacchardises into the simple form: monosaccharides, simple sugar/ glucose, so they can be absorbed by the bloodstream.

All carbs begin digesting in the mouth when it comes in contact with the enzyme amylase. Even complex carbs begin the process of breaking down into simpler types at this point. Since monosaccharides need no further digestion to be absorbed, you begin absorbing them as soon as they hit your mouth.

Enzyme activity continues in the stomach but, it is slowed by contact with stomach acids.

When the carbs hit the intestines is where the DS may assist in preventing some absorption of the more difficult to digest polysaccharides (starches). A type of amylase is secreted by the pancreas into the duodenum that cuts carbs down into simple sugars. As it passes further, more enzymes break the carbs down into even smaller bits until they are eventually converted to glucose and absorbed by the villi in your intestinal walls.

Because of the switch portion of the DS, the amount of time that a polysaccharide is in contact with panreatic enzymes is reduced. Enough to stop some of the digestive process? Likely. This is probably why many people have gastrointestinal issues when eating starches. No gas or runs? You're likely digesting them more efficiently and, therefore, absorbing more.

Also, since glucose is absorbed by the villi in the intestine, those with shorter common channels and those earlier out will also absorb less. As your body adjusts to the DS, you grow more villi to counteract the malabsorption, so more villi equals greater absorption of glucose.

It's possible that that's where your surgeon came up with the 30-60% figure. But, for anyone who is not losing or maintaining their weight effortlessly, that 30-60% guesstimate is just too wide a margin to mess with, imho. I'd avoid or severely limit all starches, too.

Sugar alcohols are technically carbs, too, like fiber. But, because they aren't completely digestible by the body, they aren't absorbed the way that regular sugar is absorbed. Some of it is absorbed, though, so (besides the unpleasant bathroom side effect) you shouldn't eat a whole bag of sugar free candy, either.

Post Date: 7/31/08 4:23 am
The whole complex carb issue is paradoxical as far as I'm concerned.

Complex carbs (besides fiber) are a wild card in how much of them we absorb. I definitely think that it's more than the 30-60% figure that your surgeon gave you, for the majority, anyway.

Plus, from what little I know of the glycemic index, it's not just what you eat but how you cook it. A baked potato is absorbed less than one cooked in the microwave and a boiled one is even better. I have no doubt that adding fats probably helps you absorb fewer, but I haven't done the research to prove it. And, even if that's the case, carbs seem to effect different people differently (as your own superb weight loss will attest), so there really can't be a "rule" about how much is ok.

That's why I tend to spout that only the most complex of carbs, fiber, is ok and the rest need to be restricted. Better safe than sorry.