For more information on this more superior weight loss procedure, the Duodenal Switch (dubbed the platinum standard!), links to published medical studies proving it, and the most up to date, reliable list of doctors that perform this procedure, please go to

*Please scroll all the way down for the most informative thing I have ever read regarding the duodenal switch!!

I guess I should introduce myself...
(I wrote this last year...BEFORE I had my DS!)

My name is Leslie and I live in Burbank, CA. I'm happily married to my best friend, Joseph, who loves me so much, no matter what size I am! We have 2 kids, Tony, now 14 and our baby, Richie, who turned 3 on August 21. Right now I'm a stay at home mom and an Avon Lady! But before the baby was born I was a milliner making showgirl headpieces for Las Vegas and cruise ships. Before that I was a hairstylist.

I've been overweight for as long as I can remember. Not tremendously fat, but really big. I was always the tallest kid in the class and always on the chubby side. When I hit puberty, I really started getting a lot heavier. I graduated high school at a chubby 220lbs. I've been on every diet known to mankind! Everything from Nutri-System & Jenny Craig, where I ate the weeks worth of food and starved the rest of the week, to Atkins, where I lost 70 lbs for my wedding, but "found it" right after, as well as Weight Watchers, diet pills, counting calories, exercising hours and hours a day and even liquid diets and starving myself! Nothing has ever worked for me long term! So I guess I'm in that 95% that can't keep the weight off! Right now I'm about 325 lbs and at 5'8", that puts me at a BMI of 50.1. I am SO ready for surgery!!!!

When I got pregnant with Tony, my older son, I gained almost 80 lbs and I never really lost most of it! When I got pregnant with Richie, I was put on bedrest for FOUR MONTHS because my blood pressure was so high! I gained a lot of weight with that pregnancy too, over 75 lbs! I'm still on medicine to control my blood pressure today. Four pills every day! My back is always sore, my knees ache, my feet hurt, my legs swell up, I have huge dents in my shoulders from these massive boobs and I basically have no energy! Then there's the acid reflux and the incontinence. Thanks God for Nexium! And I want to play with my kids, not just watch him!

MEASUREMENTS!! (in inches)

                      Pre-Op   1mo      2mo     3mo       4mo      5mo      7mo        8mo      10mo      1 Year

Bust:                56           54       52        49 1/2     47 1/2       47       45 1/2       45        44 1/2      42 1/2

Waist:               48          45       42           41           40        39 1/2    37 1/2      36 1/2      36           34

Hips:                  54        52          49          46          45        44 1/2       42         41 1/2     40           38

Belly:              61 1/2     57 1/2       56       53 1/2       51        50 1/2      47        46 1/2      44           43

Thigh:              33 1/2      32           29         28       27 1/2       27       25 1/2      24 1/2     23 1/2       23

Calf:                22            21 1/2     20         19 3/4    19 1/2     19 1/2  18 1/2       18        17 3/4        17

Ankle:         10 3/4          10 1/2    9 3/4       9 3/4     9 3/4       9 3/4      9 1/4      9 1/4       9 1/4       9 1/8

Upper Arm:   19             18 1/2      18         17 1/2     16 1/2     15 1/2      15        14 1/2      13 /2     13 1/4

Neck:           17               16       15 1/2        15         15          14 1/2    14 1/4       14          14       13 1/2

*1. Have a full body massage
*2. Wear a tank top
*3. Run on the beach in a bathing suit!
*4. Go on a roller coaster
*5. Be in lots of pictures, not just be the photographer
*6. Surprise my husband with sexy lingerie (from Victoria's Secret)...often!
7. Hike up to the Hollywood Sign
*8. Make heads turn (and not from disgust)
*9. Chase my kids at the park and catch them!
10. Climb to the top of the Statue of Liberty
*11. Cross my legs under a table
*12. Not be embarrassed to go to the beautiful City Pool when it's over 100 degrees outside!
*13. Climb through those tube things at Chuck E. Cheeses to get my youngest kid!
*14. Step on the scale and SMILE! .......AND SO MUCH MORE!!!
*done!    *will do after plastics!!

THIS IS THE MOST INFORMATIVE THING I HAVE EVER READ ABOUT THE DS!! PLEASE READ THIS BEFORE MAKING YOUR DECISION ON WHICH SURGERY TO GET!

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: http://tinyurl.com/9ufl3 )

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)

Obesity Surgery, 17, 1421-1430 (2007)

Duodenal Switch: long-Term Results

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 < 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.

****************

Discussion

In our view, morbid obesity is a metabolic disease that extends beyond uncontrolled appetite and abnormal food intake.  For the past 25 years, our goal has been to change the basic physiology of these patients, allowing for excess weight loss, maintenance of weight loss and continuation of a normal life. We consider that it is important for quality of life to be able to eat normally. We felt that it was preferable not to concentrate our effort on food restriction, giving a false impression that the only problem is a lack of control of food intake, but rather to target correction of the metabolic dysfunction.  In these patients, the difficulty has never been to attain weight loss, but to maintain that weight loss. Morbid obesity should be considered a chronic disease, which requires treatment for life.

The first 8 years (1982-1990), BPD as described by Scopinaro was the procedure of choice within this center. While the results were positive, a decrease in side effects with improvement of absorption were further targets. The procedure was modified successfully. For the last 15 years (1992-2007), DS has been our primary procedure for all patients. This choice has been reinforced with additional knowledge on important involvement of intestinal hormones in the etiology of obesity.  It was also reinforced by the high long-term failure rates reported for numerous other procedures.

The present study could be considered exceptional.  The Canadian medical system has facilitated an efficient follow-up of a large unselected cohort.  We are not aware of any comparable study, using a consistent procedure with such an extended and thorough complete follow-up.

Our review shows excellent long-term results after 15 years. Both the weight loss and its maintenance compared favorably with any other procedure.  It has the best "cure rate" where cure rate is defined as the absence of morbid obesity: 83% of those with an initial BMI >50 maintained a BMI <40 and 92% of those with an initial BMI <50  maintained a postoperative BMI <35.

DS also targeted co-morbidities. It "cured" most diabetic and dyslipidemic patients. For other associated morbidities, results were related to the extent of weight loss, where DS was as efficient as any other procedure.

The reluctance for using DS has been the concern over long-term risks. The present review should be reassuring. The procedure saves lives. A 15-year survival rate of 92% is much better than that of nonoperated morbidly obese subjects and perhaps even better than after RYGBP.8  The operative mortality was found to be comparable to that of RYGBP.13

There have been people who have had severe and life-threatening complications. People have died. People have had issues with eating and food that have lasted beyond the expected few weeks. People have become malnourished. People have had problems with gas and loose stools and incontinence that have made them homebound. People have not lost nearly enough weight and/or regained. People have lost weight and become severely depressed and have even commited suicide when their lives didn't improve the way they thought they should have.

There, we've put it on the table. The DS isn't a panacea for all that ails you.

Having said that, the above issues are rare and/or mostly easily manageable:

* All surgeries, especially those on MOs and SMOs, have a non-trivial rate of complications and dying. You can minimize that by (1) going to the BEST DS-experienced surgeon you can find, with no fewer than 100 DSs under his/her belt; (2) performed in a facility that is beyond reproach; and (3) get yourself in condition for surgery as best as you can: quit smoking, start walking, start taking vitamins; use an inspiration spirometer or blow up balloons pre-op; get your ass out of bed ASAP after surgery and WALK; don't worry about protein the first month or two, but DO worry about fluids. And taking your supplements, and following up with your surgeon and doing all your blood work REGULARLY.

* The surgery has a long term weight loss statistic of 75% of excess weight lost. That isn't 100%. It is a bell curve that means that there are 50% who do better and 50% who do worse. Be prepared to deal with that statistic. By the way, it ALSO has a long term weight loss statistic of 94% "success rate," by which is meant, that 94% of all patients kept off at least 50% of EWL. Yes, the measure of success is only 50% EWL. But that statistic in particular beats the hell out of the long term RNY statistics.

* If you are in danger of losing too much weight, there are strategies for coping and adapting short of revision surgery. Eat more is an enjoyable one. Take fistfuls of pancreatic enzymes with each of several meals a day is less appealing, but should only be necessary for a few months until your body adapts. Only about 3% of patients need revisions to their DS, usually to lengthen the common channel when these methods fail, which is a relatively easy lap surgery.

* Stinky gas and loose poops usually can be treated. For some of us, that's as easy as taking probiotics and TiVo'ing our white flour or other carb food choices to more convenient times (i.e., only eat them at dinner or on the weekends so you can fart to your heart's content in the privacy of your home). For others, it can be more of a struggle, but still manageable -- taking Flagyl prophylactically, avoiding trigger foods, using medications to ameliorate smell or absorb bile acids. It is quite rare that this is an intractible problem, and even then, revision is an option. More commonly, people who have the DS and then lose touch with their support community and surgeon support think nothing can be done and give up trying -- THAT is almost always wrong. There are LOTS of strategies that can be tried and usually one or more will help.

* Some people can sabotage even the DS and not lose enough. The DS is not a free ride in particular for sugar and alcohol. There are one or two surgeons who have or have had a reputation for having way more than the average number of patients who fail to lose enough -- my understanding is that asking whether your surgeon uses the Hess method of measuring the intestines is critical to reducing the likelihood of this problem.

* If you are depressed before surgery, you will likely be depressed afterwards. Get treatment. Psychological treatment is a good adjunct to a post-surgery program, especially if you suffered from mood disorders, addictions, sexual abuse, eating disorders, a marriage that was sucky before surgery, etc. Weight loss isn't going to cure the problems in your life, and in fact may bring even more of them to the surface if you buried them in food and fat.

If you want to avoid regrets, learn everything you can, with an open mind, before you chose a surgery and before you commit to a surgical program. This includes reading here, on your surgeon's chat site, and at:
http://health.groups.yahoo.com/group/DS_PostOp_Problems/
http://health.groups.yahoo.com/group/duodenalswitch/
http://www.duodenalswitch.com/forum/forumdisplay.php?f=25

But for me, the almost effortless weight loss, ease of maintenance of that loss, quality of life, my ability to feel SATIATED for the first time, ablity to eat pretty much what I want, including fat and protein to my heart's content, is beyond worth the risk I took to have this surgery in the first place, and is all the impetus I need to do the modest amount of work that it takes to stay healthy (eat protein, take my supplements, go to the doctor once a year or when I need it). It is my gift to myself.

Good luck, and work hard at preparing and informing yourself fully.

 ***********************************************************************************************************

Diarrhea and DS? No more than gastric bypass. A new journal article finds that bowel habits in DS and GB patients who lost at least 50% of their weight are so similar that there is no statistically significant difference between the two. I interpret this to mean that, after the immediate postop period, people with GB and DS have virtually identical experiences in the bathroom. Those who exaggerate lifelong diarrhea as an argument against DS can't do it anymore. On average, DS patients more often had one bowel movement per day than two. My experience confirms this. 

Challenge: How long will it take OH to change their description of DS in response to this scientific research? 

Bowel Habits after Gastric Bypass Versus the Duodenal Switch operation. Obesity Surgery. 2008; August 28. Authors:Wasserberg N, et al.