Why DS over RNY?

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.

A lot of it for me came down to what possible side effects could I live with? Being sick to my stomach is the all time, dreaded act for me. I hate vomiting. Not that anyone likes it, but I will avoid it at all costs, even though vomiting may make you feel better.
The idea of dealing with possible nausea, vomiting, dumping, food getting stuck, or strictures from the RNY, scared me.
Possible things on the DS side, were more "back door" issues. OK, I can deal with that. These of course were the "what ifs", worse case scenario type things I was looking at.
Most people don't have these side effects, but I had to look at what the worse could be, and ask myself if I could I live with it.
Now, I must clarify, I don't currently have any issues with the "back door" dept. I have, however, become lactose intolerant. Sucks, but hey, no big deal.
A couple of the other reasons others have mentioned, also were important to me. Intact stomach. No blind stomach. One surgery. Don't have to watch fat content. I also, didn't want to worry about sugar. You do need to watch carbs, but won't have ill effects if you indulge. I don't want to use sugar free ketchup, dammit! I like my Heinz, and I ain't parting with it!
Keep researching. Good luck, and keep us posted. Ronni

I am not going to read the other responses before I respond because there are so many reasons for choosing the DS over the RnY. IF the RnY is the gold standard, the DS is the Platinum. I was 50 when I had my DS but started researching WLS much younger. I really wanted the RnY - because that was all I knew. I just wanted the pain of living with obesity to end. And I wanted insurance to pay for it. I jumped through all the hoops and my HMO would have paid for the RnY just 10 miles from my house. I chose the DS instead because of my research and the folks on this board. My first site was www.duodenalswitch.com. What a life saver that was! I couldn't believe that a surgery could be THAT good.

Then, I heard HORROR stories about the DS...from whom? The surgeons that only did the RnY!! I was so scared but I continued to research all sites. Memorial pages, WLS gone wrong pages... What I saw were folks that wanted their RnYs reversed, revised or taken down! When I read about the DS, I heard about gas.

The most painful thing for me, being a very successful dieter, several times over, was the pain of REGAIN. That was so shameful to me. Personally, I never wanted to go through that again. Maybe that is why I did not tell very many people at work about my surgery. I did not want to face them again if I should so through something as radical as weight loss surgery only to regain my weight back. The DS offers the lowest chance of that. That is JUST one reason I chose the DS.

ANother reason - my quality of life when weight is no longer an "issue". It was hard to believe that I could ever get to that point....but I did. Now, I get to live my life to the fullest without DIETING, without restriction. Now, do I eat the same way I did before?? No...but I eat what I want.

The DS gave me saity. I no longer want to eat mass quantities of food. I can leave my fork on my plate (amazing!) and I can leave the table satisfied before I am overly STUFFED.

That was something I did not know about the DS but that was its gift to me.

Good luck with your decision. How do you want your "AFTER SURGERY" life to be?

Dianne from FL

OK, here's a different perspective.  I had the RNY.  I also had staple line disruption and stoma enlargement, otherwise called mechanical failure.  I regained 110% of my weight back.  (my body thought it was just another yo yo diet)

At 53, I didn't want my RNY fixed because I didn't want to chance another surgery that could and most likely would (IMO) fail again.  How many adhesions would I have by the time I needed to look into a 3rd weight loss surgery?  What surgeon would touch me?  Would I even be able to have another surgery?  Did I want to lose more years to being obese?  Was I tired of vomiting, dumping, getting food stuck (although I never knew the trick of drinking meat tenderizer then, I just dealt with the pain, had I known, I'm sure I would have used it)

The answers to all these questions were negative and once I started reading the revision forums, I saw I wasn't alone with my problems.  The boards are filled daily with people who have regained from the RNY and other surgeries.  I never saw a post by a DS'r there who had regained all their weight. But  many with other surgeries who had regained 50 to 100 lbs or more back.  (edited because it sounded like it was the DS's *****gained 50 to 100 lbs back)

Then I started reading the DS board and everyone was so danged happy with their DS and could actually eat.

It really was a no brainer for me.

Having had the sucky RNY, I was more than ready to give up the crapppy life from it.

My surgeons completely took down my RNY, then gave me the DS and you can see on my profile the pictures of my progress and in my siggy there's a link to the lab rat charts which are very useful.  If you click on my name, you can see I've now lost 105% of my EWL (excess weight loss)

Any other questions, please feel free to ask.


My best advice to you would be to urge you to go over to the revision board and see how many posts are from rny'rs and bander's who have regained and are miserable.

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

One of the reasons I chose the DS is that my primary insurance covers DS but not the VSG.  Also, I wanted a fully-functioning stomach with the pylorus valve intact and to be able to eat like a non-WLSer and not have to worry about dumping, puking, or getting the foamies.  I have seen RNYers and lap-banders being able to eat only a couple of small bites before they say that they're full.  To me, that's not real eating!  Plus, I wanted to be able to take meds like a non-WLSer.

Reason I didn't want RNY:  When the local TV station was doing a medical investigation of "gastric bypass" surgery about 10 years ago, the reporter used a two-liter bottle for the pre-op stomach and unscrewed a bottle cap from the same bottle for the post-op pouch.  I knew right away that I would never opt for that kind of surgery!

Also, I learned in the surgery prep seminar that RNYers have to cut foods into sizes of erasers on pencils to accommodate their 50-ML pouches.  Real DSers eat just like any non-WLSer!

You are wise to look into the DS. While the DS is an excellent option for anyone with morbid obesity, it is especially recommended as the procedure of choice for people with a BMI over 50.

Here are some articles to support it:
http://www.medpagetoday.com/Surgery/GeneralSurgery/4162
http://www.ncbi.nlm.nih.gov/pubmed/16998370
http://www.seco2007.es/archivos/dr_baltasar_duodenal_switch. pdf
http://www.nature.com/ncpgasthep/journal/v4/n5/pdf/ncpgasthe p0791.pdf

The problem is that there still aren't nearly as many surgeons who do the DS compared to the RNY. And unfortunately, if you see an RNY surgeon, chances are he/she will tell you that you don't need the DS and that the RNY should be sufficient. But that's not necessarily true. Make sure you meet with an actual DS surgeon to discuss your options.