sugar lows after RNY...

Ask your "diabetic doctor" (does the doctor have diabetes?), if she has seen this study.  I think it's absolutely pathetic what our doctors are ignorant of.  The best way to care for yourself is to educate YOURSELF, then you can educate your doctor.

Duodenal Switch without Gastric Resection: Results and Observations after 6 Years Journal Obesity Surgery Publisher Springer New York ISSN 0960-8923 (Print) 1708-0428 (Online) Issue Volume 14, Number 10 / November, 2004 DOI 10.1381/0960892042583851 Pages 1354-1359 Subject Collection Medicine SpringerLink Date Friday, August 24, 2007

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Duodenal Switch without Gastric Resection: Results and Observations after 6 Years

Maria Laura Cossu¹, Giuseppe Noya², Gian Carlo Tonolo³, Stefano Profili⁴, Giovanni B Meloni⁵, Matteo Ruggiu⁶, Patrizia Brizzi⁷, Franca Cossu⁸, Luca Pilo⁹ and Pier Luigi Tilocca¹⁰

(1)	Centro di Chirurgia Generale e Della Grande Obesita', Policlinico Universitario, Italy

(2)	Dipartimento di Scienze Chirurgiche, Universita' di Perugia, Italy

(3)	Servizio di Diabetologia, Istituto Clinica Medica, Italy

(4)	Istituto di Scienze Radiologiche, Universita' di Sassari, Italy

(5)	Istituto di Scienze Radiologiche, Universita' di Sassari, Italy

(6)	Servizio di Diabetologia, Istituto Clinica Medica, Italy

(7)	Servizio di Diabetologia, Istituto Clinica Medica, Italy

(8)	Centro di Chirurgia Generale e Della Grande Obesita', Policlinico Universitario, Italy

(9)	Centro di Chirurgia Generale e Della Grande Obesita', Policlinico Universitario, Italy

(10)	Centro di Chirurgia Generale e Della Grande Obesita', Policlinico Universitario, Italy

Published online: 01 November 2004

Background: The results on metabolic effects of the classical biliopancreatic diversion (BPD) have led us to investigate the operation without gastric resection, thus preserving stomach and pylorus, in patients who are not seriously obese but suffer from hypercholesterolemia, often associated with type 2 diabetes and hypertriglyceridemia. Methods: Between 1996 and 1999, we performed the duodenal switch (DS) without gastric resection on 24 mildly obese patients. Mean preoperative BMI was 36.2 kg/m². 17 patients (70.8%) suffered from type 1 diabetes, 4 (16.6%) had impaired glucose tolerance, while the remainder had fasting hyperglycemia. In 20 patients (83.3%), hypercholesterolemia and alterations in lipid profile were present. Another 20 patients were taking drugs for arterial hypertension. The pluri-metabolic syndrome was present in 41.6% of patients. Results: Mean follow-up was 4 years. BMI reduction and weight loss were not large. 2 patients who had severe longstanding diabetes type 2 needed a second operation of the classical BPD because of failure in improving diabetes. Another 2 patients were changed to classical BPD because of a relapsing chronic duodeno-ileal ulcer. The incidence of ileal ulcer was 29.1%. Regarding hypercholesterolemia, hypertrigliceri-demia, and type 2 diabetes when there is a good pancreatic "reservoir", the operation seems effective in the long-term. Protein absorption is better than that obtained with the classical BPD. Conclusions: Our long-term results suggest that in carefully selected patients suffering from serious hypercholesterolemia or type 2 diabetes with insulin reserves still at an acceptable level, and with BMI 30-40, DS without gastric resection can be proposed as a surgical treatment for metabolic diseases but not for obesity.

Also, see the discussion here:

http://www.obesityhelp.com/forums/AL/board_id,4803/cat_id,44 03/t

nope...my doctor does not have diabetes...I just can't spell endocronologist very well so I worded it differently. I appreciate your encouragement to look at the DS procedure.  I've discussed many options with my surgeon and I (not we) decided the RNY was best for me.  Again...I appreciate all the information you provided...knowledge is a good thing!

Oh yeah, I had many episodes of reactive hypoglycemia when I had the RNY.  That is another reason I chose the DS for my revision.

Reactive hypoglycemia is an increasingly recognized complication of the RNY.  MeltingMamaish has researched about and blogged her struggles with it at http://meltingmama.typepad.com/wls/hyper_hypoglycemia/index. html It is truly unfortunate that OH still does not have a search function for the message boards, so you can find the many many posts about this problem. (And now a word from the DS side of my brain): The DS rarely if EVER has this result, because we retain a normally configured and functional stomach and our pyloric valve controlling the release of food in normal amounts into our intestines.  We also have a 98+% CURE rate for type II diabetes with data going out 10+ years.  Although we need to be careful of drinking full sugar sodas like normal people (DSers absorb 100% of sugar) for caloric reasons, we CAN enjoy one from time to time without untoward physiological reactions.  It is rare if ever that we need them for their "medicinal" value as a treatment for hypoglycemia.

Hello Diana, OH has two features for searching old posts.  1.)  Go to the top of the website (to the right of the OH symbol) and click on "OH".  Then type in the subject you are wanting to search in the box.  Click search and it will give you all information on the website pertaining to hypoglycemia, including old posts.. 2.)  Go to People, Questions and Answers.  There you will find an option for the last 300 questions asked.  You can also go to the bottom of that page and search by hypoglycemia. If you have any other questions about the function of the OH board or lack there of, please contact us at [email protected] Thank you, ObesityHelp Staff

RNY is still the "gold standard" of WLS options, as a nurse I chose the surgery that best fitted my needs.  Do your research and pick the surgery that is best for you (if you are even contemplating DS)  Both have been successful surgeries and both have pros and cons - one thing for sure is that RNY has been around longer and has more long term data behind it.  Just wanted to throw that out there.. DS is a wonderful surgery for many but do keep in mind that overall general health is the goal and whichever procedure you chose should include an active lifestyle and good eating plan with appropriate supplementation. Good luck.

It can happen after RnY - but it's certainly not a given or "prevalent" as certain people would have you believe.  Many of us don't experience it, a few of us have.  You must take everything you read here with a grain of salt - especially from those who chose a different surgery and who are only speaking about selected things they've read....(i.e. - they're not speaking from experience). If, as a pre-op, you're experiencing sugar lows/highs - it's something you need to discuss with your doctor as it sounds you're already pre-disposed to it.  RnY has just as good of a track record in curing and remissing diabetes as does DS - that's born out in the numbers other people like to throw out there as well.  Your doc and surgeon may have more info about your personal history that will help you better understand your choices in relation to these stats. Only 40-50% of RnYers experience dumping syndrome - which is an entirely different phenomenon from what the rest of the thread is harping on....your original concern was being able to consume sugar - you should know that nearly half of us can consume sugar after RnY with no dumping symptoms or ill effect - so sugar isn't entirely an off-limits deal for everyone.  I'm one of the category that doesn't have a reaction to sugar, I can consume it, I choose not to consume it in drinks and fruit juices - I reserve it for desserts and occasional treats I hope you're able to wade through some of this and get the info you were originally looking for. Take care!

RnY has just as good of a track record in curing and remissing diabetes as does DS - that's born out in the numbers other people like to throw out there as well.  I'm sorry, but you're just WRONG on this.  The DS is VASTLY superior to any other WLS in CURING type II diabetes, especially when the long-term outcomes are compared. In the landmark article by Buchwald et al in JAMA,  http://jama.ama-assn.org/cgi/content/full/292/14/1724 the overall data were as follows:

There was a difference in diabetes outcomes analyzed according to the 4 categories of operative procedures. With respect to diabetes resolution, there was a gradation of effect from 98.9% (95% CI, 96.8%-100%) for biliopancreatic diversion or duodenal switch to 83.7% (95% CI, 77.3%-90.1%) for gastric bypass to 71.6% (95% CI, 55.1%-88.2%) for gastroplasty, and to 47.9% (95% CI, 29.1%-66.7%) for gastric banding. The percentage of patients with diabetes resolved or improved showed different results (Table 5); this variation from the trend solely for diabetes resolved may be due to the far greater number of patients assessed for this variable (n = 1846) compared with the number assessed for the combined variable (n = 485) in the total population. Please don't try to minimize the difference between 98,9% and 83.7%.  That's a difference of more than 15 people out of 100.  But still further, the DS results are ROCK STEADY over 10+ years as discussed in the Hess paper.  98.9% 10 years out!  Whereas, according to these study below, after 5 years, the success rate for the RNY drops to 76.5% (or 24 patients out of 100!), and the more weight is gained back (whi*****reases over time with the RNY as you all know), the more the diabetes returns, which conclusively DOESN'T happen with the DS:  Obes Surg. 2007 May;17(5):601-7.   ^{Follow-up of Roux-en-Y gastric bypass patients at 5 or more years postoperatively. Pajecki D, Dalcanalle L, Souza de Oliveira CP, Zilberstein B, Halpern A, Garrido AB Jr, Cecconello I.}

^{University of São Paulo School of Medicine, São Paulo, Brazil. [email protected]}

^{BACKGROUND: Short-term results (24 to 36 months) after Roux-en-Y gastric bypass (RYGBP) have been extensively described. Little is reported on the patients operated > or = 5 years ago. We analyzed the results of weight loss, resolution of co-morbidities and nutritional complications of patients submitted to the silicone ring RYGBP, at least 5 years before. METHODS: 75 morbidly obese patients who underwent silicone ring RYGBP between Oct 1995 and Dec 1999, 18 men and 57 women, were studied. Demographic data, nutritional status and the presence of co-morbidities (type 2 diabetes, hypertension, sleep apnea, dyslipidemia) were accessed. Pre- and postoperative BMI were registered, along with excess weight loss (EWL). Nutritional deficiencies were accessed by laboratory assays. RESULTS: Mean follow-up was 87 months. Initial BMI was 56.7 +/- 10 kg/m2. After 2 years, BMI had dropped to 29.3 +/- 6.8, and by the last interview BMI was 35.5 +/- 10. %EWL after 2 years was 80.2 +/- 17.3%, and at the end was 71.8 +/- 21.6%. After 2 years, only 1 of the 75 patients (1.33%) had not achieved an EWL of at least 50%. At the end, 23 patients (30.6%) could not maintain this EWL. Resolution of diabetes was 76.5%, arterial hypertension 37.3% and sleep apnea 93.5%. Iron, vitamin B12 and vitamin D were the most common nutritional deficiencies. CONCLUSIONS: Long-term follow-up (5 to 9 years) after the RYGBP was associated with satisfactory mantainance of EWL, and resolution or improvement of the main co-morbidities was observed in the majority of the patients.}

 

"please don't try to minimize...93 vs. 83"  Why?  Because pointing out the flawed logic might deflate a couple of balloons? Please don't insult people's intelligence - 83% of hundreds of thousands of people who've had RnY done over several decades vs. 93% of what - maybe multiple thousands at best that have had DS done in its various forms for what, maybe a decade at best? Because you're extrapolating these studies to be indicative of ALL populations.   Fabulous results for BOTH procedures - DS has not been done on enough people to even BEGIN comparing diabetes results in BOTH populations as a whole.  If the number of people with DS becomes the same number as the RnY population - THEN you may have cause to say that 93% is better.  83% with RnY is fantastic - when you factor in the TOTAL NUMBER OF PEOPLE WHO HAVE HAD THE PROCEDURE.  But again - you're looking at a small study, nothing at all even posted in your cut-and-paste about the populations being studied and applying it to a large, diverse whole.  How interesting. You're not the only person who's trained to interpret scientific studies.  Why not simply post the raw data and leave the biased interp out of it?  You'd have an easier time of "selling" your position without jumping to a conclusion that isn't really even being made here.

That's NINETY-EIGHT POINT NINE percent (98.9%), nearly 100%.  Your vitamin A levels OK? From the Hess paper, reporting 6 years out results for diabetes (Surgery for Obesity and Related Diseases 1 (2005) 329–333):

Of 105 consecutive patients with type 2 diabetes mellitus, 1/2 were taking insulin and 1/2 were taking only oral hypoglycemic medications. After BPD/DS, the patients have not needed diabetic medicines by 6 months postoperatively, and their blood glucose level remains normal. Two patients who were taking large amounts of insulin (up to 500 U/day) later required an oral hypoglycemic agent. Therefore, this group of patients has a cure rate (euglycemic) of 98%. The excess weight loss at 6 years is 75% (Fig. 2). Perhaps more importantly, as Hess discusses, it the completeness of follow-up of the patients in this study:

As of April 2004, of 161 patients who underwent BPD/DS surgery at least 10 years earlier, follow-up was available for 148 (91.9%); these patients had an average excess weight loss of 74% (Fig. 1). Averages on occasion will not give a true picture; 95% of these patients were in the “satisfactory” category defined as excess weight loss of 50% or more (Table 1). Since 1988 we have performed more than 1400 cases. The BPD/DS produces excellent long-term weight loss and patient satisfaction. Our patients can eat small, normal meals.

Long-term follow-up of 90% or more is very important in evaluating the results of an operation. If one does not count a significant number of patients, then one cannot know whether or not the operations performed were successful. But I don't expect you to appreciate or even understand the significance of those statistics, especially as compared with any RNY studies that have been presented as counterpoint (if any).