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Well, I'm down another 16 lbs this month for a total of 54 lbs.  I'm very happy with my loss this month.  I only lost 8 lbs my second month, so it seems things have picked back up nicely.  Hope it keeps up at this pace.  Things are going good.  I can pretty much eat anything.  Not that I eat the wrong things, but everything I eat goes down smoothly without that stuck feeling.  I can chug water again.... YAY!!  It sucks being thirsty and only being able to sip.  Thank goodness thats over.  On to month 4!

April 4, 2008 Surgery Day     304 lbs
May 4, 2008                             274         -30 lbs
June 4, 2008                           266         -8 lbs
July 4, 2008                             250         -16 lbs
August 4, 2008                       238         -12 lbs
September 4, 2008               225         -13 lbs
October 4, 2008                     219         -6 lbs
November 4, 2008                 208          -11 lbs
December 4, 2008                203           -5 lbs
January 4, 2009                    198            -5 lbs
February 4, 2009                   196            -2 lbs
March 4, 2009                         193           -3 lbs

I am 3 days away from my 2 month surgiversary.  The reason why I am writing today is because I have lost 40 lbs.  I am very excited because I have lost 3 lbs in 2 days.  And I have been a slow loser this second month.  

This is me before (holding my baby):






And here I am 2 months post op at least 40 lbs lighter:

This post was written by Dina on a different group.  I have asked her if she minded if I copy it to my profile so that I won't lose it and can refer back to it.  She hasn't answered me yet, but in order to not accidentally delete it, I put it here until I hear back.  I hope she doesn't mind because its very useful to all DSers and I may need it someday.  So here it is.  THANK YOU DINA!!!

I know there are several out there who have talked about how they feel as if bathroom issues are ruling their lives, so I figured it was time to start talking in earnest about what can be done for this.  But before we go there, I think I need to back up to the beginning just a bit.

 

There is great urban legend out there that says that DS = butt glued to the toilet.  I’m sorry, but that just really isn’t so.  And if it is, then something is NOT right.  So if that’s been your understanding and you’ve decided that you’ve just got to live with it, can I just encourage you to take a minute and do some careful examination of some basic choices in your life to see if we can’t find a better quality of life for you?  Okay?  Seriously – it’s not supposed to be like this, and if it is – I kid you not, there is something wrong going on.

 

First of all – let’s define diarrhea.  I know, seems obvious – but until I worked for GI doctors, I really had no idea what the definition of it was.  So here we go!

 

Diarrhea is watery – there is no form.  There is no waiting if you have the urge.  It is no respecter of time or place.  It is in control.

 

Here are some excellent references that everyone should read:

 

http://en.wikipedia .org/wiki/ Diarrhea

http://www.mayoclin ic.com/health/ diarrhea/ DS00292

http://www.nlm. nih.gov/medlinep lus/ency/ article/003126. htm

http://www.medicine net.com/diarrhea /article. htm

http://www.medicine net.com/script/ main/art. asp?articlekey= 14220

http://www.webmd. com/digestive- disorders/ digestive- diseases- diarrhea

 

Next, if you are a newbie – i.e., less than three months post-op, and feel like every BM is essentially pudding consistency and wonder if that’s diarrhea, then the answer to your question is this:  NO.  Those are pudding poops, and that’s normal early out.  In fact, that may be normal for more than early out.  I’m five years post-op and I still have some pudding poops.  (Hooray – that means the surgery is still doing it’s thing!)

 

There are things that can cause diarrhea – for anyone!  And there are things that can definitely tip a DS’er in that direction.  The problem with all of this – you have to factor in the basic detail that every person has a unique physiology.  So for one person – lactose may be the big enemy.  For someone else – it may be simple sugars.  Both instances may be true for a normie, but for some DS’ers it’s even more true.

 

When I talk to a DS’er who has having bathroom issues that involve more than a few trips to the toilet for a BM daily, I immediately want to know:

 

1. How many non-sweetened (artificially or otherwise) fluids are you getting in daily?
2. Are you consuming a lot of simple sugars?
3. Are you using a lot of artificial sweeteners?
4. How much dietary fiber are you getting in your diet daily?
5. Have you tried eliminating diary from your diet?
6. What percentage of your diet is coming from fat?  What kind of fat?
7. How much calcium are you taking daily, and what type?
8. Are you taking additional magnesium?
9. Have you tried tracking your intake on www.fitday.com or www.sparkpeople. com to try and see if there is any cause and effect?
10. Have you been tested for c. diff or h. pylori?

 

People erroneously assume that having the DS is a license to craziness when it comes to basic nutrition.  I know for me – when I was a pre-op and watching with amazement at the reports of what it was that people were consuming and encouraging others to consume – I remember thinking – will this all hit the fan in one form of the other in the future?  The answer is:  for most people, yes!  There is the rare exception, but for the rest of us, being wise simply is basic and normal and should not be expected to be otherwise.

 

There are basic first steps that need to be taken if you are living your life chained to the loo.

 

The first thing to ask yourself is:  how far post-op am I?

A#1.  If you’re in the first three months post-op, then relax a little.  You should be seeing that as your diet gets bulkier, things should be getting far less frequent and less fluid.  If they aren’t, then my question would be – are you taking your vitamins?  Getting them all in?  Taking a minimum of 2000 mg of calcium citrate daily?  Is your diet becoming more balanced, are you gradually incorporating more dietary fiber into your day to day life?  Are you getting your protein in?  Are you adequately hydrated?

A#2.  If you’re past your first six months post-op and you’re still having more than four BM’s daily, then it may be time to examine diet first and foremost.  Then we’d want to turn an eye toward your vitamins and any other supplements you might be taking.

 

The next thing to ask yourself:  am I doing the DS basics daily, faithfully, day-in and day-out?

If you don’t know what the basics are, let’s recap:

 

ü      Minimum of 64 oz of non-sweetened (artificially or otherwise) fluids daily, with the goal of doubling that consistently

ü      90 to 120 grams of protein daily

ü      30 to 35 grams of dietary fiber daily

ü      Sufficient fat intake – and good for you fats are important!

ü      Taking all of my vitamins daily  See http://www.bodybyba ltasar.com/ DS_vitamins. pdf if you’re not sure about vitamins.

ü      Getting my labs done consistently

 

If you’re doing the basics, then it’s time to start looking at whether or not you need to tweak some stuff.

 

First and foremost, it’s really important to understand that chronic dehydration can and will feed chronic diarrhea.  The problem being that there is some urban understanding that you should just throw any fluids at dehydration and everyone will live happily ever after.  Unfortunately, not so.  Some people find that sugar (whether it’s high fructose corn syrup – which is in a LOT of drinks, or other forms of regular sugar) can actually cause the problem to be worse – or at least enable it to continue on.  There are also folks who find that artificial sweeteners actually cause problems for them.  The only way you’ll know one way or the other for either regular sugars or artificial sweeteners is to do some little cause and effect trials.

 

Next, you gotta be realistic about the fact that human beings are not designed to consume massive amounts of sugar.  I know – everyone wants tons of license with no repercussion – but sorry, that’s not real life.  If you are consuming LOTS of sugars I have two thoughts:  one, are you getting enough protein in?  cause if you’re not, your body may be asking you for a quick fix to it’s basic need for a good consistent intake of protein; and second, are you dehydrated?  Cause if you’re not, you may be answering your body’s basic thirst with a quick pop of something in the mouth that gives you a brief warm fuzzy in exchange for what it really needs – to be hydrated.  Basic fact:

 

Sugar feeds the BAD bacteria in the gut.  It not only CAN, but in most folks WILL cause a serious imbalance that CAN and WILL cause looser stools.

 

That’s why so many folks find that probiotics are SO helpful.  They restore the balance of good and bad bacteria in the gut.  Not making a change in your sugar intake, however, will not help you – probiotics can only do so much.  You’ve got to accept the fact that shooting yourself in the foot will not make you a better marathon runner.

 

Next, dietary fiber is your friend!  If you are not getting in enough dietary fiber, you will have bathroom issues.  Not just because the dietary fiber increases the bulk, but because dietary fiber is rich in vitamins that you need to have healthy flora and fauna in your gut!  Please – EVERY single post-op should read http://www.slrhc. org/healthinfo/ dietaryfiber/ - and pay serious attention to the fact that you gotta get good for you food in your body.  It takes work.  It takes forethought.  It takes – yes, that horrible word we all hate:  discipline.  If you don’t know what dietary fiber is, then look at the content chart on that site.  Another excellent resrouce:  http://www.nal. usda.gov/ fnic/foodcomp/ Data/SR20/ nutrlist/ sr20w291. pdf   The cool thing about dietary fiber is that quite a bit of it packs serious protein punch.  A 1/4^th cup serving of lentils has a ton of dietary fiber and is very protein rich as well!

 

Now, lest you think, “my bathroom issue is constipation, so I don’t need dietary fiber,” let me just make a point of saying:  wrong!  If you’re constipated, you DO need more dietary fiber, and more fluids, and probably more fats.  But that’s for later.

 

Next, do you know that some DS surgeons “require” their post-ops to avoid dairy for the first 18 months post-op?  Wanna know why?  Cause a significant number of post-ops (but no, not everyone) develop lactose intolerance as early post-ops.  If you’re not sure what lactose intolerance is, or what it would feel like if you had it, try reading these:

 

http://digestive. niddk.nih. gov/ddiseases/ pubs/lactoseinto lerance/

http://www.gastro. org/wmspage. cfm?parm1= 854

http://www.mayoclin ic.com/health/ lactose-intolera nce/DS00530

http://www.nlm. nih.gov/medlinep lus/lactoseintol erance.html

 

Know what?  If you were lactose intolerant BEFORE your DS, you’ll probably be lactose intolerant AFTER your DS.  (Although some people report improved tolerance as further out post-ops.)  Also, some people who do have issues with lactose intolerance as early post-ops sometimes find that it lessens as time goes on.  It’s not a given, but it’s also not unheard of.

 

Something to keep in mind:  lactose is sometimes places that you wouldn’t think of right off of the top of your head.  You gotta pay attention to the details!  You gotta read food labels – it’s just basic common sense!  This from the NIH web site:

 

What is hidden lactose?

Although milk and foods made from milk are the only natural sources of lactose, it is often added to prepared foods. People with very low tolerance for lactose should know about the many food products that may contain even small amounts of lactose, such as

 

• bread and other baked goods
• processed breakfast cereals
• instant potatoes, soups, and breakfast drinks
• margarine
• lunch meats (other than kosher)
• salad dressings
• candies and other snacks
• mixes for pancakes, biscuits, and cookies
• powdered meal-replacement supplements

 

Some products labeled non-dairy, such as powdered coffee creamer and whipped toppings, may actually include ingredients that are derived from milk and therefore contain lactose.

 

Learn to read food labels with care, looking not only for milk and lactose, but also for words such as whey, curds, milk by-products, dry milk solids, and non-fat dry milk powder. If any of these words are listed on a label, the product contains lactose.

 

Lactose is also used in more than 20 percent of prescription drugs and about 6 percent of over-the-counter medicines. Many types of birth control pills contain lactose, as do some tablets for stomach acid and gas. However, these products typically affect only people with severe lactose intolerance.

 

SOOOO….  If you are using protein products (powders, shakes, bars, etc.) keep that in mind!  Also, people are often terrified that being lactose intolerant means they will never be able to again consume cheese.  Remember – there are alternatives available!  Some people do GREAT with goat’s milk or sheep’s milk cheeses where they are irritated by cow’s milk cheese.  Just remember to do any “trials” with some basic controls in place – i.e., don’t consume something that may or may not be an irritant for you around the time you are doing a test to see if goat’s milk cheese is a good alternative for you!

 

Next, some people are just super sensitive to fats.  And it’s an easy thing to want to make a sweeping generatlization and say “all fats are bad” or “all one type of fat or the other” is bad.  The fact of the matter is we each have unique physiology and some people tolerate fats poorly all the way around.  If that’s the case, respond accordingly – use fats sparingly.  Do, of course, give it a good go of trying some alternatives to the fats you use in your day to day life.  I.e., if you’ve always used margarine, then try butter.  If butter isn’t working out for you, try olive oil.  So on, and so forth.

 

Next, supplements.  This is basic stuff, but sometimes we forget it.  Calcium citrate – not in company of magnesium – is something akin to quick dry cement in the bowels.  So – again – a basic:  every post-op needs 2000 mg of calcium citrate daily.  Calcium citrate typically comes in a formulation that includes a 2:1 ratio calcium to magnesium, and hopefully has some D3 thrown in there as well.  All good and wonderful – unless you are sensitive to magnesium.  Some folks are.  If that’s the case, you need to try a trial and error between calcium citrate and calcium oxide.  Magnesium citrate is actually used to specifically move the bowels (more than move – actually clean out!) – ever been given a bowel prep?  That’s what it is!  So, if your labs are showing that you need magnesium, use magnesium oxide, not citrate!  Now – you can/will have some benefit from the citrate – particularly if you are one of us who lean more toward the side of constipation as a post-op – but that’s not the topic at hand.

 

If you find that the brand of calcium is bugging your gut – and there are different variations on that theme – sometimes it’s stomach ache (Citracal is notorious for this!), sometimes it causes gas/bloating/ distension (again, Citracal is not unusual to see with these types of complaints – THEN IT’S TIME TO TRY ANOTHER BRAND!  There are LOTS of them out there.  BUT – PLEASE – be certain you are choosing Calcium Citrate.  It’s the best choice for DS’ers.  Honestly.  Totally serious.

 

The product that more people say has made their lives vastly improved with regard to lessened BM frequency is UpCal-D.  It’s a powder, it has 500 mg of calcium citrate in one serving (which is awesome!), and it has D3 in it.  I like it because it’s so easy to take.  I get the little packets of it, open one up – dump it in on my tongue, let it dissolve a bit, and then chase it with a sip of tea or something.  It tastes a little bit like pixie stix dust.  You can find it at Vitalady or Amazon.com – compare prices – bargain shop.  This stuff is worth it’s weight in gold.  Thankfully, it’s nowhere near that expensive!  (I think we pay $12 for about 120 packets.)

 

You may need more than 2000 mg of calcium citrate a day to firm things up in the bathroom department.  That’s okay.  The key is to baby step to the correct amount for you.

 

Next, accountability sucks – but we all know it’s good for us.  That’s why I love www.fitday.com or www.sparkpeople. com – they are a great place to get a reality check.  Do some basic recording of what goes into your mouth – and then also pay attention to what’s going on in the bathroom department.  It’s hard to know if the stuff that’s going into your mouth is causing a problem if you don’t know what’s going into your mouth.  I know, I know – it smacks of weight watchers – but if it’s going to improve your quality of life significantly, is it worth working past the flashbacks of WW?!  LOL!  (The answer to that is supposed to be yes, by the way!)  Pay attention to the details.  If you’re finding that having a Wendy’s frosty is giving you killer gas, distension, bloating, and then a little later on explosive diarrhea – well, folks, there’s proof in the pudding there.  (Sorry, I couldn’t help it!)

 

Next, it’s entirely possible you’ve got a bug going on in your gut that needs medical attention.  Get tested for c. diff, h. pylori, and bacterial overgrowth.  These are treatable.  Why suffer if there’s something that can help – even though it may take a little bit of dedication and work to get there?

 

Finally, if you’ve tried all of these things and you’re still experiencing frequent BM’s, your labs are showing you to be in malnutrition (and there’s a profound difference between managed malabsorption and malnutrition, folks!), then it’s time to talk seriously with Dr. Baltasar and your PCP about whether or not you are in need of a revision.  Lest you be panicking right now – it’s not the norm – not everyone goes through this – it’s the exception.  It totally and completely as profoundly as possible SUCKS big time that *anyone* has to go through it.  BUT, the great news is that those who do find that a surgical response is the best option for them find that it DOES, in fact, make a huge difference and brings hugely improved health and quality of life.  (Just see Jeff’s experience for such an example.)

 

All of that being said, we have to be honest with ourselves, as well.  I’ve lost count of the patients I’ve talked with who have been suffering horrible bathroom issues, have identified the cause (not at all out of the ordinary for it to be won ton indulgence in sugars – remembering that sugars come in lots of different forms!) and then look me in the eye and say, “I’m not willing to give up the sugar.”  To that I have to say, “That’s completely your choice.  I can’t make that choice for you.”  But if you do make that choice – own up to it.  Please.

ETA: Another thing that was suggested later was to try and eliminate gluten from the diet to see if that could be an issue.

April 4th it is!!!!! 

Some of you may have read how my surgery date interferred with my plans to go see Larry the Cable Guy.  Interferred is a strong word, but I felt the need to git-r-done, er, I mean, go, as it has been 2 years since I last saw him.  Thankfully Red questioned me about my priorities (thanks Red!!) and brought me back to my senses.  So I have kept my surgery date of April 4th and I would like to say, Lord, I apologize for that right there, and please be with the starvin' pygmies down there in New Guinea, A-men.   

Ok, y'all KNEW I had to do it!!!!!   

Ricotta Protein Bars
1 square unsweetened chocolate
1/3 c. plus 2 T. peanut butter

Melt together in the microwave. Stir in:

1/4 c. Splenda Granular
2 scoops protein powder (I use the IDS chocolate)
1/3 c. Ricotta cheese

Mix well and shape into a round flat disc about 6 inches across. Cover tightly with plastic wrap and chill until hardened. Cut into 12 pie shaped wedges.

Protein Poppers
1 C. protein powder
1 C. non-fat dry milk
1 C. peanut butter
Cocoa powder
2 tbsp water
½ C. ground flax seed
½ C. rolled oats
Splenda to taste
1 tsp. rum extract

Mix protein powder, milk powder, rum extract and peanut butter. When totally mixed, add flax and oats. Put water in bowl on side, make one inch balls, dipping fingers into water if too sticky.
In separate bowl, mix splenda and cocoa. Roll each ball in cocoa mixture. Chill one hour before eating.

Apprx. 10 grams of protein per ball.

Nutty Fudge Protein Bar (from Ann B/Ann in TX)
2 1/3 cups chocolate protein powder (I use Champion Whey Stack)
1 oz square unsweetened chocolate
1/2 cup butter
4 oz cream cheese
1 oz chopped pecans
1 teaspoon vanilla
2 teaspoons peanut butter
1/4 cup Splenda

Melt butter, cream cheese, peanut butter and chocolate in bowl in microwave and mix together very well.
Add Splenda and vanilla, mix well again.
Add pecans and protein powder and mix.
Place in a baking pan, press down and refrigerate.
When cooled and hardened, cut into 20 square bars. This does not get baked but the mixture will be warm from heating the first five ingredients in the microwave.

Makes 20 bars

Nutrition counts:
(Based on using real butter and cream cheese, could be lower if diet butter, low fat cream cheese, or if applesauce is substituted for the butter.) I am sure these would be good using sugar free chocolate but I prefer not to have the extra calories or manitol.

Grams Per big bar:
Calories 123
Fat 8
Carb 1.5
Protein 7.5



protein balls:

1 cup Peanut Butter (I use no-sugar-added Peter Pan)
1 cup rolled oatmeal -- not the instant stuff
1 cup protein powder (I use Matrix Chocolate, but you can use other flavors)
5 packets Splenda


PROTEIN BALLS I
1 cup Peanut Butter
1 cup rolled oatmeal -- not the instant stuff
1 cup protein powder
5 packets Sugar substitute

Warm the peanut butter in microwave about 30-40 seconds -- it melts it and makes mixing in the other ingredients much easier. Add the oatmeal, protein powder, and Sugar substitute and mix well. (If needed, you can add a little bit of water to make it easier to mix) Roll into walnut sized balls, refrigerate. Store in fridge in zip-lock baggies. This recipe makes 20-24 balls.

PROTEIN BALLS II
1 cup of protein powder (chocolate or vanilla)
1 cup of non-fat dry milk
1 cup of rice crispy cereal
1 cup of peanut butter
Sugar substitute to taste
Cocoa powder mixed with Sugar substitute

Add the Protein Powder, Dry Milk, Cereal and Peanut Butter in a mixing bowl. Mix thoroughly making sure that all the dry milk is in the mix and not really visible. If you like it really sweet, add some more Sugar substitute to fit your taste. Form the mixture into small balls (about 1.5 inches in diameter) Roll in the cocoa/Sugar substitute mix. Refrigerate.

PROTEIN BALLS III
1 cup peanut butter
1 cup sugar free honey
1 cup unflavored protein powder
1/2 cup grape nut cereal
sprinkle of cinnamon
sprinkle of Sugar substitute

Mix peanut butter, honey and protein powder together till well blended. Form into balls. In another bowl mix grape nuts, Sugar substitute and cinnamon together. Wet peanut butter balls with water and roll into grape nut mixture. Place in frig and grab when you need a yummy snack!

PROTEIN BALLS IV
1 cup peanut butter
2 scoops of chocolate protein powder
1/2 cup low carb special K cereal
3 tablespoon of sugar free maple syrup
1/4 cup chopped nuts
oatmeal (not instant)
3 packets of sugar substitute

I mixed everything up in a bowl and then rolled them in oatmeal.

PROTEIN BALLS V
1 cup protein powder
1 cup peanut butter
1/2 cup sugar free maple syrup or honey

Mix together well and roll into balls - about the size of a ping pong ball. Store in a Tupperware or Ziploc bag in the refrigerator..

PROTEIN BALLS VI
1 cup protein powder (chocolate or vanilla)
1 cup non-fat dry milk
1 cup rice crispy cereal
1 cup peanut butter
Sugar substitute to taste
cocoa powder mixed with Sugar substitute

Add the protein powder, dry milk, cereal and peanut butter in a mixing bowl. Mix thoroughly making sure that all the dry milk is in the mix and not visible. If you like it real sweet, add some more Sugar substitute to fit your taste. Form the mixture into small balls (about 1.5 inches in diameter) Roll in the cocoa/Sugar substitute mix. Refrigerate. Each ball has about 10 grams of protein.

I can't believe I started this journey in October of 2006.  Almost a year and a half and several denials and appeals later, here I am finally approved.  It feels so weird.  When the girl on the phone told me I was approved, I was like, "huh?"  I was certain I didn't hear her right.  Unbelievable!

Thanks to everybody that helped me along the way.  All of the studies that were sent to me, all of the post op DS life discussed on the forum, all of the debates over surgeries... all of this has helped educate me and gave me the stamina to keep plugging along.

Here I go................!!!!!!

Thank you again Diana Cox for finding this article so that we can help educate people. 

A new paper by Marceau et al. detailing 15 years of DS results:

Obesity Surgery, 17, 1421-1430 (2007)

Duodenal Switch: long-Term Results

Picard Marceau, MD, PhD1;Simon Biron, MD, MSc1; Frederic-Simon Hould, MD1; Stefane. Lebel, MD1; Simon Marceau, MD1; Odette Lescelleur, MD1; Laurent Biertho, MD1; Serge Simard, MSc2

'Department ofSurgery, Laval University, Laval Hospital, Quebec, Canada; 2Biostatistician Laval Hospital Research Center

 

 

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

The long-term risk for malnutrition is real but preventable. Deficiency in albumin, iron, calcium and fat-soluble vitamins requires compliance and medical attention. These deficiencies were rare, they appeared slowly, and were always  reversible without permanent damage.

The procedure was relatively secure for bone maintenance.  It is possible that with the medical attention provided after surgery, including increased physical activity, better alimentation and appropriate nutritional supplements, the procedure may even be beneficial for bone metabolism, rather than representing a risk.

The negative side-effects with DS were not benign.  The unpleasant odor of stool and gas and the frequent abdominal bloating were the price to pay for these patients and it was a major preoccupation for many of them. However, 95% of patients declared themselves satisfied despite this handicap and no one has required reversal of the procedure for this reason.

The present evaluation has an important characteristic, in that it is comprised of a non-selected group of patients. No pre-selection was done on the basis of age, BMI, eating behavior, financial or psychological conditions, merits or expected difficulties for follow-up. With appropriate support, the procedure was found to be useful for all groups.

Thus, the global applications should be appreciated. We conclude that with a structured and devoted treatment team, DS is a very efficient bariatric operation, to the great satisfaction of both the patients and the care-providers.

Finally, one of the striking conclusions of this study is that, in spite of the inherent mortality risk of the bariatric surgery, the long-term outcomes are more positive than the mortality risk without surgery.  Furthermore, in spite of the side-effects which are not minimal, the overall patient satisfaction dominates.  These two points highlight the profound effect that morbid obesity has, not only on mortality, but also on quality of life.

 

 

 

 

 

 

 

 

 

 

It is NOT true that there is the same success rate with the DS and RNY.  The DS long-term has a FAR higher success rate, both in amount of weight lost and long-term maintenance of that weight loss.  The complication rate difference, if any, can almost certainly be ascribed to the fact that there are more SMO patients, on average, who have had the DS, and who are sicker and at higher risk in the first place, because of insurance limitations on access to the DS, and that there are so many revisions from other failed surgeries to the DS, and revisions are even more likely to have complications.  Another reason to have the DS as your first, and LAST, WLS.

This is a comparison from two papers of the long-term results with the RNY and DS. The RNY study (Shah et al.) can be found at http://jcem.endojournals.org/cgi/content/full/91/11/4223, and the Hess study was published in Obesity Surgery, 15, 408-416 (2004) (I have a .pdf copy if anyone wants to have it).

Even if the curves are oppositely oriented, and one measures percent weight change, and the other percent excess weight lost, and even if you assume that both DSers and RNYers end up at the same initial maximum EWL% (which isn't the case), the curves are pretty directly comparable. The first is from the Shah study; the second is from the Hess study.


FIG. 1. Weight changes among subjects participating in the Swedish Obese Subjects study over a 10-yr period (11 ). There were 627 control subjects who did not undergo bariatric surgery, 156 who underwent banding, 451 who underwent vertical banded gastroplasty, and 34 who had gastric bypass.



Also, there is this study from Christou, reporting long-term RNY results: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pub med&pubmedid=17060766
in which he reports:
There was a significant increase in failures and decrease in excellent results at 10 years when compared with 5 years. The failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients and 34.9% for super obese patients. CONCLUSIONS: The gastric bypass limb length does not impact long-term weight loss. Significant weight gain occurs continuously in patients after reaching the nadir weight following gastric bypass.

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Here are some comments from the bariatric surgeons hired by CHDR (see below) who review appeals of patients who want the DS over the RNY, copied from the California Department of Managed Health Care's decisions: http://tinyurl.com/o4js9

A 60-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (DS) for treatment of her morbid obesity. Findings: The physician reviewer found that with a BMI of 43.2 and multiple comorbid conditions, the patient met nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the DS as compared to other surgical procedures. Published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the DS. The patient’s assertion that the DS is the most effective surgical weight loss alternative is well supported in the literature and this option was a medically reasonable approach to surgical weight loss. Psychological, nutritional and cardiology evaluations indicated the patient was an appropriate candidate for the surgery.

A 44-year-old female enrollee has requested bariatric surgery including duodenal switch and laparoscopic cholecystectomy for treatment of her morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity. The question raised relates to what would be the best surgical approach. Serious consideration should be given to the medications the patient is likely to take the rest of her life for her SLE and associated joint pain. Specifically, NSAIDs, Methotrexate, Plaquenil, and potential high-dose steroids with exacerbation of SLE symptoms. These medications can predispose the patient to ulcer formation and other gastrointestinal complaints. In comparing the duodenal switch procedure to the standard Roux-en-y gastric bypass, the literature indicates that the duodenal switch has proven to be superior with regard to gastritis, marginal ulcer formation, dumping syndrome, nutritional abnormalities and the stability of the weight loss. 

There are many more such statements in the many MANY decisions overturning insurance company denials of the DS on this site.  Please have a look.

Regarding CHDR: http://www.maximus.com/corporate/pages/CHDR.asp:

MAXIMUS CHDR is the nation’s leading independent medical reviewer of disputed health insurance claims. CHDR serves more than 25 states in the role of reviewer of appeals made by health plan enrollees. We also are the official Medicare Managed Care Independent Review Entity for the Federal Centers for Medicare & Medicaid Services (CMS). We serve in a similar capacity for the federal Office of Personnel Management (OPM), reviewing claims disputes in connection with the Federal Employee Health Benefits Program (FEHBP).

So you can imagine that Medicare and FEHBP would engage a relatively conservative reviewing agency, to appease their insurance companies -- but their bariatric surgeons believe the DS is best.  Go figure.

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From the Shah paper http://jcem.endojournals.org/cgi/content/full/91/11/4223 (relates primarily to RNY and GB [gastric banding):

	Effect of Bariatric Surgery on Nutritional Status and Intolerance

Top Abstract Introduction Long-Term Effect of RYGB... Mechanisms for Weight Regain Effect of Bariatric Surgery... Recommendations References

 
Micronutrient deficiency

Deficiency of iron, vitamin B12, folate, calcium, and vitamin D has been frequently observed after RYGB surgery. Deficiency of vitamin A has also been observed, although less frequently. Nutrient deficiencies after GB surgery are less common because it does not have a malabsorptive component, and an adult multiple vitamin and mineral supplement is considered sufficient to prevent these problems (64). Reviewed below are the studies that have reported nutritional deficiencies in RYGB surgery patients (Table 2). The majority of these studies were uncontrolled case series, and so it is important to note that the studies may have somewhat overestimated the effect of surgery on nutritional status, especially given that nutritional deficiencies have been noted in severely obese subjects before surgery (65) and that many of the patients are menstruating women who are more likely to have poor iron status.

View this table: [in this window] [in a new window]   TABLE 2. Effect of RYGB surgery on incidence of nutritional deficiencies

 
Serum iron deficiency is seen frequently in RYGB patients (66, 67, 68, 69), with the incidence rate as high as 52% (66). The incidence of anemia (type not specified) has been reported to be as high as 74% (66). Supplements containing usual daily doses of multivitamins (70), and even high doses of oral iron (320 mg twice daily) (71), do not consistently prevent anemia in menstruating women. Contributing factors to iron deficiency anemia include malabsorption due to bypassing of the duodenum and proximal jejunum, the main sites for iron absorption (Fig. 2); intolerance to iron-rich foods, especially red meat (15); and reduced stomach production of hydrochloric acid (72) required to reduce ferric iron to the ferrous state before it can be absorbed.

View larger version (31K): [in this window] [in a new window]   FIG. 2. Schematic representation of the normal gastrointestinal tract (A) and its perturbations in the two common bariatric surgery procedures, RYGB (B) and adjustable GB (C). A, Major sites of micronutrient absorption and gastrointestinal hormone production. Absorption of iron and other minerals such as calcium and magnesium occur mostly from the duodenum and proximal jejunum. Whereas the absorption of dietary fats and concomitantly the fat-soluble vitamins such as vitamins A and D occurs in the distal small intestine, it is facilitated by the action of pancreatic enzymes and bile salts released into the duodenum. Water-soluble vitamins are absorbed throughout the small intestine. Among the gastrointestinal hormones, ghrelin is secreted predominantly from the gastric fundus. Glucose-dependent insulinotropic peptide (GIP) and cholecystokinin (CCK) are secreted mostly from the proximal small intestine, whereas the distal intestines are the primary site of production of the satiety-inducing hormones, GLP-1 and PYY. B, In RYGB, the stomach is divided into a small proximal pouch, excluding much of the ghrelin-secreting regions, and a larger distal segment. The pouch is anastomosed with the proximal jejunum through a narrow end to side anastomosis, whereas the distal segment along with the duodenum and part of the jejunum are attached to the distal jejunum. This surgery combines restrictive and malabsorptive procedures. C, GB is a purely restrictive procedure in which the prosthetic band divides the stomach into a small proximal segment and a larger distal segment. The band aperture between the two segments can be adjusted by changing the volume of the saline reservoir, which has a sc port.

 
Vitamin B12 deficiency, assessed by serum vitamin B12 levels, is also frequently seen in RYGB patients (66, 67, 68, 69, 73) with the incidence rate as high as 64% (67). Most vitamin B12 deficiencies in RYGB patients may be corrected by 500 µg/d oral B12 supplementation (74), and a minimum dose of 300 µg crystalline B12 per day is necessary to maintain normal serum levels (75). Only a small number of patients require parenteral administration of B12 (2000 µg/month) (64). Possible factors that contribute to B12 deficiency include achlorhydria (72), which prevents its cleavage from foods; decreased consumption due to intolerance to its main sources (milk and meat) (15); and poor secretion of intrinsic factor needed for its absorption (73). Because of the latter problem, Elliot (64) recommended taking the supplement in a sublingual form.

Serum folate deficiency has been reported to be as high 38% after RYGB surgery (67). Brolin et al. (74) reported that a supplement containing 400 µg of folate per day consistently corrected low folate levels in patients who underwent RYGB surgery, although 1000 µg/d have been recommended by others (64). Primary reason for folate deficiency is decreased folate intake. Malabsorption may not play a big role, even though folate is preferentially absorbed in the proximal part of the small intestine, because absorption can occur along the entire part of the small intestine with adaptation after surgery (76). Maintaining adequate folate levels is important, however, because of the possibility of megaloblastic anemia. Also, there have been reports of neural tube defects in infants born to mothers who underwent RYGB surgery (77, 78).

Calcium and vitamin D deficiency may occur in patients who undergo RYGB surgery, and a deficiency rate of 10% for serum calcium and 51% for serum 25-hydroxy vitamin D levels has been reported (66). PTH levels, however, were not reported (66). Possible contributors to calcium deficiency in the RYGB patients include malabsorption of calcium because of bypassing the duodenum and proximal jejunum in which calcium is mostly absorbed; intolerance to rich sources of calcium such as milk; and defective absorption of vitamin D because of fat malabsorption. Fat malabsorption is due to the short common channel and delayed mixing of fat with pancreatic enzymes and bile salts as a result of bypassing the duodenum. Deficiency of calcium is not always apparent, however, because of release of calcium from bone. Coates et al. (79) and von Mach et al. (80), who followed subjects for 9 and 24 months, respectively, reported elevated markers of bone turnover and/or decreased bone mass in patients who underwent RYGB surgery, compared with patients who underwent GB surgery (80) or the matched obese controls (79, 80). The higher bone turnover in the RYGB patients, however, may be partly due to the increased weight loss in these patients, compared with the other patients. PTH levels were not different between the RYGB and obese control groups (80) nor did they change over time after surgery (79). Nevertheless, to prevent metabolic bone disease, 1200–1500 mg/d of calcium and 400 IU/d of vitamin D supplements are recommended (64, 65). These amounts, however, may not suppress serum PTH or bone resorption, and increased supplementation may need to be considered (81). Because of reduced stomach acid content, calcium citrate rather than calcium carbonate is recommended because the latter requires acid for absorption (64, 65). Regular monitoring of markers of bone resorption such as urinary N-telopeptide level and markers of bone formation such as serum osteocalcin level may also be necessary.

Serum vitamin A deficiency has been reported in 10% of RYGB patients (66, 67). Whereas symptoms of vitamin A deficiency are rare in this population, a case study reported xerophthalmia and nyctalopia in a patient after a duodenal switch gastric bypass surgery due to inadequate vitamin A supplementation (82). A contributing factor to vitamin A deficiency in RYGB patients is fat malabsorption. Careful monitoring of serum vitamin A status and supplementation as needed is necessary to avoid a deficiency.

Despite the evidence of nutritional deficiencies, many surgeons do not recommend adequate supplements or evaluate serum nutrient levels (83), and most patients do not comply with the recommended supplement regimen (70). Education of both the physicians and patients is thus necessary to prevent malnutrition after RYGB surgery.

Macronutrient deficiency and intolerance

Protein deficiency, assessed by serum albumin levels, is less common than most other nutrient deficiencies (Table 2) (66, 67, 68, 69). To consume enough protein, patients should be advised to consume fish, which is better tolerated than meat.

Simple sugar intake, especially added sugars (64), has been reported to cause dumping syndrome in as many as 76% (84) of the RYGB patients. The food rapidly enters the small intestine causing an osmotic load, which leads to movement of fluid from the blood into the intestine (85, 86). Rapid food entry into the jejunum also stimulates a substantial release of peptide hormones (85, 86). Clinical manifestations of the dumping syndrome include gastrointestinal symptoms such as early satiety, nausea, cramps, and explosive diarrhea and vasomotor symptoms such as sweating, flushing, palpitations, dizziness, and an intense desire to lie down (85). The insulin response is exaggerated and causes hypoglycemia (85, 86). To prevent dumping syndrome, patients should avoid consuming fruit juices and foods and drinks with added sugar (64); consume frequent, small, dry meals because water can make the food more soluble; include dietary fiber; increase dietary protein (especially fish and chicken); and modestly increase dietary fat (to delay gastric emptying) (86). 

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Nobody is trying to make post-ops feel badly about their surgery choice.  The DSers postings are aimed at pre-ops and potential revisions, to make sure they know about the DS BEFORE they choose which surgery to have.  I'm sorry if that's how our postings make them feel, but that is not our intent. 

We DSers also want people to know that we can help people with insurance issues, as most insurance companies can be FORCED to pay for the DS if the patient wants it and is willing to jump through the hoops to appeal -- one of the major independent medical reviewers in the country (used by many insurance companies and the federal government) TOTALLY supports the DS over the RNY when the IMRs are sent to them.  Medicare changed their rules in 2006 (in no small part in response to a letter-writing campaign by us DSers!) to include the DS as a covered surgery.  As more and more people stand up for their rights to have the surgery of their CHOICE, the insurance companies, one by one, are giving in and making the DS equally available, which is one of our major goals.


Thank you Diana Cox for this information!!

To anyone keeping up....

My insurance company denied me twice and I have no external appeal.  A little birdy told me that Dr. Anthone may be able to work with my insurance.  So I drove 500 miles one way to have a consultation with him.  I am so glad I did!  Not only is he world renown for his surgical skills, he is such a nice man!  I'm really hoping this all goes through so I get to have him do my DS.  I had a Nissen Fundoplication done on me in 1995, so I may wake up with a RNY pouch and DS intestines.  I'll be a hybrid!  I trust him with whatever he feels he needs to do.