DeShanna C.
Interesting Article: RNY vs DS/BPD
Dec 09, 2009
I didn't know anything about the DS procedure until after I became more active on this forum. My Dr.'s office didn't even offer this procedure as an option. They offered the Lap-Band, RNY, and the sleeve. I went with the RNY. So, after reading more about the DS, I was a bit bummed out and wandered if I had missed out on something. I read about people being able to eat more of what they want, being curred quicker, losing more weight...I had started wondering..."Oh No! Did I make the wrong decision?"
Well, after more reading on the procedure, and talking to my OH friends, I calmed down and I am once again happy about my RNY procedure. True, I have had been on a bumpy road to recovery, but each day gets easier. I was googling something...at the moment, I don't even remember what...but I came across this Dr.'s comparison of the RNY vs DS/BPD.
Of course, everyone's situation is different and its not meant to show preferential treat or "Holier Than Thous" attitudes about one procedure over another. I also recognize its an older article, and a lot has changed since 2003 I just found it informative and wanted to share it in my Blog.
I welcome comments/feedback. Just don't be ugly about it because its not necessary and I don't want it on my blog!
Direct Link: http://gastricbypass.netfirms.com/clark-ds-rny.htm
RNY vs DS/BPD
by Wesley Clark, MD
co 2003 - reprinted by permission.
Dear SueW,
You raise the issue of the value of the DS/BPD vs the RNY. We have had considerable experience with both procedures, beginning in 1986, when we began doing the BPD. By about 1992, we had one of the largest series in the United States, and were strong proponents of the operation. We then began to offer the RNY also, after associating with Dr. Richard Catlin, who was one of the pioneer proponents of the small-pouch RNY (15cc volume, vs 60cc with the older style). For a while, we offered both procedures, according to the preference of the patient, but within about 2 years, without any conscious decision to favor one procedure over the other, we found we were doing almost exclusively the RNY.
The reason was simple: our RNY patients got equally good weight loss, with much less side-effects, and risk, than the patients who had a BPD. When observed side-by-side, RNY patients had better skin color and looked healthier. BPD patients tended to look pale and sallow, often appeared weaker, and sometimes even tended to smell bad. Until recently, two of our BPD patients worked in our office, and both observed the results of the two operations, from the standpoint of someone who owns one. Both stated emphatically, that they would prefer to have had an RNY. And both were very careful to do everything we told them, to get the best results. Patients who did not follow instructions, and did not return for regular checkups, sometimes became very ill.
WHY?
The DS/BPD causes weight loss primarily by impairing the absorption of certain foods, namely fats and starches, as well as some vitamins and minerals. They are called "malabsorptive procedures", because interference with normal absorption of food is the way they operate. Although there is some decrease in the capacity to eat, caused by reduction in the size of the stomach, the re-arrangement of the bowel, with a short segment of "common channel", in which absorption is fully empowered, causes most of the fat consumed to be wasted, and about 75 - 80% of starch as well. Patients can eat fairly normal meals, and absorb only a small fraction of the total calories that pass thru their mouths. Most persons who are hearty eaters are captivated by the concept that they can continue to eat large amounts, without suffering the adverse health consequences.
Althought this seems superficially to be a great solution, it is an illusion. The physiology of digestion and absorption of the many nutrients we need is a very complex process, of which we really understand very little. Surgical tinkering with this complex process is a bit like letting a 5 year-old pull parts out of the back of one's color TV. The downside and risks are considerable:
a.. Protein malnutrition occurs in up to 10% of patients, and may require revision (not reversal).
b.. Absorption of essential vitamins and minerals is seriously impaired (Calcium, iron, Vitamins A, D and E).
c.. Metabolic bone disease is quite common.
d.. Bizarre effects on overall metabolism occur, causing strange halitosis and body odors, and a pasty pallor in many patients.
e.. Wasted starches which are eliminated in the colon (large intestine) lead to production of severely foul-smelling gas, which can be a serious social problem.
f.. Wasted fats which are passed to the colon are acted upon there by bacteria, to produce irritating byproducts which cause irritable and explosive bowel activity.
g.. Patients can still regain weight, or fail to lose, by eating foods containing simple sugars or simpler carbohydrates.
h.. Patients expend a considerable amount of energy and effort in seeking solutions and work-arounds, to avoid these side-effects and inconveniences.
The Duodenal Switch (DS) attempts to solve some of these problems, although the success of this modification has not yet been clearly demonstrated. Neither the BPD nor the DS are easy to reverse, but in most instances a reversal is well within the capability of the experienced surgeon. However, reversal should seldom be necessary, so I don't see this as a major liability. Revision is more often needed, and if serious malnutrition has occurred, the risk of that surgery may be much increased by the underlying poor health.
The RNY works by limiting the volume of food which one can eat, and simultaneously producing a sense of satisfaction after eating just a small amount. Almost all of the food which is eaten is absorbed, and nutritional deficiencies are quite rare, provided that a simple food regimen is followed. Even though the amount of food that can be eaten is very small, the early sense of satisfaction (which I call the "Who Cares?" feeling) means that there is no sense of loss or deprivation, such as occurs with dieting and eating small portions.
It is necessary, as with the DS/BPD, to take a broad-spectrum vitamin and mineral supplement every day, and there are some basic rules to follow, for best results, the most important of which is to avoid eating between meals, which can slow down weight loss, or lead to weight regain (the surgeon changes your stomach -- you have to change your mind). Although there can be some bumps in the road, during the first few months of the recovery process, RNY patients very rarely suffer any metabolic problems over the long term, and can live a normal life in a normal-sized body, without abnormal gas, irritable stools or diarrhea, and with a very healthy and happy lifestyle. Compared to the DS/BPD, their existence seems so much more happy and normal, that I am thrilled to do the RNY, and reluctant to even consider a BPD any more.
After all, every surgeon wants the satisfaction of a successful operation and a happy patient.
I hasten to add that some very eminent and experienced surgeons have a different view than I do. I had the privilege of debating this very issue at the annual June meeting of the American Society for Bariatric Surgery. Although about 75% of my colleagues agreed with my position and arguments, many very significant figures in Bariatric Surgery did not. I respect them and their views. We agree to politely disagree, and I'm sure we will continue to debate and argue for many years to come.
G. Wesley Clark, MD
http://www.gastricbypass.com/
