Question:
DS - So few DS Drs & Insurance won't cover... Are others finding this to be the case?

Why are there so FEW DS DOCTORS and why are INSURANCE companies so reluctant to cover the BPD w/DS or DS procedure????? Everything I've read seems to indicate that the BPD w/DS is the surgery that keeps your system in the most "normal" state. I have read nothing but success stories on this procedure... both short and long term. — wpc5032 (posted on April 25, 2004)

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April 25, 2004
My surgeon says its because the long term risks are so much higher than the RNY. Vitamin mineral and protein problems, plus since parts are removed its never really reversible. See barb hensons profile here for the troubles DS can have
— bob-haller

April 25, 2004
Barb Henson did indeed have serious problems, but she is FAR from exemplary of the DS procedure. We can bring up horrible stories on any procedure, including complete stomach removal after an RNY that I know of, band erosion resulting in horrendous troubles for a Lap-Bander that I know of... etc., etc. So, it's not really fair to hold up a worst-case scenario as examplary of "why insurance companies are reluctant". That's not why. In the 5 years that I have been in the DS community, I have NEVER EVER heard of an insurance denial based on "possible bad outcome". I have heard of denials based on bogus "experimental" status, based on lack of adequate diet history, and a myriad of other reasons. Never heard of a denial based on the notion that a complication might occur. See my profile for links to lots of reliable DS information.
— mmagruder

April 25, 2004
The reason that there are so few surgeons doing the DS is because its a more technically difficult surgery that takes longer to properly complete. It is COMPLETELY reversible, except for the section of the stomach that is removed, and after 18 months, the partial stomach is still "normal" sized, plus everything will work as it did originally. As for why its "harder to get insurance approval," I think it depends on the insurance company; I was approved on my first submission. I know that some insurance companies say its experimental (not true), and others are restricted by the policyholder's preferences; for example, at my last job, the company had put a LIFETIME LIMIT of $1000.00 for the treatment of morbid obesity. This was not the insurance company, but my employer, who set the limitation. Do the research- its no harder to get a DS approved than an RnY or lap band. And don't even get me started on Barb H- her story changes every time she opens her mouth. I'm sorry she's having problems, but she's told so many different stories I can't decide what to believe..
— Liane F.

April 25, 2004
I really wish those who have not had the DS would not disparage what they don't know, and I ESPECIALLY wish those whose doctors don't DO the DS and therefore have little familiarity with the procedure wouldn't repeat their doctor's ininformed -- and self-serving -- views. There is a VERY strong lobby of RNY surgeons opposing the DS procedure, both within the ASBS and in collaboration with the insurance companies. The reasons behind this opposition are manifold, but can be summarized (in my opinion) as follows: 1) The RNY is an easier surgery to do, as the procedure takes place solely in the upper abdomen (for the most common proximal bypass), whereas the DS is a two part procedure, in the upper abdomen for the gastric sleeve and the mid abdomen for the construction of the distal bypass. In fact, there are weekend courses that general surgeons can take to teach them to do the RNY, and frighteningly, that's all the training some RNY surgeons have before starting their practices. Also, the anastamosis of the duodenal tissue is a technically more difficult procedure than the portion of the intestine that is anastamosed in the RNY -- it requires more skill and experience on the part of the DS surgeon. 2) The DS takes longer to do, in particular laparoscopically. Therefore, it is usually somewhat more expensive, by a few hundred or thousand dollars. And the almightly dollar is how the insurance companies measure the value of a procedure, especially when there is an "alternative" treatment available. 3) In fact, while there is a qualitative difference in the malabsorption between the RNY and the DS, BOTH require lifelong supplementation. DSers are rarely deficient in B12, because we retain the B12 absorbing portions of the stomach and duodenum; similarly, iron malabsorption is less of a problem in the DS as compared to the RNY. DSers malabsorb primarily fats after the initial weight loss phase, although protein malabsorption is of concern. However, this is not so different from the RNY concerns, except that DSers can easily eat sufficient protein to overcome the malabsorption, whereas RNYers often require protein supplementation in the form of shakes and bars etc. I haven't eaten or drunk a single one of those things, and would gag if I had to (my own issues -- I'm sure some people LIKE those things, but I can't put one in my mouth). And both surgeries require lifelong calcium supplementation. However, since dairy, including cheese (remember, I malabsorb fats, so they are not something I have to avoid), milk, yoghurt and low carb ice cream are good sources of both protein and calcium for me, adequate intake of calcium (including supplements) is not onerous. 4) While this isn't an exhaustive answer to your question, I think there is a bit of a "morality"-based opposition to the DS prevalent not only among surgeons and insurance companies, but also among the morbidly obese themselves. Let's face it, the RNY for many, if not most, results in a lifetime of food issues post-op, including a lifelong diet, extreme care in not eating the wrong foods, not chewing enough, not eating things that might make you dump, not drinking with meals, fear of regain, etc. Many many restrictions on the enjoyment of eating last long past the inital weight loss phase. In contrast, the DS allows a much more normal lifestyle, little if any restriction in allowable foods or modes of eating or drinking after the weight loss phase (and, to be honest, during the weight loss phase too, for those of us willing to lose more slowly but still steadily), and somehow, I think it OFFENDS some people that we don't suffer as much as the RNY patients. After all, we are at fault for eating ourselves into morbid obesity -- shouldn't we be punished continuously and permanently for doing that, in payment for getting this expensive surgical cure? I think many people harbor such feelings towards us (and themselves), and I think this pseudo-morality issue taints the dialog. 5) As for citing Barb Hansen's experience as a surrogate for all DS procedures, that is patently inappropriate. If you research this person, you will find that Barb had her surgery several years ago by a surgeon in MS who subsequently lost his hospital privileges and then abruptly retired. Barb disclosed that when her revision was done, it was found that her "DS" was not at all what it was supposed to be -- I believe she may have been given a blind loop of intestine, like the now-discredited JIB, instead of a proper proximal bypass. This may have resulted in the development of her many many problems, including developing the autoimmune disease Sjogren's Syndrome, due to toxins being incarcerated in her body -- or she might have developed it anyway, as the vast majority of people who have Sjogren's never had WLS. In any case, the primary lesson of Hansen's experience is not that the DS is dangerous, but rather that you MUST do your research and investigate your surgeon's qualifications VERY carefully -- find out his record of morbidity and mortality during and after surgery; if he has been sued; talk to his patients at his aftercare sessions -- MAKE SURE HE HAS AN AFTERCARE PROGRAM, etc. Barb clearly received something other than a DS, and received horrendous followup care (or none at all) -- she is NOT the poster child for not having a DS! So, do your research, listent to what us DS patients who have actual experience are telling you, do what you think is best for yourself not only in the short run but also for the rest of your life. I was approved immediately by my insurance company for the RNY, and I would have paid for the DS out of pocket rather than accept what for me was an inferior procedure resulting in an inferior quality of life. For many, there is no such choice available -- I can understand that. But if there is any way of fighting the system of misinformation and insurance blockade of paying for the DS, and you are convinced it is the best for you, don't compromise. Many of us have fought our insurance companies and won -- we stand ready to support and help you. Check out http://health.groups.yahoo.com/group/DS-Insurance_Authorization_Problems/ for this support. Good luck with whatever you decide. Diana DS Dr. Robert Rabkin 8/5/03 285/208/160?
— [Deactivated Member]

April 25, 2004
I originally planned to have the DS but switched to the RNY because Cigna (PPO) would not cover the DS. Their specific language in the letter they sent me was "The requested Duodenal Switch procedure is not on the approved list of bariatric surgical procedures". On the phone they further explained that this procedure is still considered "experimental" and is reserved for patients with a bmi greater than 50. So I had a choice, pay for it myself or go with the RNY and let them pay. I chose the latter. Now after much time on this website I am more comfortable with my decision to have the RNY. Quite honestly the thing that scares me the most about the RNY is that I don't have what it takes to keep the weight off. At least with the DS the malabsorption aspect gives you a "safety net". Then again the malnutrition part of it could be scary long-term especially if you are not good about taking your supplements. In my opinion that is why insurance companies shy away from it for the time being. Anyway, tough decision and there is no right answer only what is right for you. Thank God we have all of these options right?
— Teri F.

April 25, 2004
Teri wrote, "'The requested Duodenal Switch procedure is not on the approved list of bariatric surgical procedures'. On the phone they further explained that this procedure is still considered "experimental" and is reserved for patients with a bmi greater than 50." I'm not sure when you were told this but this information is no longer correct. The ASBS officially adopted the DS to their list of accepted surgeries last year. Insurance still is claiming "experimental" status now based on how few doctors are performing the surgery. It is a more technical and difficult surgery and the learning curve tends to be longer with the DS than the RNY. Its actually scary how many doctors are jumping on the band wagon of the DS now that the ASBS is supporting it. It is very important to research your surgeon for this and other obvious reasons. As for the DS being for patients only over a BMI of 50, well that isn't true either. Some may still follow that theory of patient selection but many now will do the DS in any patient over a BMI of 40. So long as you can safely lose 40% of your total weight then you are a potential candidate for the surgery. If you have done your research and feel that the DS is the right surgery for you, the one you want to live with for the rest of your life, then the ball is in your court. I know people who have fought their insurance company for the DS and won. I know people who have had insurance offer then them the RNY, but refuse the offer and self pay the DS themselves. I know lots of people from online who have gone to Spain or Brazil, even a couple who have been to Mexico in order to have the DS at a price they could afford. Its all up to you, what you want for yourself, and if you're willing to work at getting it either through the insurance process or through private financing. Btw, don't let people scare you. As someone already said, there are people who have had trouble with all the types of WLS available but these are in the minority. Do your research and learn the facts rather than listening to horror stories. Good luck!
— Shelly S.

April 26, 2004
Diana, I think the morality-based opposition rests on both sides. Your statement in #4 does not apply to all or most RNY's after they are further out. "4. While this isn't an exhaustive answer to your question, I think there is a bit of a "morality"-based opposition to the DS prevalent not only among surgeons and insurance companies, but also among the morbidly obese themselves. Let's face it, the RNY for many, if not most, results in a lifetime of food issues post-op, including a lifelong diet, extreme care in not eating the wrong foods, not chewing enough, not eating things that might make you dump, not drinking with meals, fear of regain, etc. Many many restrictions on the enjoyment of eating last long past the inital weight loss phase. In contrast, the DS allows a much more normal lifestyle, little if any restriction in allowable foods or modes of eating or drinking after the weight loss phase (and, to be honest, during the weight loss phase too, for those of us willing to lose more slowly but still steadily), and somehow, I think it OFFENDS some people that we don't suffer as much as the RNY patients. After all, we are at fault for eating ourselves into morbid obesity -- shouldn't we be punished continuously and permanently for doing that, in payment for getting this expensive surgical cure? I think many people harbor such feelings towards us (and themselves), and I think this pseudo-morality issue taints the dialog." I do not live on a diet, I do not eat diet food, I do not have any food problems except with a handful of foods, not drinking with meals is something I got used to within the 1st month PO and is no big deal now. I do not fear tons of regain but expect the usual 10% regain, but I know if I choose to use my tool and listen to my body I can keep things in check. I do not dump unless I go nuts with sugar, but who needs to do that anyway? I have yet to have a true dumping so obvisouly I have found the balance that works for my body. I no longer need to chew the crap out of my food. The things you refer to are things that an earlier PO is much more likely to have problems with. At 15 months PO I have a very normal life and not a ton different than it was before surgery. Just eat less food and don't live on sugar anymore. Seems like a healthy thing to me, not a life of deprivation as you seem to portray. Paying more attention to what I eat now is not a bad thing. It sounds like you wanted a surgery you never had to make any changes for. If the DS provides that for you fine, but for me I needed a total change in my lifestyle and a new relationship with food. I needed for food to no longer control my life, so the restriction of an RNY was the right way to go. You would be shocked how much I eat now that I am further out. It's no longer the couple of teaspoons. Who ever said that eating large volumes of food is "normal"? Normal is what each of us decides it is for us. Yes I will get 3 meals out of a steak dinner, but so what. I spend less on food than you do, is that such a bad thing? I am satisfied and get plenty of food and that's normal for me! Enough to feel like I have had a complete meal. I eat potatoes, breads, veggies, sugar, sweets etc. Do I eat large quantities, no, but I can eat just about anything. A DS person does need to make changes also, so don't try and kid anyone that it is a free for all pig out. I've done enough reading on DS boards to know that there are choices to be made. They are just different choices than an RNY has to make, but still choices. In your mind the DS is not as restrictive in required changes as an RNY, and that's fine, as it's your opinion. Most DS people to not like it when an RNY refers to the possible bowel/bathroom issues. Many DS people lately really get ticked about that one, yet when I do reading on DS boards it is something that is talked about quite a bit. Yes it is more of an issue earlier on and usually long term settles out some, but it's the same with an RNY and the issues that possibly go along with that surgery. Time settles out many things in both surgeries. Most RNY's don't like it when a DS assumes and vocalizes how an RNY lives on a diet for the rest of their life, as it is total hogwash! So fair is fair! I'm glad that your surgery works for you and you are happy with it, but there is no need to trash the RNY. I normally go out of my way not to write derrogatory things about the DS because I truly believe for some it is the right surgery. For me it was not. I was SMO and 442 lbs, so I certainly qualified as being the ideal person to have one. Yes my insurance would not have paid for it but I had already disgarded it for me before I even knew that. So money never factored into my decision. It is important for each person to find the right surgery for them as they have to live with it the rest of their life. Just because the ASBS has accepted the DS does not mean the NIH has and that's what most insurances go by. That said, I personally believe an insurance company should just approve the fact that a person need WLS and then let the patient and their surgeon determine which procedure is right for them. The RNY has a history and a lot of early failures, but it continues to be improved with better and better long term success. The DS does not have that long term track record yet, so let's talk in 25 years and see if it still is the "perfect" surgery. I suspect there will be some things that come up long term that people did not foresee, just like the RNY. But the more it is done the better it will be perfected. There is nothing wrong with a DS but please don't cram it down everyone's throat, as it is not for everyone! No surgery is right for everyone!! Okay, I am off my soapbox now and I hope you are off yours!
— zoedogcbr

April 26, 2004
I had the RNY done almost a year ago. Although I honestly do not know all that much about the DS I am writing in response to the statements that I've seen here and in other places regarding our inability to enjoy food and eating anymore. Let me tell you, I think I actually enjoy eating MORE now than I did before I lost 121 lbs. Okay, so I can't eat junk food, candy, cake, cookies, BUT, I can and DO enjoy eating the things that make me healthy. I enjoy going out to dinner with my family now, because I am not embarressed to order something I like to eat. And my social life is more about being social, than stuffing my face. I'm not eating all the things that helped put me close to 300 lbs. I have learned to enjoy the things I CAN eat. And the phrase "Nothing tastes as good as being thin feels" is absolutely the truth. There is nothing in this world that I can enjoy eating so much that I will sabotage my weight again. I hope this made sense cause I feel like I am babbling. LOL. Good Luck to everyone out there.
— KellyJeanB

April 26, 2004
Oh WOW! I had to chime in here too. I'm not particularly educated on the DS but would completely respect anyone's decision to have that particular surgery. However, to address #4 on the list below - I don't find that I'm suffering all the time. I, too, have learned to enjoy food more fully than ever. For the most part I control food - it doesn't control me. I have the ability to eat ANYTHING but just exercise caution with the junky stuff....just like the entire population of the world who watch their weight and who HAVEN'T had weight loss surgery. As far as RNYers thinking DSers don't have to suffer enough.........I don't even know how to respond to that. Why in the world would one WLS patient hope another WLS patient would have a more difficult time post operatively? The hard and cold facts are that both RNY and DS patients can and do experience regain following WLS if they're not mindful of what they eat. And remember....being mindful of what we eat is not the same as being obsessed with what we eat. I don't debate whose surgery is best. I prefer to respect everyone's choice. That's the way it should be on this site. However, I am compelled to dispel the myth reported here that RNY patients no longer enjoy food and must stay on an eternal diet. It simply isn't true. Best wishes to you in whatever procedure you choose and may the procedure of your choice END the suffering you experience as a result of being an obese person. You deserve to be happy and healthy.
— ronascott

April 27, 2004
Hey we dont agree but neither do all surgeons! Now I a RNYer dont diet constantly but have to be careful I dont get addicted to things like oreo cookie bars, a box or two a day can pack on the pounds:( Been there done that. I can and do eat everything, and have a more varied diet than pre op, thanks to my gerd being gone, I love spicey foods I couldnt eat pre op. DS folks have shown up here with regain issues, it can occur after any surgery. As to my surgeons opinion about the ds I literally trust dr schauer with my life. His biggest patients who get a very long RNY, or possibly a DS, the 700 pounders have had troubles with anemia and vitamins. Although my surgeon does primarily RNY and adjustable bands he makes exceptions for exceptional cases where good reasons prevent a particular procedure. I LOVE my RNY, its a great tool that works wonderfully provided I follow the rules. In no way do I feel deprived or suffer at all. I MUST exercise and have found I feel better not only physically but mentally too when more active.
— bob-haller

April 27, 2004
"Just because the ASBS has accepted the DS does not mean the NIH has and that's what most insurances go by." Unless something truly recent has come out that I'm unaware of, the last NIH study was about a decade ago and had almost no data or research on the DS then which they reviewed. Truthfully it looked more like a passing thought to even mention it. In my opinion, insurance companies will use ANYTHING they can lay hands on to discredit something that will cost them money. Until last year they placed great emphasis on the ASBS not supporting the DS, then as soon as the ASBS changed its position, insurance turned their back on it and pretends it is irrelevant, though the only thing to change honestly is whether or not its a position that is economically beneficial to themselves. If a person wants the real scoop they need to read the anals of medicine and see what doctors are publishing about their trials, statistics, and such. And I agree with whomever mentioned reading the boards for the surgery you're interested in. They are totally right. You'll get to see what post ops really face. From there if you're still interested in that surgery then talk with 3+ year post ops who have lived with it a while. Everyone loves their surgery (usually) so ask the tough questions and find out about what's important to you. Most importantly though do your research thoroughly and then seek others experiences and opinions. As you can see from the rather testy little debate here, what each person feels or believes, really isn't what you'll be able to base your own decisions on. Or at least it shouldn't be.
— Shelly S.

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