Question:
Why do surgeons that do both choose RNY vs DS
I live in Northern VA. and don't have any surgeons that do the DS around here. I am considering coming to NYC to have Dr. Gagner perform one. I have a BMI of 40. I've called his office and found that he sometimes chooses the RNY over the DS. Why is this? The DS seems to have a much smaller lifestyle change after surgery with little to no future weight gain. Is this true? Why do more surgeons not do the DS? My insurance company says that since it has not caught on over the last 5 years ( only 11 surgeons do it in the US ) that it can't be as good because this is a competitive business and all surgeons want the best long term results, even though the DS is more difficult. Could you help me understand? I'd prefer the DS even though it requires that I go out of network and pay $2500 out of pocket, but perhaps its not right for me. I've called the National Institute of Health, they didn't know much about the DS. I've called the American Society of Bariatic Surgeons and they knew very little and said it was a much more extreme surgery, and said they agreed that more surgeons would offer it if it was so great. It really does sound easier. Also please don't just send me to duodenalswitch.com as I've asked questions there but gotten no answers and can't find info there on specific questions very easily. I'll probably end up with a RNY but want that to be the right surgery for me not just the most convinient one. Thank you for your time and effort. Marilyn Marilyn — Marilyn M. (posted on August 13, 2000)
August 13, 2000
Marilyn: If you want answers go straight to the horses mouth so to
speak.. If you're wondering why the majority of surgeon do not offer
DS then call or email many surgeons and ask them about the DS procedure
ask them all the questions you want. Most surgeons will talk very
open and honest about their feelings and findings about DS.. .. That way
you will get the answers you're looking for and not second hand biased
information.. This is what I did before I made my selection.. Good Luck
in what ever you decide.
— Victoria B.
August 13, 2000
Hi Marilyn... first of all, I never saw your question at the DS site. I am
sorry I missed it. I would have answered you. Just to help you along,
there are 26 <a
href="http://www.duodenalswitch.com/Surgeons/surgeons.html">DS
Surgeons</a> in the US. There is a new addition to the website, in
down-to-earth language about the DS, it is called <a
href="http://www.duodenalswitch.com/Surgeons/Hess_Brochure/hess_brochure.html">The
Hess Brochure</a> . It is true that there is <a
href="http://www.duodenalswitch.com/Procedure/DS_vs__RNY/1998Hess/1998hess.html#conclusions">little
to no late regain of weight</a> . Generally, patients with a lower
BMI are educated about the RNY, but it has been my experience that if you,
the patient, are educated about the DS, then the surgeon leaves the
ultimate decision up to you. Personally, my surgeon feels that the quality
of life with the DS is the best. Although I dont know what it feels like
to have the RNY, I can assure you that the post-op life of a DS'er seems to
be the closest thing to normal. I eat anything I want, only smaller
portions. Since the stomach is left functioning normally, one will
generally not have problems often associated with other surgeries. As for
your insurance company, I seriously feel that whoever made that statement
is just full of baloney. The DS is a much more complicated surgery and a
lot of surgeons just dont feel comfortable in working in the quadrant where
all the magic takes place. I feel very comfortable with the decision I
made to have the DS. My post-op life has been unremarkable... just
normal. I believe in this surgery so much that I allowed my 16 yr old,
super morbidly obese daughter have it, without reservation of the long term
outcome. I would do it again, in a heart beat. If you have any further
questions, please feel free to email me.
— Kris S.
August 13, 2000
ADDENDUM: Marilyn, I would agree with what Victoria said about calling
surgeons and asking about the DS. It has been my experience (I have asked
this question many times to many RNY surgeons via email and telephone),
that they will either answer your question with silence (meaning they dont
have a clue) or that they havent given any serious effort to find out about
the DS and will rely on rumor. Your best bet, honestly, is to talk to
surgeons who perform both surgeries so that you can get an unbiased
opinion. In order to choose the right surgery for you, perhaps you should
write down all the pros and cons of each surgery type and choose the one
you can live with. If you are interested, I would love for you to read
<a
href="http://www.duodenalswitch.com/Patients/Kris/kris.html">my
story</a> to give you some insight.
— Kris S.
August 13, 2000
I would like to follow-up on what Ray said. There is little you have to do
as a post-op concerning vitamins. I take a multi-vit in the morning and a
multi-vit + iron at night. No b-12 injections or anything like that. We
have very low maintainence as far as post-op protocol goes.
— Kris S.
August 13, 2000
I hit the enter key before I realized it. Sorry. Again, in response to
what Ray said. We DS'ers have the excess stomach removed, since it serves
no purpose and will assure that we will not develop ulcers, the gall
bladder and the appendix. This is normal protocol. Ray said *I would
suspect that most drs feel an acceptable result
can be achieved with an RNY and they are therefore reluctant to go to
a
more radical procedure that will not have an appreciably better
result.
With a BMI of 40, very acceptable results can be achieved with an RNY.*
This is a very good point. But from the point of view as a post op... do
I want *acceptable* results or do I want the best results? Good luck,
Marilyn.
— Kris S.
August 13, 2000
Marilyn: As Dr. Gagner's 7th DS patient from 10 months ago, and someone
who is very active in his support group and who have referred MANY patients
to him for the lap DS, I may be able to shed some light on this issue.
When Dr. Gagner first started offering the DS he did seem to offer it as a
preference to the Super Morbidly Obese. When I requested it, with a BMI of
ONLY 51, he made me feel like a petite little flower, but was comfortable
that I knew the importance of post-op followup bloodwork and vitamin
supplements. Since that time I have seen him offer the DS to lower BMIs
whenever he is assured that they understand the followup protocol. I have
heard him express the opinion that the patients that request the
Duodenalswitch are the most well researched and WLS educated people in his
practice. Looking back at a year of DS surgeries, I am also aware that
there have been problems with people who did not followup with their
supplements. If you do not understand the specific needs of a distal
malabsorptive procedure, or cannot commit to taking 3-4 vitamins a day,
this surgery will not be for you. However, I have seen Dr. Gagner prefer
DS for people with low BMIs for other medical reasons. Since our intact
stomachs are not prone to ulcers as RNYs are, people who must take
arthritis or other pain medications can continue to do so w/o worrying
about imflaming your stomach. Personally, my irritable bowel syndrom has
been completely cured and I know that Dr. G. has had all of his diabetic
patients 100% cured.
Knowing Dr. G, I know that he likes a challenge, whether it is doing a
surgically more demanding procedure (and being the first in the world to
perform it lap) or doing this procedure on someone who has adhesions and
been turned down by other surgeons, or by routinely doing this surgery on
patients who are 800+ lbs. Most surgeons prefer to do the easiest and
fastest procedure. It's one of the reasons many surgeons continue to do
open, until they are forced to modernize due to patient demand.
Quality of Life is another story. That, in addition to the DS's better
record of not having long term regain, was a major influence in my choosing
the DS. I don't know that it is in the forefront of most surgeon's minds.
However, I have to live and eat for the rest of my life and it's my life to
live, so ever if everything else were only equal, and not superior, as it
is, this was a major asset and has proved to be the blessing I hoped it
would be. Talk to Dr. Gagner more & let him know all your concerns.
He's a sweety.
— Jill L.
August 13, 2000
Marilyn,
My surgeon, Dr. Welker at OHSU does both the RNY and the DS. I chose the
DS and I had a BMI of 44 (less than that at time of surgery). Dr. Welker
was entirely supportive of that decision and never asked me to consider the
RNY.
Six people in our small community in rural Alaska chose the RNY and all are
losing weight. Some have problems; some do not. All had at least a six
week period where they could only drink liquids. I started eating on the
third day. I was interested in the RNY but when I spent months
researching, I knew I had found my surgery in the DS. Frankly, I was
afraid to have the RNY living so far from medical care (3 hours by plane to
a surgical hospital) because of all the problems with obstructions, ulcers,
etc.
I wanted a "normal" lifestyle. Even now, at just 10 weeks
post-op, I feel I am pretty darn normal. No gas, no diarrhea, no odor.
And I can eat, say, half a grilled cheese sandwich for lunch. I take
vitamins twice a day. That's it.
Many surgeons, both RNY and DS are devoted to their patients and give them
a great deal of time. Whatever you choose, watch out for surgery mills.
It's unlikely you'll find any associated with the DS, as the surgery takes
longer and requires more expertise. With RNY, a surgeon COULD perform 4
surgeries a day -- definitely a financial incentive. With DS, two are
probably the limit.
Many surgeons are trained to avoid surgery around the duodenum because of
risk of damage to the liver or spleen. In trained hands, this is a minimal
risk.
As far as why a surgeon who performs both surgeries would recommend the RNY
over the DS for a particular, that would have something to do with BMI --
although many people with BMI of 40 do have DS -- but also other factors.
This could include someone who has bowel problems, for example.
If you are deciding between the two surgeries, please take the time to
speak with someone who performs both surgeries. During the conversation,
be sure to elucidate why the DS is attractive to you. Your potential
surgeon will factor all things and recommend a procedure -- or say that
either would work equally well for you, depending on the lifestyle/eating
habits you have.
— Merry C.
August 13, 2000
Hi Marilyn: This question, or something similiar, always seems to stir up a
lot of emotion! I thought you'd like me input too as I had open RNY on
4/4/00 with no complications. I feel great and eat what I consider to be
normally. I do avoid high sugar and high fat foods to avoid
"dumping" but that is a side effect of this surgery that I wanted
to help me change me evil ways of eating. I have never thrown up but I
have experienced the severe abdominal cramping and diarrhea and shakiness
and heart palpitations that go with 'dumping' and I learn quickly to watch
what I eat. I can eat meats, I was on 'real food' at only 2 weeks post op.
My surgeon has been doing this for 30+ years and is a founding member of
the national bariatric surgeons community. He has never lost a patient.
He routinely performs a vagotomy on his patients to reduce the likelihood
of developing a stomach ulcer from around 33% to only 1%. He also
routinely removes the gallbladder (because if it isn't already diseased,
rapid weight loss will cause stone formation) and he even removes the
appendix 'if it is handy' (and mine was, so he removed it). These are all
done to help you avoid another surgery. RNY patients are also required to
take vitamin supplements daily for the rest of our lives. My surgeon also
includes 500 mcg of B-12 daily. Since surgery, my reflux has totally
disappeared, as has my 'irritable bowel syndrome' which I now think had
more to do with my poor food choices than anything else! I do not have a
problem with gas or with smelly gas as some people do either. I've never
gotten anything stuck or had any complications and I think that's because I
following instructions. I am not recommending either surgery over the
other. But, I do recommend that you find an extremely experienced surgeon
no matter which surgery your choose and that you have all the facts you
need to make your decision beforehand. Best wishes to you.
— Cindy H.
August 13, 2000
Marilyn, I agree with Cindy that this question always sends people into a
tizzy. Bottom line is that you have to do what you think is best for YOU.
Do not be swayed by propaganda. Do your own research. Talk to as many
doctors as you can. That's what I did. One of the first sites I found
when I was investigating WLS was the DS site. Some have said that the only
reason RNY is chosen is because people don't do research prior to surgery.
I suppose that's possible, but I've never been one to let someone cut me
open from breastbone to belly button without at least giving it some
thought. I went to the drbaltasar.com link and read "Not all the MO
have the same obesity in terms of grade and risks and they would not
require the same operation. We recommend the duodenal switch technique for
the super obese patients with BMI over 50 since they are in need of a more
secure and effective operation to return to a normal weight. On the other
hand we recommend the gastric bypass for the morbidly obese with BMI
between 40 and 50. Gastric bypass is a very good operation and even better
if done by laparoscopy." After discussions w/ my surgeon, I decided
that with my BMI and goals, RNY was the way for me to go. This isn't true
for everyone. Although most people think that all obese people are the
same, WE ARE NOT. It always seems so strange to me when people who have
had different surgeries criticize what others have done. We are not cookie
cut copies of each other. I have a friend who is now researching
surgeries. Because her BMI is in the 60s, she may be better served by DS
instead of RNY. I make a point of not recommending any procedure because
I'm NOT a doctor. I have no idea what would be best for her. I only know
what's best for ME. I just gave her all the information I had so she could
start her own research. If DS is what you want, you'd probably be very
unhappy with RNY. Do whatever you need to do to get the WLS that you think
will work best for YOU. After all, you're the only one that has to live
with the decision. Best of luck!
— Maxine E.
August 13, 2000
Marilyn,
I admire you for your continuing research into your options for weight loss
surgery. You have been given some really excellent responses. The only
thing I would add to what I have read is that another reason I think there
aren't more MDs performing the DS procedure (though more are being trained
all the time) is a financial reason. The insurance companies are paying
for the distal gastric bypass/duodenal switch procedure just as if it were
a regular RNY procedure. It takes twice as long to do the DS procedure. I
very much admire the physicians who are willing to do the DS procedure,
knowing that they are committed to the procedure because of the quality of
life it offers to their patients. Generally, by the end of the first year,
a DS patient will be able to eat a normal-size 14-16 ounce meal, while
knowing that they will not suffer a regain of lost weight that plagued so
many of us when "dieting".
I wish you much luck for whatever you decide.
— Jamie L.
August 13, 2000
No one is saying that we are all the same.
What I am saying is that if you want a "NORMAL" Quality of Life
(QOL),
then the DS is probably the way to go. I had a BMI of of 47.3
and my daughter's BMI was 49.5. Clearly,we did not fit the
super MO category. It was about QOL and Dr. Baltasar concurred! He never
said the RNY was a bad
operation, but what he conveyed to me is that he wasnt as happy with the
long-term results as he
is with the DS, coupled with the QOL factor. I will reiterate what I have
said before... a surgeon who does both types of WLS will be
able to give you the best information. If you have your heart set
on the DS, let your surgeon know and he will leave the final
decision up to you, providing you dont have any health problems
that could bar you from having the DS.
Propaganda? I dont think so. It speaks for itself. Ask around.
Ask the surgeons who only do the RNY and see what they say
about the DS. Chances are you will either get no answer, because of lack
of knowledge or a bullsh*t answer fueled by rumor.
— Kris S.
August 13, 2000
See <a
href="http://www.duodenalswitch.com/Procedure/DS_vs__RNY/1998Hess/1998hess.html#conclusions">conclusions</a>
concerning late regain of weight.
— Kris S.
August 14, 2000
Hello...just though I'd let you guys know that DS is a choice under the
types of surgery. Don't know exactly when it was added but, it's been that
way for for at least a month. :-)
— Michele A.
August 14, 2000
Michelle, there is a glitch somewhere in the system. DS is not a choice
for about 5 of us, that I know of. We all have gone to the post-op
clinical survey and did the pull-down and it is simply not there. Thats why
it was brought up in the first place.... we cant even put the right
surgery type in our profiles.
— Kris S.
August 14, 2000
Marilyn, Please check with surgeon's who offer both procedures.
Especially concerning what will or will not be removed. The statement
"The DS is a very radical operation that includes the removal of
several body organs." is a blanket statement that sounds like a DS
surgeons are crazy surgeons just yanking and discarding organs carelessly.
To say any organ much less to say SEVERAL organs are going to be removed,
is not something than can be said of all DS surgeons. There are some who
only remove the unused portion of the stomach. I had to have my
gallbladder removed when I was 19 thanks to a lifetime of obesity and I
hope to have the DS one day but I can tell you I don't plan on having any
organs removed that don't need to be!
— Sheila B.
August 14, 2000
I have a question about Ray's answer... What exactly are the several major
organs that are removed? I only know about the removal of a portion of
stomach, and if necessary the gallbladder as in rny. From what I
understand the rest is mostly a re-routing.
— Meli ..
August 14, 2000
Hi Meli.... see? This is how rumors get started. Rest assured that
nothing more is taken out other than what the normal protocol is. The
excess stomach is removed, since it serves no purpose. This also
safeguards against developing ulcers in that portion that acts as a blind
organ when it is not removed. The gall bladder is almost always removed as
well as the appendix. Thanks for asking this question.
— Kris S.
August 14, 2000
The appendix and the gallbladder are removed during a DS for very a very
important reason. If anytime after haveing a DS you experience abdominal
pain doctors can rule out that it is either of these two organs. Doctors
take a wait and see approach to abdominal pain. If you have an obstruction
it needs to be taken care of.
I, personally, have choosen the DS as it seems more normal to me. I have
heard first hand account of too many leaks, staple lines failing and
blocked stoma. I also heard, again first hand accounts, of weight gain.
There are also many incidents of revisions from other surgeries to a DS. I
would not want to go trough a major surgery twice. The having to take very
small bites and chewing food into pulp are not my idea of a good time.
In reasearhing the procedures you will see that the DS is more complicated
(takes longer, need more skill) and that other surgeries are simplier
(short and sweet, most surgeons could do it).
As far as "radical" goes, think of all the things that have been
called that through the years and are now the norm.
These are my opinions and I hope they can ve of some value to you.
Good luck on your journey and may you get what is best for you.
— Marisa B.
August 14, 2000
Hi all - just wanted to check in on this topic. First of all, IMHO, the
only way to get a truly unbiased answer is to check with a surgeon who
performs both types of surgery. ALL of us patients have our biases - it's
why we chose one surgery over another (unless you're one of the unfortunate
folks who doesn't have access to a DS surgeon). And to clarify any
possible misunderstandings, I have NEVER, EVER posted the contents of the
recently-released Hess report, contrary to recent claims that I did so.
— Kim H.
December 1, 2002
The DS is a longer surgery, it takes about twice as long as RNY. The RNY
loses a little faster but regains half of their weight in five years. The
DS patient only regains about 10% of their lost wait over seven years. The
DS patient can eat fairly normal after surgery the RNY can't. The RNY has
to take vitamins and so do the DS patients. The RNY has to worry about
blockages and ulserations the DS patient doesn't. The DS has to worry about
gas and frequent bowel movements for up to nine months. The RNY have to
worry about the dumping syndrome for two years. The dumping syndrome can be
mild and give you a upset tummy or you could pass out and have to wait it
out.
So in my opinion the RNY is great for the surgeon's bottom line while the
DS is great for yours.
— Mark L.
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