Questions to ask your surgeon

June 21, 2020 11:38 am

Listed below are questions to ask surgeon at the time of consultation. Patients’ should not be afraid to ask a surgeon about their mortality and complication rates; any reputable surgeon will be happy to discuss those statistics with a patient. Note, that all surgeons will have complications and any surgeon that claims there are no complications, may not be paying close attention to the patients to know when the complications occur!  

Experience Performing Duodenal Switch

How long has the surgeon been in practice? What bariatric procedures are performed? How many of each procedure is performed annually? Where was training received in the Duodenal Switch (DS) procedure? How long has it been since performing Duodenal Switch (DS)? What criterion determines if a patient will be considered or qualify for Duodenal Switch? How many DS surgeries are performed open-laparoscopically? What criterion determines a patient having a surgery done laparoscopically? What is laparoscopic to an open conversion rate? How many two-stage duodenal switch procedures are performed? And why? How many DS procedures started, but were unable to complete? Reasons? Are there any post-op patients available to talk to?

Complication and Mortality Rates

What is the operative mortality rate for the surgeon considered? What is the percentage of major complications? What types of complications? What were the causes for these complications? What is the percentage of minor complications? What are the types of complications?

Procedural Preferences

What size of is the stomach? (Note that the evidence placed relatively little value to the size of the stomach with regards to the short-term outcome of DS [72]). How are the small bowel lengths for common, alimentary and the biliopancreatic determined? Percentage based (Hess Method) or an absolute –predetermined length? Will the gallbladder or appendix be removed during surgery? Is a leak test performed during surgery or post-op? Will a liver biopsy be done? How will the incisions be closed; staples, stitches, other?

Revision Patients

How many revisions will be performed? How many ___ to DS revisions have you done? What is the percentage of revision patients with major complications? Types? Mortality rate and causes of death?

Insurance- directed to the office staff

Do you accept my insurance? If I have encountered problems in my insurance approval, will your office assist me? If I have to pay a portion of the costs that my insurance doesn’t cover, will you accept payments? Do you require a deposit? If so, how much?

Self-Payers-directed to the office staff

What is the cost of the surgery and what does it include? Do you require a deposit? If so, how much? Does it include after-care? For how long? What specifically does it cover?

Qualifying for Weight Loss Surgery

June 21, 2020 11:36 am

The National Institutes of Health (NIH) has set the criteria for qualifying for weight loss surgery. Most surgeons and insurance companies abide by these guidelines.

Surgery should be considered for individuals who can show that dietary attempts at weight control have been ineffective and have a BMI greater than 40 or greater than 35 in the presence of comorbidities. If your BMI is between 35 and 39.9 your insurance company may require that that you also have at least one of the following obesity related comorbidities: sleep apnea, diabetes or hypertension. Check with your insurance company on their policy.

Patients considering weight loss surgery should be well-informed and motivated with acceptable operative risks. The patient must clearly and realistically understand how their lives may change after operation and be able to participate in treatment and long-term follow-up. These guidelines apply to adults only.

BMI Calculator

Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women. BMI does not differentiate between body fat and muscle mass. Therefore, body builders and people who have a lot of muscle bulk will have a high BMI but are not overweight. A BMI > 35 indicates you may qualify for weight loss surgery.

Calculate you Body Mass Index (BMI)
Free BMI Script by BMI-Club
Waist circumference

BMI Range     Meaning
< 18.5            Underweight
18.5 – 24.9     Normal
25.0 – 29.9     Overweight
30.0 – 39.9     Obese
40.0 – 49.9     Morbid Obesity
> 50              Super Morbid Obesity

Obesity Comorbidities

To follow is a list of comorbidities (additional conditions or diseases) related to obesity which may help you in qualifying for weight loss surgery.

• Family history of heart disease
• Family history of stroke
• Family history of diabetes
• Family history of heart attacks
• Hyperinsulinemia
• Diabetes
• High blood pressure
• Coronary-artery disease
• Hypertension
• Migraines or headaches directly related to obesity or cranial hypertension
• Congestive heart failure
• Neoplasia
• Dyslipidemia
• Anemia
• Gallbladder disease
• Osteoarthritis
• Degenerative arthritis
• Degenerative disc
• Degenerative joint disease
• Recommended joint replacement from specialist
• Accelerated degenerative joint disease
• Asthma
  
• Repeated pneumonia
• Repeated pleurisy
• Repeated bronchitis
• Lung restriction
• Gastroesophageal reflex (GERD)
• Excess facial & body Hair (Hirsutism)
• Rashes
  
• Chronic skin infections
• Excess sweating
• Frequent yeast infections
• Urinary stress incontinence
• Menstrual irregularity
• Hormonal abnormalities
• Polycystic ovaries
• Infertility
• Carcinoma (breast, colon, uterine cancer)
• Sleep apnea
• Pseudotumor cerebri
• Depression
• Psychological/sexual dysfunction
• Social discrimination
• Premature death

For more information on the NIH qualifications for weight loss surgery:
Gastrointestinal surgery for severe obesity. Proceedings of a National Institutes of Health Consensus Development Conference, March 25-27, 1991.

Getting Duodenal Switch Surgery

June 21, 2020 11:35 am

Getting Duodenal Switch Surgery contains information you will need to consider once you decide Duodenal Switch is for you. Find out if you qualify for weight loss surgery; use our BMI calculator and view our list of obesity related comorbidities that may help you when applying for coverage through your insurance company. Soon you will find information on having Duodenal Switch surgery in Brazil, Mexico or Spain, self-pay costs, insurance appeals, and revision surgery.

Duodenal Switch in Ontario

June 21, 2020 11:32 am

To find out if you qualify for bariatric surgery in Ontario see the list of Bariatric Surgery Criteria below. To start the process you need a doctor to register you in the Ontario Bariatric Registery . Once registered you will be assessed by a surgeon from your assigned Regional Assessment and Treatment Centre. To our knowledge only one surgeon in Ontario is performing Duodenal Switch (DS) surgery. If the surgeon you have been assigned to does not, at your assessment you can ask for a referral to Dr. Dennis Hong at St. Joseph’s Health Centre in Hamilton to be evaluated for the DS. Resources Bariatric Services in Ontario Ontario Bariatric Network Ontario Bariatric Registery Remember, if you do not meet the requirements for Duodenal Switch surgery coverage in Ontario you have the option to self-pay. There is a surgeon in Quebec, Dr. Gagner, and surgeons in the US and internationally that provide these services. Please make sure you thoroughly research your surgeon’s credentials and experience.  

Bariatric Surgery Criteria

These are the criteria to qualify for bariatric surgery acccording the the Schedule of Benefits updated September 2011: 29. Bariatric surgery S120 (gastric bypass or partition), S189 (intestinal bypass) and S114 (sleeve gastrectomy) are insured services only when all of the following four criteria are satisfied: 1. Presence of morbid obesity that has persisted for at least the preceding 2 years, defined as: a. Body mass index (BMI) exceeding 40; or b. BMI greater than 35 in conjunction with any of the following severe co-morbidities: i. Coronary heart disease; ii. Diabetes mellitus; iii. Clinically significant obstructive sleep apnea (i.e. patient meets the criteria for treatment of obstructive sleep apnea); or iv. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); 2. The patient’s bone growth is completed (18 years of age or documentation of completion of bone growth); 3. The patient has attempted weight loss in the past without successful long-term weight reduction; and 4. The patient must be recommended for the surgery by a multidisciplinary team at a Regional Assessment and Treatment Centre in Ontario.

Regional Assessment Treatment Centres

Windsor Regional Hospital Thunder Bay Hospital Sudbury Health Sciences North Kingston Hotel Dieu Hospital  

Pediatric Regional Assessment and Treatment Centres

For children 12-17 yrs old. Children’s Hospital of Eastern Ontario (CHEO) Hospital for Sick Children (STOMP Program)  

Bariatric Centres of Excellence

1. Hamilton Bariatric Centre of Excellence St. Joseph’s Healthcare Hamilton Hamilton Health Sciences Centre (Medical Site) 2. University of Toronto Collaborative Bariatric Surgery Program Humber River Regional Hospital Toronto East General Hospital St. Michael’s Hospital St. Joseph’s Health Centre The Hospital for Sick Children University Health Network’s (Toronto Western Hospital) 3. Ottawa Bariatric Centre of Excellence 4. Guelph Bariatric Centre of Excellence  

Don’t Have a Family Doctor?

If you are trying to find a family doctor you can make use of Ontario Ministry of Health – Health Care Connect web site. This program helps Ontarians without a family health care provider find one.

Benefits of Duodenal Switch

June 21, 2020 11:31 am

The numerous benefits of Duodenal Switch further enhance the superiority of this weight loss surgery when compared to other procedures. These benefits include successful post-op and long-term excess weight loss (EWL), resolution of obesity related comorbidities, and a improved quality of life.  

Better Success as Measured with Weight Loss

The accepted measure of a satisfactory weight loss success is defined as > greater than 50% excess weight loss (EWL). Dr. Douglas Hess et al. [1] reported that of 161 patients more than 10 years after Duodenal Switch, 94% maintained successful EWL, while failure was defined at less than 20% EWL, was only 1%. In Dr. Picard Marceau’s et al. [2] study of 1,356 DS patients, 82% achieved success and failure was defined at less than 25% EWL, was only 1%. Dr. Gary Anthone [9] reported 73% successful EWL among his duodenal switch patients with a pre-op BMI greater than 50.  

Greater Excess Weight Loss

Duodenal Switch surgeons have reported 70-80% excess weight loss (EWL) over long term follow up. [1-7] Dr. Picard Marceau et al. [2] reported that of 1,356 DS patients over a 15 year span, the EWL was 77% for patients followed for less than 5 years (n 618); 69.4% for patients followed 5 – 10 years (n 451), and 68.9% for the group followed for more than 10 years (n 284). Hess et al. [1] reported the average excess weight loss at 10 years for 167 of his patients was 75%.  

Superior Resolution of Comorbidities

The Duodenal Switch weight loss surgery procedure has seen the highest rate of type 2 diabetes cure, leaving the hospital following surgery and is one of the most astounding benefits of Duodenal Switch. A number of other obesity related comorbidities are also improved or cured by doing this procedure. Dr. Hess et al. [1] reported type 2 diabetics have had a 98% cure (i.e. became euglycemic) a few weeks after surgery. For more information on how DS surgery can have such a quick result, see the metabolic effect of our section on the Duodenal Switch Procedure. In a study by Buchwald et al [58] the following observations were reported on the resolution of obesity comorbidities following the Duodenal Switch procedure and demonstrate the benefits of Duodenal Switch.

• Type 2 Diabetes 99%
• Hyperlipidemia 99%
• Hypertension 83%
• Sleep Apnea 92%

 

Improved Quality of Life

With Duodenal Switch, overall quality of life is improved with rare occurrence of vomiting and more than 90% of patients are eating whatever they desire. [5]

Required Preop Weight Loss

June 21, 2020 11:30 am

Studies demonstrating that required preop weight loss or wait time for surgery is not a predictor of postop bariatric surgery weight loss success.


Preoperative weight gain does not predict failure of weight loss or co-morbidity resolution of laparoscopic Roux-en-Y gastric bypass for morbid obesity.
Harnisch et al. May 2008
PubMed Abstract

BACKGROUND: Success with preoperative weight loss (PWL) is often mandated by the bariatric team to assess patient compliance and has been suggested to correlate with improved postoperative weight loss outcomes.

METHODS: We performed a retrospective analysis of 1629 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at Duke University Medical Center. Patients with a preoperative weight gain (PWG) or loss of > or =10 lb were compared. Patients with <12 months of follow-up were excluded.

RESULTS: We found no difference between the 2 groups (PWG, n = 115, PWL, n = 88) with regard to age, gender, race, preoperative body mass index, presence of co-morbidities, or interval between the initial program-entry weight and surgery (149 versus 141 d). No difference was found in the percentage of excess weight loss (EWL) at 12 months, when calculated using the patient’s immediate preoperative weight (PWG group, 63.5% EWL versus PWL group, 63.9% EWL, P = NS). If the %EWL was calculated using the initial program-entry weight, the PWL did confer a transient postoperative weight loss advantage; however, this did not persist past 24 months postoperatively. At both 12 and 24 months, the resolution rates of diabetes (82% versus 83% at 2 yr; P = NS), hypertension (48% versus 42% at 2 yr, P = NS), and continuous positive airway pressure discontinuation (87% versus 87% at 1 yr, P = NS) were equivalent. No differences in perioperative complications or conversion rates were detected. The operative time was slightly longer for the PWG group (119.7 versus 104.9 min, P = .02).

CONCLUSION: The results of our study have shown that weight loss before laparoscopic Roux-en-Y gastric bypass is not mandatory and might deter patients from considering weight loss surgery. Laparoscopic Roux-en-Y gastric bypass can be performed safely with equivalent co-morbidity resolution and %EWL regardless of PWG or PWL.

Does preoperative weight loss predict success following surgery for morbid obesity?
Mrad et al. May 2008
PubMed Abstract

BACKGROUND: We analyzed preoperative weight loss as a predictor of postoperative success in patients after bariatric surgery.

METHODS: Data were obtained from a retrospective chart review of 562 patients in a multidisciplinary obesity clinic.

RESULTS: One hundred forty-six patients met the inclusion criteria (23 men and 123 women). The mean age was 39.5 years, and the mean body mass index (BMI) was 52.6 kg/m(2). Comorbid disease includes diabetes (15.7%), hypertension (30.8%), mental illness (38.4%), and musculoskeletal disease (56.8%). Procedures performed were 16 vertical band gastroplasties, 43 open gastric bypasses, 52 laparoscopic gastric bypasses, and 35 laparoscopic adjustable gastric bands. Preoperative weight change was as follows: 31 patients gained weight (21.2%), 56 patients lost weight (38.3%), and 59 patients maintained their weight (40.4%). Postoperative weight loss was not influenced by preoperative weight change among women. However, men who gained weight preoperatively had significantly worse outcomes.

CONCLUSIONS: Patients may achieve satisfactory early postoperative outcomes despite inconsistent or marginal preoperative weight change.

Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome.
Fujioka et al. Mar 2008
PubMed Abstract

BACKGROUND: Roux-en-Y gastric bypass patients often undergo preoperative dieting and psychological assessment before surgery. We examined preoperative weight loss, binge eating disorder (BED), and sexual abuse history and the interactions of these predictors to determine whether a cautionary approach to Roux-en-Y gastric bypass is warranted.

METHODS: Consecutive subjects undergoing Roux-en-Y gastric bypass at our institution from January 1997 to December 2002 were reviewed. The postoperative excess weight loss (EWL) at 1, 3, 6, 12, 18, and 24 months and the perioperative complications were measured. EWL was compared at 12 and 24 months postoperatively in the categories of the presence/absence of preoperative weight loss, BED, and sexual abuse history. The perioperative complications were examined in the preoperative weight change groups.

RESULTS: Of 154 patients, 121 were included. No significant difference in EWL or perioperative complications was observed between those who lost or gained weight preoperatively. Of the 121 patients, 32% and 17% reported a history of BED and sexual abuse, respectively. No statistically significant difference was observed in the EWL between those with and without BED at 12 and 24 months postoperatively. The EWL in those with and without a sexual abuse history at 12 and 24 months was 57.67% and 66.32% (P <.05) and 64.40% and 70.97% (P = NS). No statistically significant interaction between EWL and sexual abuse*BED/sexual abuse*preoperative weight loss was observed.

CONCLUSION: Only sexual abuse history at postoperative month 12 had a negative effect on EWL. Otherwise, physicians can expect to see successful EWL in these subjects up to 24 months postoperatively. We recommend that additional investigation be done of those with BED and a sexual abuse history.


Patients who are delayed from undergoing bariatric surgery do not have improved weight loss.
Madan et al. Mar 2008
PubMed Abstract

BACKGROUND: Many patients have a prolonged wait time between initial surgeon visit and actual surgery day. Whereas there are various reasons for this, few have examined if patient wait time for bariatric surgery has any affect on weight loss. This investigation studies the hypothesis that patients who wait longer for bariatric surgery do not have improved weight loss over those with shorter wait times.

METHODS: All patients in a private academic practice who underwent laparoscopic gastric bypass over a 6-month period were included in this study. The time from initial office visit to actual surgery date was calculated to be wait time (WT). Reasons for short or long WT were not investigated. The relationship between WT and percentage excess body weight loss (%EBWL) was examined. In addition, patients whose WT was greater than 6 months (WT > 6) were compared to those less than 6 months (WT < 6). Pearson's correlation coefficients and two-tailed Mann-Whitney tests were used as appropriate.

RESULTS: There were 104 patients with 99 patients who had a >1 year follow-up. WT did not correlate with %EBWL (r = 0.09, p = 0.37). There was no difference in %EBWL in the WT > 6 group versus the WT < 6 group (73 vs. 70%; p = NS). Patients who had <50% EBWL waited an average of 281 versus 254 days for those who have >50% EBWL (p = NS).

CONCLUSIONS: Patients who wait longer before having bariatric surgery do not show improved weight loss. Weight loss success was not related to wait time. These results suggest that prolonged mandatory weight times are not an effective method for improving bariatric surgery weight loss outcomes. Mandatory delays for bariatric surgery should not be required, as they have no scientific merit.

History of Duodenal Switch

June 21, 2020 11:29 am

The History of Duodenal Switch explains why this hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch (BPD-DS). Duodenal Switch is sometimes confused with old or outdated weight loss surgeries, but this is only being stated because Duodenal Switch has a long history starting in the 1950’s. By going over the history of this procedure and explaining the differences between Duodenal Switch and other procedures, hopefully it will clear up the misconception of Duodenal Switch being outdated.   Jejunoileal Bypass (JIB) The Jejunoileal Bypass, a strictly malabsorptive procedure, was performed in the 1950’s and was the first surgery developed to achieve significant sustained weight loss. In the JIB, the stomach remains intact and all but 35 cm (18 in) of the small intestine is detached and set to the side where it is not reattached anywhere proximally, but is connected to the last segment (35cm section) far from the center of origin. With no liquid flowing through the bypassed intestine to cleanse it some potentially serious complications could develop, such as toxic bacterial overgrowth leading to sepsis, risk of developing severe malnutrition and liver failure from not effectively absorbing vitamin B complex and vitamin C. The JIB is no longer recommended as a bariatric surgical procedure and many patients have had this procedure reversed or revised.   Roux-en-Y Gastric Bypass (RNY, RYGBP or Proximal Gastric Bypass) Roux-en-Y Gastric Bypass was pioneered by Dr. Cesar Roux, a Swiss surgeon, who described the procedure in 1892 for patients with obstruction of the stomach. Interestingly, by 1910, he had abandoned the Roux-en-Y (RNY) procedure because of the high rate of the associated marginal ulcers and the nutritional deficiencies. In late1960’s, Dr. Mason resurrected the gastric bypass with Roux-en-Y anastomosis for treatment of morbid obesity. In the gastric bypass, RNY, a small (15-30 cc) pouch is created at the top of the stomach to restrict food intake. The small bowel is divided about 45 cm (18 in) below the lower stomach and is re-arranged into a Y-formation. The pyloric valve at the bottom of the “blind” stomach and is not in use because food travels out of the top “pouch” stomach straight into the small intestine via the roux limb. For this reason, sugar moves quickly into the bowel and can cause “dumping”. Proximal patients have their roux limb measured approximately 80 – 150 cm (30 to 60 inches) from the top of the small intestine. Therefore, most of the small bowel absorbs nutrients and the malabsorption is mild. A less common modification of the RYGBP is the Distal Gastric Bypass. Distal patients have the same “pouch” stomach as proximal patients, but have their roux limb measured approximately 100 to 150 cm from the bottom of the small bowel. As a result, Distal Gastric Bypass patients have increased malabsorption. Distal Gastric Bypass is a procedure where one combines all the side effects of the duodenal switch and the gastric bypass together with no measurable benefit.   Biliopancreatic Diversion (BPD) Dr. Nicola Scopinaro introduced the Biliopancreatic Diversion in Italy during 1979.The procedure combines malabsorption with some gastric restriction. A large pouch between 250 and 400 ccs is created with the upper portion and the lower stomach is surgically removed (distal gastrectomy). The pyloric valve is circumvented so “dumping” often occurs. The duodenum (top part of the small intestine) is bypassed and the stomach pouch is connected to the lower 2-3 meters of the small intestine. Then, 4-metres of the small bowel (60%) is bypassed making the channel approximately 50 cm.   Stand-Alone Duodenal Switch The Stand-Alone Duodenal Switch procedure (without the accompanying gastric bypass as used in weight-loss surgery) was developed by Dr. Tom R. DeMeester in the 1980’s to treat bile-reflux gastritis, a condition in which the stomach and esophagus are irritated by bile that goes back through the pylorus to the stomach.   Biliopancreatic Diversion with Duodenal Switch (BPD-DS) In 1986, Dr. Douglas Hess modified BPD and combined it with Duodenal Switch. This hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch, or GR-DS (Gastric Reduction- Duodenal Switch). Keep in mind; the BPD portion has been modified from the original procedure so the name can be misleading.   Duodenal Switch (DS) DS surgeons and patients commonly refer to this procedure as the Duodenal Switch. Hess’s Duodenal Switch has the advantages of the BPD, but without some of the associated problems like marginal ulcers, stoma closures and blockages, dumping syndrome, and serious protein-calorie malnutrition; all of which can occur after other gastric bypass procedures.

Vitamin and Mineral Deficiencies

June 21, 2020 11:28 am

Articles highlighting vitamin and mineral deficiencies after Duodenal Switch surgery.   Neurologic dysfunction and pancytopenia secondary to acquired copper deficiency following duodenal switch: case report and review of the literature. Btaiche et al. Oct 2011 PubMed Abstract ABSTRACT: The duodenal switch (DS) procedure is a type of restrictive-malabsorptive bariatric surgery that is typically reserved for severe morbidly obese people (body mass index >50 kg/m(2)) with obesity-related comorbidities, when diet, lifestyle changes, and pharmacologic therapy fail to achieve adequate weight loss. Patients who undergo the DS procedure are at risk for malabsorption, malnutrition, and nutrient deficiencies. Copper deficiency is a commonly reported long-term complication of Roux-en-Y gastric bypass (RYGB) surgery. However, data are limited on copper deficiency-associated complications and their treatment in DS patients. This article presents a case of a patient who developed hypocupremia with associated pancytopenia, myeloneuropathy, and leukoencephalopathy following DS and reviews the literature related to the pathophysiology of copper deficiency and copper replacement in bariatric surgery patients. When severe diarrhea was present, intravenous elemental copper 4 mg (as cupric chloride)/d in addition to daily oral copper gluconate was necessary to correct the hypocupremia and improve the hematologic indices and neurologic symptoms of copper deficiency. When diarrhea subsided, oral elemental copper 4 mg (as copper gluconate) 3 times daily maintained normal serum copper concentrations and avoided the relapse of severe neurologic dysfunction. Regular monitoring of serum copper and ceruloplasmin concentrations is recommended following DS surgery to detect any copper deficiency before irreversible neurologic damage occurs. Long-term copper supplementation is likely necessary to maintain normal copper status in DS patients. Nutritional deficiencies in bariatric surgery patients: prevention, diagnosis and treatment. Schweiger et al. Nov 2010 PubMed Abstract ABSTRACT: The number of people suffering from surgery and obesity in the western world is constantly growing. In 1997 the World Health Organization (WHO) defined obesity as a plague and one of greatest public health hazards of our time. The National Institution of Health (NIH) declared that surgery is the only long-term solution for obesity. Today there are four different types of bariatric surgery. Each variation has different implications on the nutritional status of bariatric surgery patients. Bariatric surgery candidates are at risk of developing vitamin and mineral nutritional deficiencies in the post-operative stage, due to vomiting, decrease in food intake, food intolerance, diminution of gastric secretions and bypass of absorption area. It is easier and more efficient to treat nutritional deficiencies in the preoperative stage. Therefore, preoperative detection and correction are crucial. Blood tests before surgery to detect and treat nutritional deficiencies are crucial. In the postoperative period, blood tests should be conducted every 3 months in the first year after operation, every six months in the second year and annually thereafter. Multivitamin is recommended to prevent nutritional deficiencies in all bariatric surgery patients. Furthermore, iron, calcium, Vitamin D and B12 are additionally recommended for Roux-en-Y Gastric Bypass patients. Patients with Biliopancreatic diversion and Duodenal Switch should also take fat soluble vitamins. Zinc Deficiency: A Frequent and Underestimated Complication After Bariatric Surgery. Sallé et al. Aug 2010 PubMed Abstract BACKGROUND: Although zinc deficiency is common after bariatric surgery, its incidence is underestimated. The objective was to monitor zinc and nutritional status before and 6, 12 and 24 months (M6, M12 and M24) after gastric bypass (Roux-en-Y gastric bypass), sleeve gastrectomy and biliopancreatic diversion with duodenal switch (DS) in patients receiving systematised nutritional care. METHODS: Data for 324 morbidly obese patients (mean body mass index 46.2 +/- 7.3 kg/m(2)) were reviewed retrospectively. The follow-up period was 6 months for 272 patients, 12 months for 175, and 24 months for 70. Anthropometric, dietary and serum albumin, prealbumin, zinc, iron and transferrin saturation measures were determined at each timepoint. RESULTS: Nine percent of patients had zinc deficiency pre-operatively. Zinc deficiency was present in 42.5% of the population at M12 and then remained stable. Zinc deficiency was significantly more frequent after DS, with a prevalence of 91.7% at M12. Between M0 and M6, variation in plasma prealbumin, surgery type and zinc supplementation explained 27.2% of the variance in plasma zinc concentration. Surgery type explained 22.1% of this variance between M0 and M24. Mean supplemental zinc intake was low (22 mg/day). The percentage of patients taking zinc supplementation at M6, M12 and M24 was 8.9%, 20.6% and 29%, respectively. CONCLUSIONS: Reduced protein intake, impaired zinc absorption and worsening compensatory mechanisms contribute to zinc deficiency. The mechanisms involved differ according to the type of surgery and time since surgery. Zinc supplementation is necessary early after bariatric surgery, but this requirement is often underestimated or is inadequate.   Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Aasheim et al. Jul 2009 PubMed Abstract BACKGROUND: Bariatric surgery is widely performed to induce weight loss. OBJECTIVE: The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN: A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS: Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS: Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.

Strategies and Resources for Appealing when your Medical Coverage Allows Weight Loss Surgery but Does not Cover the Duodenal Switch Procedure

June 21, 2020 11:27 am

By: Amanda Basmajian of Advanced Medical Billing, Inc I. Does your insurance cover weight loss surgery?

A) NO

See your HR department for different medical insurance options or shop around independently, perhaps via your state’s exchange for other coverage that offers WLS.

B) YES

i. Does your insurance cover the Duodenal Switch procedure?

1. YES

a) Make certain you understand the specifics of your coverage i.e., what criteria is used to determine if you are eligible for WLS and DS. Also, what will your out-of-pocket costs for this procedure be? Your reputable duodenal switch specialist’s office should be able to assist you with parsing your particular coverage. b) Here is a link that provides medical conditions that must be met to qualify for weight loss surgery by insurance type when a procedure is considered “covered” by your specific plan. Please note: this is just to provide a general idea as contracts vary plan to plan and sometimes a small insurer may hire a large company such as Blue Cross to only process your claims. This may not mean you have Blue Cross coverage. In short: this may provide you with a general idea, but make certain you have your specific coverage benefits obtained from your medical coverage directly.

2. NO

a) Obtain approval for a weight loss surgical procedure that is covered by your insurance.  Then appeal to your medical coverage plan to change the type of procedure to Duodenal Switch.  Be prepared to be patient as this process will take some time:

i) Go to your primary care physician and ask for a referral to a surgeon who can perform one of the weight loss surgical procedures that is covered by your plan.  (Medical industry experts advise that at this stage you do not mention to your PCP that you’d actually like the duodenal switch). ii) Initiate prior-authorization for the type of WLS covered by your plan (such as RNY). iii) While your prior-authorization is pending, find yourself a duodenal switch specialist, and pay out of pocket for a consultation (do not involve your insurance).  Request that this physician prepare a letter of medical necessity that is very specific and will address on an individual basis why DS surgery is recommended for you. You will need a letter that details specifically why DS is better for you as an individual patient. iv) Next, take your approval for the weight loss surgical procedure and immediately submit in writing your request for the duodenal switch procedure instead.  Explain that you’ve already been approved for weight loss surgery, so you are only seeking approval for a different type of procedure that will be better for you individually. Make certain to include the letter prepared by your DS surgeon. v) You will most likely receive a denial from your insurance company.  Carefully read the denial to see how to appeal this decision i.e., where to mail the appeal to.  Also note the basis for their denial and try to craft your appeal to address that denial.  As soon as possible, mail your appeal.  This appeal will essentially be exactly like the first letter you submitted, but it will state in the first sentence that you are appealing the denial of the duodenal switch. vi) If your insurance denies again (and you should expect that it will) your next plan of attack will depend on the type of insurance you have and the state you live in.

a) I have “Self-Funded / ERISA” Medical Coverage provided by my employer: Your employer’s medical coverage administrator has the power to overrule your insurance company. Review the following:

i) Court cases have determined that an ERISA administrator cannot decide to deny benefits if they “offered an explanation for their decision that runs counter to evidence.” (See page 27 of this California Medical Association’s Guide to ERISA: (ERISA) As your appeal has provided quite a bit of evidence, this is good news for you. ii) Also note that according to ERISA law, your appeals must have either been reviewed by a healthcare professional or a healthcare professional must have at least been consulted. Furthermore, this professional must have been named. (See ERISA page 21)

b) I have an HMO plan and I live in California:

i) Your insurance is regulated by the Department of Managed Care and you are entitled to an Independent Medical Review through this agency: (DMC IMR)

c) I have a PPO plan and I live in California

i) Determine which agency regulates your coverage: Some California PPOs are still regulated by the Department of Managed Care, but others are regulated by the Department of Insurance. Determine which your company is. Be careful! When Anthem Blue Cross states “Life and Health Company” after the name of their insurance they are regulated by Department of Insurance! See this example. ii) DMC and DoI provide lists of the medical coverage plans they regulate: Department of Managed Care Department of Insurance iii) If your plan is regulated by Department of Managed Care, use the link given above under HMO. If your coverage is regulated by Department of Insurance, here is your Independent Medical Review option through them: (DoI IMR)

d) I do not live in California

i) Use this table which lists the regulatory agencies by state to contact the appropriate overseeing agency for further instructions on how to appeal: (Agencies by State)

Insurance Says DS Investigational

I decided to write Insurance Says DS Investigational: A How-To Manual because of the number of inquiries I have received about how to deal with this insurance obstacle. The general process is pretty much the same for most insurance companies. First, figure out if your insurance company covers WLS at all. You can usually find this on the insurance company website. If they do, get a copy of YOUR policy to see whether they cover WLS, as employers can opt out of certain coverages. If they do, find out (from your HR department) whether your insurance plan is fully funded or self funded. It makes a difference in your route and right of appeal. If you find out that the insurance company covers WLS BUT says the DS is experimental/investigational, this is what I have found is the way to proceed:

• Ask your PCP to refer you for WLS, and be a good little sheeple and follow all the rules. Don’t mention your desire to get the DS at this point.
• What you are trying to do FIRST is to get yourself approved for WLS in general (likely the RNY), so that when you start to fight for the DS, you are only fighting for WHICH surgery you should have, not whether you qualify in the first place. If you start out asking for the DS with a company that has an exclusion of the DS in their policy, they will make your life miserable at every turn to try and keep you from getting approved for WLS in the first place — they will get hypertechnical with the 6 month diet requirements, with the proofs of being MO for 5 years, etc. They are generally less picky with the RNY.
• Note that in CA, you can avoid the 6 month diet or 10% weight loss requirement by immediately appealing to the CA Dept. of Managed Health Care. But if you don’t fast track that appeal, it will take 4-6 months anyway. I can help you get in contact with the right people at the DMHC if you come across one of these requirements.
• While you are in the approval process for WLS, find yourself a DS surgeon. Get a consult, and pay out of pocket for it. Get a letter written for you by the DS surgeon that explains why the DS is better for YOU than the RNY. This can be because you are SMO, have a family history of stomach cancer, have arthritis or other reasons to need or expect to need in the future to take NSAIDs, have the need to be on anticoagulants, have a Nissan wrap, or some other PERSONALIZED reason. You may as well get the psych consult out of the way at the same time.
• In the meantime, you will be writing your request for the DS for after you are approved for the RNY. You are gathering the papers that show the SUPERIORITY of the DS to attach to your request.
• When you get approved for the RNY, you IMMEDIATELY submit your request for the DS instead, including the well-written letter with your reasons why you want the DS, copies of the scientific literature supporting your reasons, and the letter from the DS surgeon recommending it for you in particular.
• The insurance company will take every day of the permitted period to deny you. You will try not to take this personally (HAH!).
• You will take their denial, and IMMEDIATELY submit a request for a second level review. It will essentially be a copy of the first well written letter, with a request for reconsideration. You will maintain your calm, because there is NOTHING personal about this — it is business (note that I was completely unable to follow this rule and wasted a lot of unnecessary emotion on this part of the process).
• The insurance company will take every day of the permitted period to deny you again.
• What happens next depends on your type of insurance, and possibly which state you live in. If your plan is self-funded, the company ultimately has the power to overrule the insurance company, and your route of appeal is through the company’s HR dept. If your insurance is fully funded, then you likely have the right to external medical review — that information should be provided to you in your second level denial.
• In CA, that review is generally to the CA Dept. of Managed Health Care, which is VERY pro-DS. The process takes about 30-60 days (I believe it’s 30 days from when the DMHC gets a copy of your medical records and appeals from your insurance company), and at the end, they overturn the denial in most cases. The process may vary in other cases, but the important thing is that EXTERNAL medical people will review the case.

More and more, the external medical reviewers are overturning the denials. Don’t let the insurance companies dictate how you are going to live the rest of your life. See our Articles section for clinical data to support your appeal.

Limb Length Studies

June 21, 2020 11:26 am

Duodenal Switch related limb length studies.

Maintenance of weight loss in patients with body mass index >60 kg/m2: importance of length of small bowel bypassed.
Anthone et al. May 2008
PubMed Abstract

BACKGROUND: It is commonly believed that weight loss after biliopancreatic diversion/duodenal switch is inversely related to the length of the alimentary limb and the common channel. However, the effect of the biliopancreatic limb length (BPL) on weight loss has received little attention.

METHODS: A total of 1001 patients after biliopancreatic diversion/duodenal switch (209 men and 792 women, mean age 42 +/- 10 yr, mean body mass index [BMI] 52 +/- 9 kg/m(2)) were divided into 2 groups according to the ratio of the BPL to the total small bowel length (SBL): a BPL < or =45% of the SBL versus a BPL >45% of the SBL. The nutritional parameters and percentage of excess weight loss were compared between the 2 groups.

RESULTS: In patients with a BMI of < or =60 kg/m(2), the percentage of excess weight loss at 1 year postoperatively was 66.8% for those with a BPL < or =45% of the SBL and 69.3% for those with a BPL >45% of the SBL (P = NS). At 2 years, the corresponding percentages were 73.7% and 79.5% (P = NS) and, at 3 years, were 73.4% and 75.2% (P = NS). In patients with a BMI >60 kg/m(2), the corresponding percentages of excess weight loss was 56.8% versus 61.4% (P = .07) at 1 year, 62.2% versus 77.5% (P = .04) at 2 years, and 59.8% versus 77.5% at 3 years (P = .05).

CONCLUSION: The results of our study have shown that amount of weight lost after biliopancreatic diversion/duodenal switch is directly related to the proportion of small bowel bypassed in patients with a BMI >60 kg/m(2). Also, the effect increased with the duration of follow-up. In less heavy patients, the BPL/SBL ratio had a minimal effect on long-term weight loss and a more pronounced effect on nutritional parameters.