Duodenal Switch In Adolescents

June 21, 2020 12:03 pm

Studies on Duodenal Switch in Adolescents. Long-Term Experience with Duodenal Switch in Adolescents. Marceau et al. Dec 2010 PubMed Abstract BACKGROUND: Severe or extreme obesity in children and adolescents is a progressive damaging disease, increasingly requiring surgical treatment. Timing and choice of operation are controversial. METHOD: In the last 16 years, we performed open biliopancreatic diversion with duodenal switch (DS) in 13 adolescents aged 15-17 years, who have been followed up for 2-16 years (mean, 10.6 years); three with Prader-Willi syndrome (PWS) are presented separately. RESULTS: Among the ten non-PWS children (7 girls), no deaths or perioperative complications were reported, mean body mass index (BMI) decreased from 55.9 +/- 14.0 to 28.8 +/- 33.7 kg/m(2) (% excess weight loss (EWL) = 82.1 +/- 10.5%), and none have regained weight. All comorbidities were cured except asthma, which improved in one patient. There were two reoperations: one for intestinal obstruction and one for post-anastomotic ulcer. Glucose and lipid metabolism improved, while vitamin and mineral deficiencies were mild and rare. Five of the seven girls gave birth to 11 children, aged 2-12 years, two of whom are overweight but not severely obese. Neurodevelopment is age-appropriate in all 11 individuals. PWS children, aged 15-16 years, had postoperative respiratory and infectious complications necessitating hospitalizations of 13-22 days (versus 5.1 +/- 11.2 days in non-PWS). Weight loss and comorbidity improvement lasted approximately 5 years, providing improved quality of life for patient and family. One PWS patient died from complications after reoperation for weight regain after 4 years. One was reoperated after 6 years and the third is considering reoperation 14 years after primary DS. CONCLUSION: The beneficial effects of DS in adolescents exceed the risks, even in the presence of PWS.

Economic Impact of Bariatric Surgery

June 21, 2020 11:58 am

Articles highlighting the return on investment and economic impact of bariatric surgery.   Economic Impact of the Clinical Benefits of Bariatric Surgery in Diabetes Patients With BMI >/= 35 kg/m(2). Klein et al. Sept 2010 PubMed Abstract ABSTRACT: The medical costs for a type 2 diabetes patient are two to four times greater than the costs for a patient without diabetes. Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on diabetes. We estimate the economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI >/= 35 kg/m(2). Using an administrative claims database of privately insured patients covering 8.5 million lives 1999-2007, we identify obese patients with diabetes, aged 18-65 years, who were treated with bariatric surgery identified using Healthcare Common Procedure Coding System codes. These patients were matched with nonsurgery control patients on demographic factors, comorbidities, and health-care costs. The overall return on investment (RoI) associated with bariatric surgery was calculated using multivariate analysis. Surgery and control patients were compared postindex with respect to diagnostic claims for diabetes, diabetes medication claims, and adjusted diabetes medication and supply costs. Surgery costs were fully recovered after 26 months for laparoscopic surgery. At month 6, 28% of surgery patients had a diabetes diagnosis, compared to 74% of control patients (P < 0.001). Among preindex insulin users, insulin use dropped to 43% by month 3 for surgery patients, vs. 84% for controls (P < 0.001). By month 1, medication and supply costs were significantly lower for surgery patients (P < 0.001). The therapeutic benefits of bariatric surgery on diabetes translate into considerable economic benefits. These data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI >/= 35 kg/m(2).   Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Makary et al. Aug 2010 PubMed Abstract OBJECTIVE: To examine the relationship of bariatric surgery with the use of diabetes medications and with total health care costs in patients with type 2 diabetes mellitus. DESIGN: We studied 2235 adults with type 2 diabetes and commercial health insurance who underwent bariatric surgery in the United States during a 4-year period from January 1, 2002, through December 31, 2005. We used administrative claims data to measure the use of diabetes medications at specified time intervals before and after surgery and total median health care costs per year. SETTING: Seven states in the Blue Cross/Blue Shield Obesity Care Collaborative. PATIENTS: Two thousand two hundred thirty-five patients with type 2 diabetes mellitus who underwent bariatric surgery. RESULTS: Surgery was associated with elimination of diabetes medication therapy in 1669 of 2235 patients (74.7%) at 6 months, 1489 of 1847 (80.6%) at 1 year, and 906 of 1072 (84.5%) at 2 years after surgery. Reduction of use was observed in all classes of diabetes medications. The median cost of the surgical procedure and hospitalization was $29,959. In the 3 years following surgery, total annual health care costs per person increased by 9.7% ($616) in year 1 but then decreased by 34.2% ($2179) in year 2 and by 70.5% ($4498) in year 3 compared with a preoperative annual cost of $6376 observed from 1 to 2 years before surgery. CONCLUSIONS: Bariatric surgery is associated with reductions in the use of medication and in overall health care costs in patients with type 2 diabetes. Health insurance should cover bariatric surgery because of its health and cost benefits.   A Study on the Economic Impact of Bariatric Surgery Bushwald et al. Sept 2008 PubMed Abstract OBJECTIVE: To evaluate the private third-party payer return on investment for bariatric surgery in the United States. STUDY DESIGN: Morbidly obese patients aged 18 years or older were identified in an employer claims database of more than 5 million beneficiaries (1999-2005) using International Classification of Diseases, Ninth Revision, Clinical Modification code 278.01. Each of 3651 patients who underwent bariatric surgery during this period was matched to a control subject who was morbidly obese and never underwent bariatric surgery. Bariatric surgery patients and controls were matched based on patient demographics, selected comorbidities, and costs. METHODS: Total healthcare costs for bariatric surgery patients and their controls were recorded for 6 months before surgery through the end of their continuous enrollment. To account for potential differences in patient characteristics, we calculated the cost differential by estimating a Tobit model. A return on investment was estimated from the resulting coefficients. Costs were inflation adjusted to 2005 US dollars using the Consumer Price Index for Medical Care, and the cost savings were discounted by 3.07%, the 3-month Treasury bill rate during the same period. RESULTS: The mean bariatric surgery investment ranged from approximately $17,000 to $26,000. After controlling for observable patient characteristics, we estimated all costs to have been recouped within 2 years for laparoscopic surgery patients and within 4 years for open surgery patients. CONCLUSIONS: Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years. Randomized or quasiexperimental studies would be useful to confirm this conclusion, as unobserved characteristics may influence the decision to undergo surgery and cannot be controlled for in this analysis. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Christou et al. Aug 2004 PubMed Abstract BACKGROUND: The treatment of obesity and related comorbidities are significant financial burdens and sources of resource expenditure. This study was conducted in order to assess the impact of weight-reduction surgery on health-related costs. METHODS: This was an observational two-cohort study. The treatment cohort included patients having undergone weight-reduction (bariatric) surgery at the McGill University Health Centre (MUHC) between 1986 and 2002. The control group included age and gender matched obese patients who had not undergone weight-reduction surgery from the Quebec provincial health insurance database (RAMQ). The cohorts were followed for a maximum of 5 years from inception. The primary outcome measure was overall direct healthcare costs. Secondary outcomes included cost analysis by diagnostic category for the treatment of new medical conditions following cohort inception. RESULTS: The cohorts were well-matched for age, gender and duration of follow-up. Patients having undergone bariatric surgery had significant reductions in mean percent initial excess weight loss (67.1%, P <0.001) and in percent change in initial body mass index (34.6%, P <0.001). Bariatric surgery patients had higher total costs for hospitalizations (per 1,000 patients) in the first year following cohort inception (surgery cohort = CDN 12,461,938 dollars; control cohort = CDN 3,609,680 dollars). At 5 years after cohort inception, average cumulative costs for operated patients were CDN 19,516,667 dollars versus CDN 25,264,608 dollars, for an absolute difference of almost CDN 6,000,000 dollars per 1,000 patients. CONCLUSION: Weight-reduction surgery in morbidly obese patients produces effective weight loss and decreases long-term direct health-care costs. The initial costs of surgery can be amortized over 3.5 years.

NSAIDs and Ulcers After RNY

June 21, 2020 11:57 am

Articles on NSAIDs and ulcers after RNY surgery which demonstrate why Duodenal Switch is preferred for patients requiring non steroidal anti-inflammatory drugs post-op. Perforated marginal ulcers after laparoscopic gastric bypass. Felix et al. Oct 2008 PubMed Abstract BACKGROUND: Perforated marginal ulcer (PMU) after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a serious complication, but its incidence and etiology have rarely been investigated. Therefore, a retrospective review of all patients undergoing LRYGB at the authors’ center was conducted to determine the incidence of PMU and whether any causative factors were present. METHODS: A prospectively kept database of all patients at the authors’ bariatric center was retrospectively reviewed. The complete records of patients with a PMU were examined individually for accuracy and analyzed for treatment, outcome, and possible underlying causes of the marginal perforation. RESULTS: Between April 1999 and August 2007, 1% of the patients (35/3,430) undergoing laparoscopic gastric bypass experienced one or more perforated marginal ulcers 3 to 70 months (median, 18 months) after LRYGB. The patients with and without perforation were not significantly different in terms of mean age (37 vs 41 years), weight (286 vs 287 lb), body mass index (BMI) (46 vs 47), or female gender (89% vs 83%). Of the patients with perforations, 2 (6%) were taking steroids, 10 (29%) were receiving nonsteroidal antiinflammatory drugs (NSAIDs) at the time of the perforation, 18 (51%) were actively smoking, and 6 of the smokers also were taking NSAIDs. Eleven of the patients (31%) who perforated did not have at least one of these possible risk factors, but 4 (36%) of the 11 patients in this group had been treated after bypass for a marginal ulcer. Only 7 (20%) of the 35 patients who had laparoscopic bypass, or 7 (0.2%) in the entire group of 3,430 patients, perforated without any warning. There were no deaths, but three patients reperforated. CONCLUSIONS: The incidence of a marginal ulcer perforating after LRYGB was significant (>1%) and appeared to be related to smoking or the use of NSAIDs or steroids. Because only 0.2% of all patients acutely perforated without some risk factor or warning, long-term ulcer prophylaxis or treatment may be necessary for only a select group of high-risk patients. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Sasse et al. May 2008 PubMed Abstract BACKGROUND: Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation. METHODS: Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively. RESULTS: We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs. CONCLUSION: Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Wilson et al. Oct 2006 PubMed Abstract OBJECTIVES: To evaluate predictors of endoscopic findings in symptomatic patients after Roux-en-Y gastric bypass (RYGBP) for obesity. METHODS: A retrospective chart review of 1,001 RYGBP procedures was performed. Two hundred twenty-six (23%) patients were identified as having endoscopy to evaluate upper gastrointestinal symptoms following surgery. Polychotomous logistic regression analysis was used to assess predictors of normal endoscopy, marginal ulcers, stomal stenosis, and staple-line dehiscence. RESULTS: The most common endoscopic findings were 99 (44%) normal postsurgical anatomy, 81 (36%) marginal ulcer, 29 (13%) stomal stenosis, and 8 (4%) staple-line dehiscence. Factors that significantly increase the risk of marginal ulcers following surgery include smoking (AOR = 30.6, 95% CI 6.4-146) and NSAID use (AOR = 11.5, 95% CI 4.8-28). PPI therapy following surgery was protective against marginal ulcers (AOR = 0.33, 95% CI 0.11-0.97). Median time for diagnosis of marginal ulcers following surgery was 2 months, and 77 of 81 (95%) presented within 12 months. CONCLUSIONS: Following RYGBP surgery for obesity, smoking and NSAID use significantly increase the risk of marginal ulceration, and PPI therapy is protective. Because a significant majority of marginal ulcers present within 12 months of surgery, it may be reasonable to consider prophylactic PPI therapy during this time period, especially for high risk patients. Spectrum of endoscopic findings and therapy in patients with upper gastrointestinal symptoms after laparoscopic bariatric surgery. Yang et al. Sept 2006 PubMed Abstract BACKGROUND: More should be known about the spectrum of endoscopic abnormalities and treatments in patients with upper gastrointestinal (UGI) symptoms after laparoscopic bariatric surgery. METHODS: Patients referred for endoscopic evaluation of UGI symptoms after laparoscopic bariatric surgery were studied. Clinical manifestations, endoscopic findings and therapy were recorded and correlated. RESULTS: 76 patients who had undergone laparoscopic vertical banded gastroplasty (LVBG) and 28 who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances of upper endoscopy. The symptoms included nausea or vomiting (n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding (n=26, 16.3%), heartburn or acid regurgitation (n=26, 16.3%), dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%). The endoscopic diagnosis consisted of normal findings (n=57, 35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or esophageal ulcer (n=21, 13.1%), food impaction (n=21, 13.1%), stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%), and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding, dysphagia and LRYGBP tended to have endoscopic abnormalities (P<0.001, P=0.09 and P=0.021, respectively). Endoscopic therapy was successful in resolving the complications including stenosis, UGI bleeding and food impaction. CONCLUSIONS: Endoscopy is an essential method of combining relevant endoscopic findings and therapeutic intervention in symptomatic patients following laparoscopic bariatric surgery. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Gumbs et al. July 2006 PubMed Abstract BACKGROUND: Marginal ulceration (MU) is a well-known complication after gastrojejunostomy; however, its incidence has rarely been reported in bariatric studies. We present 16 cases of documented MU after laparoscopic gastric bypass (LGBP) that were successfully treated with proton pump inhibition (PPI). METHODS: All patients undergoing LGBP from October 2002 to August 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with MU were analyzed. MU was diagnosed when patients presented postoperatively with mid-epigastric pain and/or upper gastrointestinal bleeding that responded to PPI or endoscopic intervention. Analysis of variance and Student’s t test were used for the statistical analyses. RESULTS: MU was diagnosed in 16 (4%) of 347 patients in whom LGBP was performed. An additional 10 patients had symptoms suggestive of MU, which raised the incidence as great as 7%. Of the 26 patients, 18 were women and 8 were men (age range 23-53 years), with a preoperative body mass index 37.1-63.9 kg/m2, similar to that of the patients who did not develop MU. Compared with the patients who did not develop MU, the operative times were longer in the MU group (180.5 versus 140.4 minutes, P <0.001). Of the 26 patients, 10 presented with abdominal pain and 16 with upper gastrointestinal bleeding. The mean interval between the initial LGBP and subsequent MU was 6.3 months (range 1-13). After an initial history and physical examination, upper endoscopy confirmed the diagnosis of MU in 16 patients. Three patients who developed MU were receiving chronic anticoagulation medication. All patients who developed MU began high-dose PPI, which resulted in 100% resolution of MU within 8 weeks. Since January 2005, 73 patients were given prophylactic PPI therapy postoperatively, with no patients subsequently developing MU (P = 0.006). CONCLUSION: We report 16 documented cases of MU occurring after LGBP. This underreported complication can be successfully treated with PPI, although MU complicated by gastrogastric fistula may require operative intervention. The institution of routine PPI therapy after LGBP lowered the short-term incidence of MU at our institution. Additionally, we recommend that all patients who undergo LGBP be given prophylactic PPI therapy postoperatively. Ulcer disease after gastric bypass surgery. Dallal et al. July 2006 PubMed Abstract BACKGROUND: The mechanism of marginal ulceration after laparoscopic gastric bypass surgery is poorly understood. We reviewed the incidence, presentation, and outcome of ulcer disease in consecutive patients undergoing laparoscopic gastric bypass surgery. METHODS: The outcomes of 201 consecutive laparoscopic gastric bypass surgery procedures were prospectively analyzed for complications. All procedures were performed using a linear stapled anastomosis and absorbable suture. RESULTS: The incidence of marginal ulcer disease was 3.5% (7 patients). One patient, the only smoker, presented with an acute perforation 4 months postoperatively. Three other patients presented with bleeding-all required transfusion. The remaining 3 patients presented with severe pain. At endoscopy, all patients had ulcerations associated with the Roux limb mucosa and were all successfully treated using proton pump inhibitors and sucralfate therapy. Symptoms of marginal ulceration occurred an average of 7.4 months (range 3-14) after surgery. The average follow-up was 19.8 months. No preoperative factors were predictors of ulcer disease, including body mass index, age, gender, or co-morbidities. CONCLUSION: Marginal ulcers using the linear-stapled technique occurred in 3.5% of patients. Three distinct clinical presentations occurred: bleeding, pain, or perforation. No preoperative risk factors were identified that predicted for this complication. Medical management is an effective treatment. Perforating marginal ulcers after laparoscopic gastric bypass. Lublin et al. Jan 2006 PubMed Abstract BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LGB) can be performed with minimal morbidity and mortality. This article describes the first presentation of a known disease entity after LGB: perforating marginal ulcers of the jejunum immediately distal to the gastrojejunal anastomosis. METHODS: A chart review of 902 LGB procedures performed by a single surgeon between April 2000 and September 2004 identified eight patients with perforating marginal ulcers. RESULTS: The patients presented an average of 157 days (range, 53-374 days) after LGB. All the patients were treated using laparoscopic primary closure followed by medical therapy. Morbidity, in one patient only, consisted of two abdominal fluid collections requiring separate drainage procedures. There was no mortality. The average follow-up period was 13 months (range, 2-18 months). No patient experienced recurrent ulceration. CONCLUSIONS: Although the etiology is unclear, marginal ulcers, a known complication of gastrojejunostomy, may present as perforating ulcers after LGB in a characteristic fashion and can be managed laparoscopically. Role of gastric acid in stomal ulcer after gastric bypass. Hedberg et al. Nov 2005 PubMed Abstract BACKGROUND: The pathogenetic mechanisms of stomal ulcer after Roux-en-Y gastric bypass (RYGBP) are unclear. In order to study the role of gastric acid, we measured acidity in the proximal pouch using a pH-sensitive probe. METHODS: 6 patients (5 females, mean age 45 years old at time of operation) with endoscopically confirmed stomal ulcer, were studied 2 to 6 years after RYGBP. All complained of epigastric pain that improved during proton pump inhibitor (PPI) therapy. Control subjects were 6 females (50 years old) who had had RYGBP at least 5 years earlier and denied symptoms of epigastric pain or heartburn. The pH-sensitive probe (Digitrapper-pH, Medtronic) was passed through the nose to the proximal pouch, guided by the calculated distance and pH response. The probe was left in place for 4 hours. The percentage of time with pH <4 was calculated. RESULTS: The probe could be accurately positioned in the proximal pouch both in symptomatic patients and in controls as evidenced by the acid pH reaction. The proximal pouches of patients with stomal ulcer were significantly more exposed to acid compared to controls. The median percentage of time with pH <4 was 69% and 20% in the stomal ulcer and the control group, respectively (P<0.01). Barium follow-through excluded gastro-gastric fistula in stomal ulcer patients. CONCLUSION: RYGBP patients with stomal ulcer have increased acid production in their proximal pouch in comparison with asymptomatic RYGBP patients. Gastric acid appears to have an important role in the pathogenesis of stomal ulcer.

Pregnancy After Weight Loss Surgery

June 21, 2020 11:54 am

Many post-op patients are concerned about pregnancy after weight loss surgery, especially the Duodenal Switch procedure which includes significant malabsorption. To follow is information from a Duodenal Switch surgeon and testimonials from post-DS weight loss surgery moms on their experience with post-op pregnancy. Do not get pregnant until your weight has stabilized after 18 to 24 months post-op and use at least TWO forms of birth control until cleared by your surgeon.

Pregnancy After Gastric Reduction Duodenal Switch

Ara Keshishian, MD, FACS Dawn R. Keshishian, RN, CCRN Weight Loss E-Newsletter – April 27, 2009 Article reprinted with permission. Due to the nutritional imbalances that may follow all weight loss surgical procedures it is imperative to make certain that your weight loss has stabilized and you have made it past your 18-month to 2 years postop anniversary. During the weight loss period a patient is in a negative nutritional balance not getting enough calories are absorbed to support the patient’s own weight and therefore would not be able to support the addition of a growing healthy fetus. There is a possibility of birth defects if you become pregnant prior to weight stabilization and your 18-month to 2-year anniversary. The decision absolutely needs to be discussed with your weight loss surgeon prior to any attempts to conceive. After all the above questions have been dealt with and resolved and you have been cleared by your surgeon to attempt to conceive there are extra steps needed for a post weight loss surgery pregnancy. We will inform you of these steps during the decision process with your surgeon. You always have to keep in mind that you anatomy has been changed and how your body works also has been changed. You should also start your preparation to become pregnant several months prior to attempting to conceive. You will need to be more diligent with follow-up with your OB/GYN and your weight loss surgeon during your pregnancy. Our office will work closely with your OB/GYN in your monitoring your lab work and the progression of your pregnancy. Central Valley Bariatrics Additional Pregnancy Information More Newsletters from Central Valley Bariatrics

Testimonials from Post-Op DS Moms

By Sarah P. Well, having the DS gave me the opportunity to do something that I have always wanted to do ever since I was pregnant with my first child – have a baby for someone else! There would have been no way in hell a reproductive endocrinologist would have approved someone with a BMI of 48 as a surrogate, no matter how healthy she was otherwise. So, two years after having the DS, I was at a good, stable weight with good, stable labs. My surgeon gave me the green light, and off I went to find a set of intended parents to have a child for. I found my couple, they knew from the get go about my surgery. I already had a perinatologist lined up who knew about the particular concerns that having WLS can pose, and he was very supportive of me. I met my couple’s RE, and got the go ahead from him – apparently my uterus is a very pretty pink! So, we were off! In preparation for getting pregnant, I had upped my B vitamins, particularly my folic acid, my D, my calcium and my iron. In December of 2008, we transferred three embryos into my uterus. On Christmas day, we got confirmation that we were pregnant! Talk about a gift to give someone. By the middle of January, we had confirmed that it was TWINS! This is where the fun really started. The hardest part of being pregnant with twins was gaining enough weight. By the end, I really hadn’t gained enough, but part of that was because I spent the last two months in the hospital due to Premature Preterm Rupture of Membranes and lost nearly 20 pounds in 10 days. Ugh. I only managed to gain back 10 of those lost pounds, but it was better than nothing. The easiest part of being pregnant after the DS was keeping up with being compliant with protein and vitamins. Knowing that you’re responsible for someone else’s two babies is a heavy load, and I watched every little thing that I did. Even when I felt I couldn’t eat any more, I made certain to get in more protein just so our little men would do well. In the end, I really do feel that everything I did paid off. Even though we were threatened with the early birth of the boys at 26 weeks gestation with the PPROM, I managed to hang in for 7 more weeks to finally give birth at 33 weeks, 2 days. Not too bad for twins at all. The boys were 4 lbs, 1 oz and 3 lbs, 8 oz. Again, not bad for pre-term twins. Neither the boys nor I were malnourished. Eating 200 grams of protein per day plus all the other possible carbohydrates that I could stuff into my pie hole made certain of that. It was hard, but doable. The only thing that I came up short on was my iron, and that was a result of having a C-section. My iron scores actually went up during the pregnancy, but then went crashing down afterwards. Typical even in “normies”. I couldn’t have been happier with the choices that I made and the decision to have the boys. And, I may possibly do it again. By mrst2001 I have had two very healthy post-DS babies. My oldest is 4 in May, my youngest turned 2 a week ago. I had very, very normal pregnancies, gained no weight with first (only 18 months out when I got pregnant), and about 15 with my second. Had some iron issues with both, but fine. My iron did truly tank about 6 months ago, and I got iron infusions, so all is fine now. Both of my little ones were full term, but little (6.5 and 6.12 lbs) and grew slowly and under the “norms” until 18-24 months, but now are “normal” or even maybe slightly larger. No health issues, and both active, happy kiddos. I had some trouble breastfeeding exclusively, I think because I couldn’t eat enough to fuel it, but I supplemented successfully with both for 8 and 10 months, respectively. From what I understand, that is not terribly common, but depends on a number of factors, so I wouldn’t assume that would be the case. Bottom line: I probably would not have kids if I had not had the DS. Either I wouldn’t have been able to conceive, would have had health issues or they would have. I am blessed. I WOULD NOT TRADE IT FOR ANYTHING. I wanted to have kids pre-DS, but we waited for me to be healthy to carry to term a healthy baby. And now that I have active toddlers, I am so glad I can run and chase them!!! At 335, that would have been impossible. Now, I encourage active play. By Joy I had my DS in 2003. I’ve had 2 children post op (2005 and 2007). My iron and calcium were both a little low prior to pregnancy. My doctors increased my supplements for both early on. Everything else was normal going in. I had issues with malnutrition during both pregnancies, and was hospitalized and put on bed rest both times. Both babies spent several weeks in the NICU. My oldest was only in the 5th percentile for weight until he was about 3. He was tiny (in 12 month clothes at 3 yrs old). Then he had a growth spurt. He’ll be 5 next month, and he’s pretty much caught up with the other kids (in 5T clothes now). My 2 year old had issues with larger than normal skull openings and an extra soft spot in the back of his head. After tons of genetics and other testing, they attributed it to my vitamin deficiencies. Both boys had delays in rolling, walking, etc., but they are both doing great now and are very bright little boys. If I had to do it all over again, I would in a heartbeat. My main motivation for having surgery was being told by my doctor that I might not ever have children if I didn’t get the weight off. So, having 2 beautiful, healthy, happy little boys makes it all worth it. Hope my story doesn’t frighten you, just wanted to be honest about my experience. Others have had perfectly normal pregnancies. By jass28 I had a very normal pregnancy and I got pregnant 6 months post op (by accident). I did have iron problems the last month but that’s pretty much it. My son was small but within a few months he is well above average for weight and height. He’s 11 months old wearing clothes for 24 months and weighing 26 lbs already. By Trish I am currently 27 weeks pregnant. The size of my baby is great and she seems to be growing normally. I got pregnant 10 months out from surgery using birth control. You will get people a bit angry at you for not “being more careful” but they are usually just trying to be helpful and warn other new post-ops. I experienced this with my “wow, I’m pregnant!” post. There are a lot of nice people that will be along to give you some great advice. Try not to get too stressed out but keep a safe sense of worry about the baby as far as vitamins, water and food. Now, onto the health of the baby…no, don’t stop taking your vitamins and get into your appointment sooner, rather than later! It would be helpful if you listed your labs levels and what you are currently taking. Go by your latest blood work levels. The baby is taking everything first and you need to keep up your levels as much as possible. I replaced my multis with prenates giving me double the dosage of folic acid. My A and D had been going lower since surgery and I had been upping it to 150K iu per day for each. I was afraid of A toxicity to the baby, but keep in mind that your blood serum level is an indication of what you are actually absorbing and the baby takes from that, not the high dosages each day. Some docs will worry about the high dosages, but I’ve found that it’s the same nod and smile routine as before pregnancy, since most of them don’t understand our malabsorption. My hemogloblin has slowly been going down during the pregnancy, so make sure you are okay on iron or start taking iron if you need it. I’m sure you are already getting labs done every 3 months for the first year anyway, but keep on top of it. Also, let your surgeon know ASAP. I have my PCP, Surgeon and OBGYN all in the loop and they communicate between each other and fax labs back and forth. At first I was told by many on the board that I’d have to go to a high risk specialist. However, my medical team thinks I am not high risk compared to how I would’ve been at 286 lbs. Increase your complex carbs to keep out of ketosis, which is harmful to the brain development of the baby. Since getting preggo, I’ve lost an additional 12 lbs but tried to stop the weight loss with added complex carbs. Each visit to the doc, the nurses are stumped as to why I’ve lost a little weight and not gained any. Stay up on your protein too, it is very important! I’m eating ALL THE TIME, healthy things, but I still feel like a machine trying to get in as much as possible to the baby.

Required Commitment for Duodenal Switch Surgery

June 21, 2020 11:53 am

All weight loss surgical procedures require commitment for the procedure to be successful and Duodenal Switch surgery is no exception. Unlike some surgeries, Duodenal Switch has proven to be a superior weight loss surgery option with the highest documented results in long-term excess weight loss maintenance. [51] However, the success for the patient does not end with the surgery alone. To maintain proper health, patients are committed to life long of daily vitamin and mineral supplements. Another requirement is having routine blood work checked yearly at minimum as well as other diagnostic and surveillance studies, such as a bone scan, may be required. To assure a long-term success of the weight loss surgical procedure maintenance of a high protein diet with a brisk level of activity must be maintained. With the D.S., the aim should be to consume 80-100 grams of protein for 24-28 months, to minimize the muscle wasting associated with rapid weight loss.

Commitment for All DS Patients:

1) You MUST take your vitamin and mineral supplements DAILY. 2) You MUST have blood labs done and a regular follow up with your surgeon for monitoring mineral and vitamin levels. 3) You MUST have a bone density scan done every year or two years to ensure that there is a good calcium blood level and is not the result of your body leaching calcium from your bones. 4) You MUST consume 80-100 g of protein every day, either through food or protein supplements for the first 18-24 months. Long term, protein should be emphasized, and carbohydrates and fats be limited. As with all weight loss surgical procedures, Patients who choose to have the DS and do not follow with the principals above are bound to find themselves experiencing long-term complications of malnutrition, and other gastrointestinal issues. Some of the complications may result in irreversible injury, organ failures, and/or even death. There are post-op weight loss surgery patients (this is not unique to D.S. and includes RNY patients) who lost all their teeth due to calcium and vitamin D deficiency while others developed osteoporosis. There have been patients who have permanent vision impairment and balance issues due to ignoring B1 deficiencies. There are patients that ignored B12 deficiencies and suffer very serious neurological impairment. You can’t ignore your vitamins, THEY ARE NOT OPTIONAL. It is also critical to understand that vitamin and mineral deficiencies develop over long periods of time. A non-compliant patient may get a false sense of security because they do not feel any different for a few months. Later on the clinical deficiencies will surface with some of the symptoms outlined above. Correcting the deficiencies will take a long time, and in some cases the impairments may not resolve even when the laboratory studies show normalized vitamin and mineral levels.

Potential Mineral and Vitamin Deficiencies and their presenting symptoms are all discussed here.

SADI, SIPS, Loop DS not the same as the duodenal switch

June 21, 2020 11:51 am

Before you consent to having duodenal switch surgery, be sure to confirm with your surgeon, IN WRITING, that the procedure you are agreeing to is the standard of care duodenal switch with TWO anastomoses, and not the Investigational-Experimental procedure procedure variously known as the SADI, SADI-S, SIPS, LoopDS or even as “improved” or “safer” duodenal switch. Unfortunately, an alarming number of patients are having these procedures done, for which there is no designated insurance code, because it is easier to perform, and touting it as “just the same as a DS.”. It has also been noted that very frequently the patients were led to believe that they were having the duodenal switch operation where no distinction was made between these procedures. Lets be clear that the duodenal Switch operation is not the same as SADI, SIPS or the Loop DS. While someday, after proper experimental protocols are performed, the single anastomosis procedure(s) may be proven to be safe and reasonably effective, it is NOT THE STANDARD OF CARE PROCEDURE KNOWN AS THE DUODENAL SWITCH specified by CPT code 43845, which has two anastomoses and provides selective fat malabsorption. These variant experimental procedures known as SADI (Single Anastomosis Duodeno-Ileal bypass), SADI-S (Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy), SIPS (Stomach Intestinal Pylorus-Sparing surgery), LoopDS (Loop Duodenal Switch), or other names, and in some cases even misleadingly calling the procedure a duodenal switch, have the following distinguishing features from a standard of care duodenal switch:

1. cookie cutter measurements that are not tailored to the patient’s particular medical condition (age, gender, height, weight, metabolic disease, length of small bowel);
2. a significantly longer alimentary tract than a proper DS;
3. an enormously longer common channel than a proper DS
4. no separation of digestive enzyme and bile from food in the alimentary tract, and thus NO SELECTIVE FAT MALABSORPTION; and
5. significant risk of bile reflux, which cannot happen with a proper DS.

Moreover, despite assertions to the contrary, these single anastomosis procedures CANNOT BE EASILY CONVERTED TO A PROPER DS IF THE EXPERIMENTAL PROCEDURE FAILS. There are a number of patients reporting that they did not understand that they were being given one of these experimental procedures, instead of the standard of care DS, until after surgery, because they were misinformed, under-informed, misled, or were given inadequate information to give fully informed consent. Some are reporting slow weight loss, bile reflux, and concerns about the specific nutritional and supplementation requirements for the procedure, which are not known or disclosed by their surgeons. Some of these patients have already returned back to their original surgeons or others for revision to the standard of care duodenal switch procedure. A revision of SADI, SIPS, or Loop DS may be more complex than just s simple bowel anastomosis. Since the alimentary tract is created to be too long in the first place, and because the intestine manufactures more absorptive capacity in response to the initial malabsorption, in order to provide the same or even somewhat similar results, the entire intestinal portion of the procedure may have to be taken down and reconstructed, with a shorter alimentary tract. A revision to a proper DS will therefore may provide the same results as if a proper DS was done initially. Risks include:

1. These experimental procedures are NOT covered by the standard of care DS CPT code 43845, and there have been a number instances of insurance companies refusing to pay for the single anastomosis procedure, including after the fact when the surgical report is reviewed.
2. Since there are no long term studies yet, proper nutritional guidelines have not been determined, much less long term results.
3. Bile reflux – impossible with the DS – has also been reported.
4. There is obviously significantly less macronutrient malabsorption with this intestinal configuration, but there may still be very significant micronutrient malabsorption, as food is still not touching a significant portion of the intestine where certain receptors are located; nevertheless, the procedure thus is being advertised by some surgeons as “safer” with less “malnutrition” but that may only be true with respect to protein and not all nutritional requirements.

If you want to have an experimental procedure, that is and should be your choice. Our concern is primarily that patients be given complete and accurate information enabling them to give fully informed consent to what is an Investigational-Experimental procedure, but which is not being described that way.

Vitamin and mineral supplement basics

June 21, 2020 11:49 am

This is a brief summary discussion about vitamins. This will review fat soluble vitamin, and provide clarity on why post-op Duodenal Switch patients need to take “dry formulary” instead of “regular” fat soluble vitamins. Vitamin and mineral supplement basics will also provide details of what to look for in vitamin and mineral labels, because often the information can be very misleading.  

A, D, E and K Fat Soluble Vitamins

The A, D, E and K vitamins are fat-soluble. This means that these vitamins are mostly absorbed by dissolving in dietary fat, and since DS patients do not absorb as much of the fat there is an associated malabsorption of the fat-soluble vitamins.  

Wet vs. Dry Vitamins.

Wet vitamins are oil filled soft-gel forms of the vitamin. Dry vitamins refers to a powdered form of the vitamin and can be called dry, allergy, miscible or water-miscible. Since wet vitamins are delivered in an oil based solution they will not be absorbed adequately in DS patients.. This is why “dry” forms of A, D, E and K vitamins are needed. These dry formulated fat-soluble vitamins have been prepared to allow the absorption without relying on a fat carrier molecule.  

Understanding Vitamin and Mineral Supplement Labels

Vitamin and mineral supplement basics continues with a lesson on how to read vitamin labels. A patient has to read the fine print; the labels on these bottles can be very deceiving. Pay particular attention to the dosages. What it says in big print on the label may not be per tablet and may need anywhere from 2-6 tablets to obtain that amount. It is very important to understand the mineral potency of the supplements. We will use calcium as an example. Elemental calcium is the amount of calcium that is actually in the supplement from the source. (The same is true for all other minerals.)   Example A: Elemental Calcium: 315mg This means there is 315mg of calcium per tablet.   Example B: Calcium (Citrate): 500mg When the source of calcium appears in parentheses it means the amount of calcium listed is elemental calcium, so in this example a recipient is receiving 500mg of calcium.   Example C: Calcium Citrate: 500mg When the source does not appear in parentheses it means it, the 500mg, is not a elemental calcium. Since calcium citrate is 21% calcium the recipient would actually only be receiving 105mg of calcium in this example.  

Scientific Units of Measure

There are different scientific units for measuring the amounts of vitamins and minerals in each soft gel or tablet. An international unit (IU) is the global standard for measuring fat-soluble vitamins (vitamins A, D, E and K). Water-soluble vitamins and minerals measured in milligrams (mg) and micrograms (mcg); one milligram (1/1000 of a gram) is equal to 1000 micrograms.  

How to Organize Daily Supplements

Some vitamin and mineral supplements have the potential to interact with prescriptions and over the counter medications. Be sure with check with the doctor. Check with the surgeon for their recommended post-op vitamin and mineral supplementation. According to Michelle at Vitalady.com these are the simple DOs and DON’Ts everyone agrees with:

• Do take iron with vitamin C
• Do take calcium with vitamin D

 

• Don’t take iron at the same time as calcium or zinc
• Don’t take zinc at the same time as iron or calcium
• Don’t take calcium at the same time as iron or zinc

  The rest of supplements can be grouped together as long as the patient keeps in mind the above rules.  

Vitamins and Minerals

Detailed vitamin and mineral information on the benefits, best absorbed sources, synergistic nutrients (works with), negative interactions and deficiency symptoms. Calcium Vitamin A Vitamin D Zinc For Vitamin and Mineral Supplements: Visit Vitalady.com  

Resources

This document is an invaluable resource for any bariatric patient or PCP providing follow-up care to bariatric patients. Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient

Weight Loss Stall or Plateau

June 21, 2020 11:47 am

A weight loss stall or plateau is a period of time during where there is no weight loss according to the scale and there may be no loss of inches according to the tape measure. This is why it is so important to take body measurements before surgery, so the patient has a reference as the weight loss progresses post-op. We suggest taking measurements of the chest, waist and hip, neck, upper arm, thigh and calf. Be aware it is very common for weight loss to “stall” shortly after surgery. Diana explains the reason for this below.  

The Inevitable Stall

By Diana C. A “stall” a few weeks after surgery is not uncommon, and here’s why. Our bodies use glycogen for short term energy storage. Glycogen is not very soluble, but it is stored in our muscles for quick energy — one pound of glycogen requires 4 lbs. of water to keep it soluble, and the average glycogen storage capacity is about 2 lbs. So, when a patient is not getting in enough food, the body turns first to stored glycogen, which is easy to break down for energy. Then when 2 lbs. of glycogen is used a patient will also lose 8 lbs. of water that was used to store it — voila — the “easy” 10 lbs. that most people lose in the first week of a diet. However, when the body stays in a caloric deficit state the body starts to realize that this is not a short-term problem. Then the body starts mobilizing fat from adipose tissue and burning fat for energy. But the body also realizes that fat can’t be used for short bursts of energy. So, it starts converting some of the fat into glycogen, and rebuilding the glycogen stores. As it puts back the 2 lbs. of glycogen into the muscle, 8 lbs. of water has to be stored with it to keep it soluble. So, even though the patient might still be losing energy content to their body, the weight will not go down or it might even gain for a while as the retention of water dissolves the glycogen that is being reformed and stored.  

What You Can Do About a Stall or Plateau

If a patient is experiencing a post-op weight loss stall or plateau further out there are a few possible causes. First, check that are you really in a stall. If the scale has stopped moving you may be losing inches, so check your measurements.   Too Many Carbs? Carbohydrates can start sneaking into foods without any awareness of how quickly they are adding up. If there is struggling with weight loss the patient may want to examine their daily carb count. Keep the carbs under 50g a day and see if that makes a difference in weight loss. Do not eat carbs before bedtime as it triggers insulin and initiates fat storage. Fit Day The Daily Plate Calorie King For more tips on keeping a food journal see the Personal Nutrition Guide.   Eating Enough? If there is under-eating or going more than 4-5 hours without eating, the body will shift into fasting mode, slow the metabolism and conserve stored energy (fat). This can contribute to a weight loss stall or plateau. Make sure the consumption of food is small meals or small snacks throughout the day, also, ensure to meet daily protein requirements. Try eating some protein with every meal or snack. For more information on protein requirements see our section on Protein.   Drinking Enough? An adequate level of water in the body aids in the effective breakdown of fat. The daily minimum recommendation is 64 fluid ounces of water a day. If a patient is in ketosis they will need to drink even more water to ensure the ketones are flushed out of the system. If there is any exercising or the patient lives in warm/dry weather there needs to be a higher consumption of water.   Exercising? Exercise can increase metabolism and burn fat. Strength training will build muscles and will boost fat burning. In a stall a patient can try increasing the volume of exercise or changing up the routine to overcome a weight loss stall or plateau. If the exercises have been mainly aerobic activity, try doing a bit of strength training; if they have been mainly strength training, try an aerobic work-out.

What to expect following surgery

June 21, 2020 11:45 am

Leading to Your Surgery and Hospital Stay

Different hospitals and practices have their own processes. For the most part, the overall process is the same. This will require patients to register in the hospitals system before the day of surgery. For most hospitals this is done after an appointment has been made and prior to surgery the surgeon will see the patient.

The day of surgery will usually start early in the morning. The patient needs to get to the office early to start signing paperwork, then the nursing staff in the preoperative holding area will start an IV access and administer the medications that may have been ordered by his/her surgeon and the anesthesiologist. These medications will include antibiotics, antacids, blood pressure and diabetic, if indicated, also something to “calm” the nerves down after consents have been signed.

A family/friend can join the patient when they’re in a surgical gown waiting to be taken to the operative room. By this time, most patients will be given some medication to relax them, and then they will be taken to the operating room and will be placed onto the operating table. The anesthesiologist and the nursing staff will connect the monitoring devices to measure blood pressure, heart rate and saturation of the oxygen in the blood. This is when patients drift to sleep due to the medication that was given to them.

Most patients’ first recollection is in the recovery room. The nurses in the recovery will assure the patient that they have adequate pain medication. This variable depends on the surgeon and the type of the procedure the patient has had. The patient may or may not have a nasogastric tube a Foley catheter, feeding tube or JP drains.

Throughout recovery in the hospital, some or all of these tubes and drains will be removed prior to being discharged home.

Pain management has also changed significantly over the last few years. Most patients will have a patient-controlled analgesia (PCA) machine that controls the amount of narcotic medication being delivered into the system; these include morphine, dilaudid, fentanyl, and Demerol. Patients may also have IV Tylenol and Toradol in addition to the PCA above. The idea is that the synergistic effect of the medication works better than individual ones, some surgeons and anesthesiologist also use epidurals. Also, some surgeons will utilize a local anesthesia infusion pressure bag. Then catheters are placed under the skin and connected to a self-contained reservoir, which continuously pumps local anesthesia into the wound.

It is important that the patient is able to distinguish between the postoperative incisional pain and intra-abdominal gas pain. Surgical postoperative pain should be treated with pain medication. Pain associated with bloating, intra-abdominal gas, and back pain associated with the uncomfortable hospital beds, should be controlled with early ambulation and pain medication. It is very important that the patient’s realize the significance of getting out of bed within hours of the surgery and spend some time sitting up in a chair or walking up and down the hallway. This not only helps with reducing the chance of blood clots in the legs, but it can also helps with reducing the intensity of the nonsurgical pain.

Some surgeons allow the patient to start a liquid diet immediately after surgery, while others would want the patient to pass gas prior to resuming diet. Most surgeons and hospitals have clearly outlined protocols for resumption of diet; the frequency, the volume and the types of the food/fluids the patients are expected to have. It is important to understand that if the patient does the surgery during the same stage, at different hospitals, operated by two different surgeons, may be instructed to follow completely different diets.

Bowel function will return, and any drains that were placed in the operating room will be removed. If a feeding jejunostomy tube was placed it will stay in and be removed later on. Do not worry about this- unlike the JP (drains that may not be comfortable coming out), the feeding Jejunostomy tubes slide out with most patients not even realizing it.

Car rides after discharge may be uncomfortable, but a patient may be provided and with an abdominal binder which will that helps. Some patients also find it very comforting to hold onto a pillow as an external support.

It is also very important for the patient to not let the pain get out of hand. This means a patient must take the pain medication for the first few days on a regular basis. As to when a patient is to resume their medications the hospital staff will discuss this after discharge. A surgeon or hospital staff will want the patient to begin their multivitamins, calcium, and other supplements; a discussion of change to their diet and care to the would or related issues will have specific instructions from the surgeon.

Furthermore, patients’ must not forget that part of the recovery includes walking in regular intervals and patients’ should increase the distance they walk continuously. This not only reduces long related consultations of atelectasis (blocked small airways of the lung), which may be due to pneumonia, but also reduces the chance of blood clot formation as mentioned before. Patients’ may also be given an incentive spirometry machine; this is a breathing exercise tool that is supposed to help expand their lungs. This should be continued being used at home.

At some point, usually the day before discharge, and a few days after being home, most patients will find themselves asking the question, “ what did I do to myself?” This reaction is normal and expected. It is important that patients keep reminding themselves as to why they decided to have the surgery and that this is a passing phase. These feelings are increased by the inability to get totally comfortable; lack of sleep, episodes of nausea, pain associated with the incision, having lost “control”, which worsens the feelings of regret. This would be a good time to reach out to the network of support that is available to the patient since they have become a part of the DS community.

The patients “job” at home, after being discharged from the hospital, is to stay hydrated, walk and slowly increase their diet. Different patients will progress at different paces. Patients must keep in mind not to compare notes and progress to other patients. Patients, while at home, won’t feel like eating or drinking; not much will taste the least bit pleasant either. Having said all of this, it is important to aim for 64 ounces of water a day; experiment with flavors and temperatures to find something that can be tolerated. Most patients tolerate room temperature much better than ice-cold water and over hot tea. Adding a few drops of lemon or limejuice also helps to break the plain taste of water, also, patients should not be discouraged if it appears impossible for them to drink the water. Because of the reduction of a small stomach associated with the surgery, patients have to resort to continuously sip, versus drinking a glass of water at a time. Patients are encouraged to take a sip before doing anything; water is also tolerated much better while in a standing position. It is a good idea to make a habit of walking with a bottle of water in hand and sipping on it while walking continuously. Note that there is more consumption of water while walking then when sitting.

Eating is not going to be any easier; protein drinks that were reasonably pleasant before surgery may taste horrible after surgery. For some patients, absolutely nothing will taste acceptable for some time. It is important to take this phase one bite at a time; focus on having the next sip of water, protein drink, and the next bite of your a meal.

Most patients also reported a significant change in their taste palate. Foods that were their favorite may not be as desired. Also, cravings will develop for things that were not desired before surgery. The sense of smell may also be significantly heightened.

Patients have reported that over time things get easier. Slowly but surely water will be easily tolerated, a toleration of a broader spectrum of food will occur, and stamina as well as activity levels will improve.

Almost all patients have commented that their recovery was better than expected and that if they had known about the surgery, they would have done it sooner.

Studies Comparing BPD and BPD-DS

June 21, 2020 11:40 am

Studies comparing BPD and BPD-DS that show how the BPD-DS procedure performed today has better results with fewer complications. Obesity surgery results depending on technique performed: long-term outcome. Gracia et al. April 2009 PubMed Abstract BACKGROUND: Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. METHODS: This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). RESULTS: One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. CONCLUSIONS: The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up. Duodenal Switch Improved Standard Biliopancreatic Diversion: A Retrospective Study. Marceau at al. Jan-Feb 2009 PubMed Abstract BACKGROUND: This was a retrospective study, performed 10 years after surgery, to compare the results between biliopancreatic diversion (BPD) with distal gastrectomy (DG) versus BPD with duodenal switch (DS). METHODS: Complete follow-up data were available for 96% of patients, allowing a comparison of weight loss, revision, side effects, and complications at 10 years. RESULTS: After BPD-DS, weight loss was 25% greater than after BPD-DG (46.8 +/- 21.7 kg versus 37.5 +/- 22 kg, respectively; P <.0001). The need for revision decreased from 18.5% to 2.7% (P <.0001), and the prevalence of vomiting during the previous month was 50% less (23.7-50.6%, P <.0001) after BPD-DS compared with after BPD-DG. Late complications were the same for both procedures. Blood analysis showed that, after BPD-DS, the levels of calcium, iron, and hemoglobin were significantly greater and the parathyroid hormone level was lower than after BPD-DG (71.3 +/- 44.2 versus 103.0 +/- 64.0 ng/L, respectively; P <.0001). CONCLUSION: The DS greatly improved the BPD, as it was initially proposed. The use of the DS increased weight loss, decreased the need for revision, resulted in fewer side effects, and improved the absorption of nutrients. Biliopancreatic Diversion with Duodenal Switch. Marceau et al. Sept 1998 PubMed Abstract Full Article In 1990 Scopinaro’s technique of biliopancreatic diversion with distal gastrectomy (DG) and gastroileostomy was modified. A sleeve gastrectomy with duodenal switch (DS) was used instead of the distal gastrectomy; and the length of the common channel was made 100 cm instead of 50 cm. A questionnaire and a prescription for blood work were sent to 252 patients who underwent DG a mean 8.3 years ago (range 6-13 years) and 465 patients who underwent DS 4.1 years ago (range 1.7-6.0 years). The questionnaire response rate was 93%, and laboratory work was completed for 65% of both groups. The mean weight loss after DG was 37 +/- 21 kg and after DS 46 +/- 20 kg. There were fewer side effects after DS: The number of daily stools was lower (p < 0.0002), as was the prevalence of diarrhea (p < 0.01), vomiting (p < 0.001), and bone pain (p < 0.001). Greater benefits related to several aspects of life were reported after DS than DG (p < 0.0001). The mean serum levels of ferritin, calcium, and vitamin A were higher (p < 0.001), and parathyroid hormone was lower. The yearly revision rate for excessive malabsorption was 1.7% per year after DG and 0.1% per year after DS. The two procedures were equally efficient for treating co-morbid conditions such as diabetes, hypertension, and hypercholesterolemia. Biliopancreatic diversion with sleeve gastrectomy/duodenal switch and a 100-cm common limb was shown to produce greater weight loss with fewer side effects. Biliopancreatic Diversion with a New Type of Gastrectomy. Marceau et al. Feb 1993 PubMed Abstract In an attempt to improve the results of biliopancreatic diversion in the treatment of morbid obesity, two aspects of the procedure performed at Laval Hospital were modified to reduce adverse physiological consequences. The distal gastrectomy was replaced by a parietal gastrectomy which preserves vagal continuity along with the lesser curvature, and leaves intact the antro-pyloroduodenal pump. The duodenum was stapled shut and nutrients were diverted through a duodeno-ileal anastomosis. The biliopancreatic diverting intestinal limb was anastomosed to the nutrient ileal limb 100 cm proximal to the ileocaecal valve instead of 50 cm proximal to it, thus doubling the length of the common ileal absorptive segment. Weight loss after either operation was greater than 70% of initial excess weight. Following the new operation, there was a lesser prevalence of side-effects, especially loose stools and malodorous gas, a lesser degree of hypocalcemia and no hypoalbuminemia. The duodenum recanalized at the staple line in 20% of the patients who had the new operation. When data from these patients were excluded, weight loss following the new operation was greater than that seen after the old one. The prevalence of side-effects and the degree of calcium and protein malabsorption remained significantly lower. Weight loss remained satisfactory with a common limb measuring 100 cm. The parietal gastrectomy was not restrictive as shown by the failure to lose further weight when the duodenal stapled diversion failed. Weight loss was thus mainly a function of biliopancreatic diversion, but increased weight loss in the new procedure despite a doubling of the common ileal limb suggests that parietal gastrectomy contributed to weight loss. Because duodenal recanalization can be corrected surgically and now prevented, the modified biliopancreatic bypass is preferred.