WLS World: 6 1/2 months post-op

Duodenal Switch

I would like to share my personal post-op experiences, fact based knowledge and background regarding my surgery which is a combination of the Vertical Sleeve Gastrectomy (VSG) and Duodenal Switch (DS), performed under 1 surgical procedure. It is medically known as a a gastric restriction with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy to limit absorption. It is known by its formality as a bilio-pancreatic diversion with duodenal switch and abbreviated as BPD/DS or DS. A not so wordy way to say it is sleeve gastrectomy with duodenal switch or just the DS.

I had my laparoscopic duodenal switch procedure on Nov 14th, 2006 for the surgical medical treatment of morbid obesity that can kill you. I am still the same person within, only my outer shell has morph to what I once looked like before this disease imprisoned me. The most important thing that matters is, I have my health back and that means more to me than the actual weight loss.

What is your body if you are not healthy with your respiratory, circulatory, cardiac and digestive system working properly and have mobility to be able to do things on your own, independently with no limitations, no complications or becoming a fatality?

This is what bariatric surgery outcome has done for me, give me my health as well as my life back!

The Duodenal Switch (DS)

The DS procedure has been performed since 1988 and combines restrictive and malabsorptive elements to help achieve and maintain long-term weight loss:

1. by restricting the amount of food that can be eaten through a reduction in stomach size

2. limit the amount of food that is absorbed into the body through a rerouting of the intestines

3. have a metabolic effect induced by manipulating intestinal hormones as a result of intestinal rerouting

The overall effect is that DS patients are able to engage in fairly normal, free eating, while having the benefit of taking on the metabolism of a lean individual.

Wednesday, May 23, 2007

6 1/2 months post-op

I am 6 1/2 months post-op. Things are going well for me. Let me update here, since some like to read what's going on with me since I had DS surgery. I have hit my half way point for the year and lost a total of 62 lbs. Overall, I have lost a grand total of 120 lbs.

I am honestly doing well, no complaints or negative effects from having DS. My blood work from a few weeks ago came back within normal range with no red flags. I need to do another bloodwork for my 6th month update which is now. I haven't lost any weight by checking the scale, but I am losing since my clothes are falling off and needed a safety pin to tighten my pants. Pants size depends on maker and style. I am in some pants size 9-10 and in other pants 11-12. Have to take into account I do have a booty on me and do not like wearing tight pants. I can fit into medium pants. In total going from size 20-22 right before I had surgery to now a size 11-12, don't want to say 9-10 just as yet. That is a total of 10 sizes down. Not bad and I am taking my SWEET ASS TIME with my weight loss.

I am in no hurry or rush to lose weight and want to prevent my skin from sagging or hanging on my body. My skin is firm and tight on me. I am 6 months out, have lost over 60+ lbs and don't have that condition and may not see it, since I only have 40+ lbs to go till I reach my goal of 140 lbs. That is a good note in my book. I do not think I will need plastic surgery on my tummy, side or to have any upper or lower body lift. The only noticeable that I see are my inner thighs. The skin is a bit loose, but it isn't bad to be honest. If I wear stocking it won't show and with pants on, you don't see any "defects". With clothes off, it isn't really that bad at all. I do wear a lot of shorts and especially black spandex biker shorts that hugs and contour my body with a tank top over it and my body isn't disproportioned. Sure, my tummy is still a bit swollen, but it isn't bad at all. As I lose more weight, I will see how my body will morph. I have less than 45 lbs to lose until I reach my goal of 140 lbs. I want to look healthy and appealing, not a bag of bones protruding out of my skin or looking like a twig. My breast are still there and haven't deflated after 60+ lbs lost. They don't have that great significant puffy volume as before, but it is looking very nice and healthy and I still have the "twin girls". Yet, they do look mighty fine. My arms look ok as well. Bear in mind, I have gone from 305 lbs to 165 lbs on my own, to gain back 85 to be 250 prior to my bariatric surgery. I do not have stretch marks on my skin or have any other concerns with my skin due to weight loss and I am glad about that. My skin I can say is firm, very smooth and what I consider tight. Time will tell, since I still have as I said another 40+ lbs to lose.

Regarding food, I am able to eat pasta that I make and its good. I use italian sausages or ground beef to make my marinara sauce and that gives me good protein intake. Sometimes, I just eat the marinara and meat and lay off the pasta. I made sauteed corned beef with potatoes, onions and tomatoes and had that with some white rice. I can't eat much of the rice, it does fill me up fast, but Libby's canned corned beef has a lot of protein and that is what I did eat a good portion of. I will have ground beef made into a burger, add some mozzarella to melt on it and some marinara sauce and that is my pizza burger. It does taste good. I will change the cheese to monterrey jack or fontina cheese. I will also make an italian sausage with grilled onion, green and red peppers. Italian sausage is very hearty and filling for me. I can only have 1/2 of it. But will eat my veggies, oh yeah, love eating veggies. Seafood is great for me. I do have my weekly share of seafood. Still, can't eat poultry. Let me make a list of what I am able to eat:

* ribeye steak
*filet mignon
* pork tenderloin
* lamb
* ground beef
* italian sausage
* ham
* salami
* corn beef

* shrimps
* codfish
* mero fish
* king fish
* grouper
* tilapia
* salmon
* crab
* lobster

* rice (long or short, but only a few teaspoons)
* pasta (freshly made or boxed angel hair or size 9)
* potatoes (mashed, fries (very small amount), baked, salad)
* any type of vegetables
* bananas
* watermelon

* milk (fat free/lactose free, 1 qt Lactaid fat free milk daily)
* tea (prefer ice tea with lemon, ready made with sugar or splenda)
* water of course
* coffee (caffeine free and I only like and drink swedish mocha)

* Special K with berries
* Cherrios
* whole grain bread and has to be toasted
* mini bagel and it has to be toasted (takes a long time to digest though)
* Pillsbury biscuits you make at home (has to be the buttermilk, the other one doesn't sit right with me)
* cinnamon rolls you bake in the oven with frosting
* Chef Boyardee spaghetti with meatballs
* soup
* chili
* yogurt (prefer blueberry or strawberry & banana)

* eggs
* any type of cheese
* butter
* cream cheese
* olive, vegetable, sesame, peanut oil (won't make me sick)

not able to eat, tolerate or digest
* chicken or turkey (any part or cooking methods)
* english muffin (painful to digest)
* almonds (gives me a bad digestion problem)
* carbonated beverage (digestive pain from HELL)
* untoasted bread (any type)
* pizza crust or any heavy dough breading

Regarding snacks, I can eat cheese nips, but not too many. I am able to eat 1 twinkie. I can eat cookies, cake and ice cream. But as I said, I don't eat these regularly. Yet, it is there as a choice. I don't need to be deprived of food or make any food a taboo for me. The option is there if I ever want it. Just have to have things in moderation, know what you are eating and not binge on it. Eventhough, I gained to be SMO, I was never much of an eater or over ate to begin with. It is nice that I can have snacks and certain food if I want it at my disposal. I don't crave it, have guilt trips or think it is bad for me. It is there if I want it and that is all I have to say about it.

The idea is to live as normally as you can and understand that any type of bariatric surgery is only a tool to work with, not a sole remedy or solution to your dilemna. You are in control as to how to utilize it and how to live with it. Also, the main focus is on health and it is accomplished through weight loss. This is not a contest to see how much or how fast you lose weight. Remember, the focus is on health and you improving your lifestyle to not be limited or disabled due to the cause of morbid obesity disease.

Regarding vitamins and supplement here is my daily regime tally count

2 Ferro-Sequel Iron pills
8 Calcium Citrate, but will be changing to liquid calcium citrate
3 ADEK
3 Centrum liquid vitamins (6 tbsps total) got tired swallowing pills
1 400 IU vitamin E
1-2 Biotin
1 Drisdol prescribed 10,000 IU vitamin D (once a week)

I do change my method from swallowing pills to having liquid forms. Gotta remember this is for LIFE and you HAVE to take your vitamins and supplement with this surgical procedure. So, every once and awhile I change from pills to liquid form.

What is the Duodenal Switch?

With the DS procedure:

The stomach, although reduced to 50-75% its original size is fully functional. The duodenum is also fully functional with no bypass mechanism occurring. The entry and exit port of the stomach and the pyloric valve are untouched in its digestive configuration and left originally the same way before and after surgery. Keeping food in the stomach until it is digested prevents dumping, provide satiety and absorption of vitamins and minerals into the body.

This is important, since, the duodenum is the part of the intestine where protein, calcium, iron and vitamin B12 are absorbed and with the Gastric Bypass causes these four nutrients to not be absorb. The DS stomach processes the intrinsic factor that contains polysaccharide and protein components to make cyanocabalamin to be absorb as vitamin B12. The stomach and duodenum organs missing from the digestive system of the Gastric Bypass and is the main reason for pernicious anemia that is an iron deficiency developed due to lack of vitamin B12.

Even though, the DS has a greater malabsorptive factor, it actually has more normal nutritional absorption than the Gastric Bypass because the duodenum, stomach and pylorus are still involved in the digestive process. Therefore, the Gastric Bypass has MORE MALABSORPTION of vitamins and mineral causing greater possibilities of deficiencies, due to the complete removal (bypass) of the stomach and duodenal from its digestive absorption process and to have no function whatsoever.

Restriction
The restrictive part of the DS procedure is known as the vertical sleeve gastrectomy (VSG) and is achieved via partial gastrectomy (removal of the outer/greater curvature of the stomach). It reduces the size of the stomach 25-30% its original size and into a 2-3cm in diameter tubular structure which holds 3-4 ounces (80-120ml), compared to teh Gastric Bypass that holds 15-30ml restriction of food.

The grehlin hormone is also removed and eliminates head hunger, cravings and binging from occurring. The sleeve gastrectomy keeps and maintain the pylorus valve intact for the function in the emptying of the stomach contents to the duodenum at its normal controlled pace for better food tolerance and to limit the amount of food to be eaten.

Malabsorption
The malabsorptive component of the DS procedure is the intestinal bypass known as the duodenal switch. It is achieved by rerouting the small intestine into 2 intestinal tracts known as limbs. One tract separates the flow of food, known as the alimentary limb (or food limb) that measures on average 150-200cm, from the second tract known as the biliopancreatic limb (or digestive limb), where the flow of bile and pancreatic juices comes from the liver and pancreas to process for digestion. Reducing the amount of bile and pancreatic juices the food comes in contact with, reduces the amount of food that is digested and decreases absorption. The digestive limb, eventhough it is an intestinal bypass, is fully functional for processing in the digestive system.

Metabolic Effect

The alimentary limb:

1. absorbs proteins from ingested food

2. secretes the peptide hormone Enteroglucagon or GLP-1, which has 37 amino acids that controls the metabolism of glucose from undigested food. (This is the key reason (along with #4), why a DSer will NOT have Reactive Hypoclycemia occur or Diabetes resurface, even if they gain weight or are years out as post-op).

3. it suppresses the insulin response when carbs is ingested to reduce the amount that is converted to and stored as fat.

4. it increases insulin secretion as it decreases glucagon secretion from the pancreas that helps to treat and cure at a rate of 98.9% with PERMANENT REMISSION for Diabetes, even if there is a regain in weight.

Diabetes (type 2) will not return as per medical research and long-term studies that has been published, documented and recorded in medical journals, with the extremely small and rare exception of 1.1% whose Diabetes was still evident after surgery. With the Gastric Bypass, there is a high possibility that weight gain will cause Diabetes to resurface. It is NLIKELY with the DS to have post-ops with Diabetes or to have Reactive Hypoglycemia, as proven to occur among those with the Roux-en-Y or Gastric Bypass surgical procedure (whether at goal or regained weight), after being post-op for over a year or more.

For a RNY post-op, reactive hypoglycemia disorder does occur in those who never had Diabetes (related or non-related) prior to surgery or in their life. Again, this is NOT an occurrence that will happen with post-ops DSers.

Further down the digestive tract, the two separated limbs of the small intestines are rejoined to be connected at the ileum known as the common channel. This is where the food and digestive juices begin to mix and limit fat absorption, essential for good health to occur. The common channel length varies according to Hess method (100cm) or according to patient's needs, malabsorption level desired, etc., from 50-150cm. The common channel section is the ONLY portion of the intestines that a DSer is able to absorb calories, fats and complex carbohydrates and no where else in the small intestine digestive system.

With the DS, a person eating food will be unable to absorb:
* 50% of calories
* 80% of fats
* 40% of complex carbohydrates
* 0% of simple carbohydrates

Unlike the Gatric Bypass, the Duodenal Switch is an intestinal bypass and NOT a gastric bypass procedure. It is also a gastric restrictive procedure and again NOT considered a gastric bypass, since, digestion begins in the stomach breaking down food and it keeps the pyloric muscle between stomach and small intestine intact, allowing the stomach contents to start their digestive process before food enters the duodenum. This preservation eliminates the symptoms of dumping syndrome, marginal ulcers, strictures and blockages.

The gift of the DS is about OPTIONS. If I do eat anything, the malabsorption level and metabolic effect will prevent me from gaining weight and won't affect my arteries, blood or cholesterol level.

The majority of DSer do not have bathroom (diarrhea) or gas (flatuence) issues. A DSer become very much in tune. listening to their body for signals and its digestive system. You might have to moderate some food, but it does not need to be omitted or considered forbidden. The focus is not on calories, fat and not even on complex carbs as much. The main focus is on protein and nutrients. We must all eat food to survive and fuel our bodies for energy and nourishment.

The malabsorption of the DS is very powerful and will help you lose weight and keep it off long term. Without it, you're just on a diet after diet whether low calorie, low fat, avoiding certain food to not gain weight for life. The DS malabsorption eliminates the need to count fat, calories, certain amount of complex carb or any other diet mentality practices needed to either lose weight or to not regain weight. You eat normally (just smaller portion than a non-WLS) and do not have to deal with issues that it will harm or "punish" you since your stomach is fully functional to properly digest the food.

Gastric Bypass versus Duodenal Switch

In RNY procedure:
The duodenum and pyloric valve are bypassed and the intestines are connected to a newly created stomach pouch, known as a stoma. This digestive configuration is known as a gastric bypass. The stoma is able to hold one ounce of food, but its exit port is always open and does not store food causing it to glide through into the intestines non-stop which causes a possibility of dumping syndrome. Food is held in the pouch, depending on certain texture or bulk may get stuck with difficulties in processing to pass through the stoma, if not chew down to mush consistency. The stoma is similar to a funnel and does not have the ability to process food. Some consider dumping to be a key component of gastric bypass. Yet, it has been medically proven with published scientific report, medical data and research studies that there is no relation between dumping and weight loss. Due to the absence of a functional stomach and duodenum, nutrients are unable to be absorb. The duodenum is the site where most of the breakdown of food passes through and secrete an alkaline mucus that supports the intestinal enzymes and aids in the absorption of nutrients. The stomach is a secretory organ that include digestive enzymes, hormones, hydrochloric acid and intrinsic factor for vitamin B12 absorption are missing with the RNY or gastric bypass.

With the DS procedure:
The stomach, although reduced to 50-75% its original size is fully functional. The duodenum is also fully functional with no bypass mechanism occurring. The entry and exit port of the stomach and the pyloric valve are untouched in its digestive configuration and left originally the same way before and after surgery. This allows food and drink to be consumed at the same time and become iso-osmolar during digestion.

Keeping food in the stomach until it is digested prevents dumping, provide satiety and absorption of vitamins and minerals into the body. This also helps control weight as the DS stomach stretches a bit with time, as it is normally suppose to do. The pylorus stays shut while food and fluid are in the stomach, causing the stomach to work as a hopper and digest the food that provides nutrients as it process, then passes into the duodenum as it continues to absorb nutrients to the body.

This is important, since, the duodenum is the part of the intestine where protein, calcium, iron and vitamin B12 are absorbed and with the RNY causes these four nutrients to not be absorb. The stomach processes the intrinsic factor that contains polysaccharide and protein components to make cyanocabalamin to be absorb as vitamin B12. The stomach and duodenum organs missing from the digestive system of the RnY or gastric bypass is the main reason for vitamin B12 deficiency to occur.

Even though, the DS has a greater malabsorptive factor, it actually has more normal nutritional absorption than the RNY because the duodenum, stomach and pylorus are still involved in the digestive process.

As can be observed in the chart above, the DS is able to provide LESS MALABSORPTION of nutrients compared to the RNY, since a portion of the the true stomach and the duodenum are left intact and in full functional capacity to process in its digestive system.

Therefore, the RNY has MORE MALABSORPTION of vitamins and mineral causing greater possibilities of deficiencies, due to the complete removal (bypass) of the stomach and duodenal from its digestive absorption process and to have no function whatsoever.

The duodenal switch surgical portion has been perform as a stand alone treatment for Diabetes on obese and non-obese patients for over 20 years, based on the mechanics and metabolic process that takes place in the digestive system.

The majority of DSer do not have bathroom (diarrhea) or gas (flatuence) issues. A DSer become very much in tune listening to their body for signals and its digestive system. It all comes down to, the DS does most of the work for me, not me do most of the work to stay healthy or lose/maintain my weight. It is pleasant life to live with no restriction of food or ingredient being denied, considered wrong, not allowed or taboo. You might have to moderate some food, but it does not need to be omitted or considered forbidden.

The focus is not on calories, fat and not even on complex carbs as much. The main focus is on protein and nutrients. We must all eat food to survive and fuel our bodies for energy and nourishment.

The malabsorption of the DS is very powerful and will help you lose weight and keep it off long term. Without it, you're just on a diet after diet whether low calorie, low fat, avoiding certain food to not gain weight for life. The DS malabsorption eliminates the need to count fat, calories, certain amount of complex carb or any other diet mentality practices needed to either lose weight or to not regain weight. You eat normally (just smaller portion than a non-WLS) and do not have to deal with issues that it will harm or "punish" you since your stomach is fully functional to properly digest the food.

Metabolism
The actual duodenal switch in your intestines kick start your metabolism, even after being 5 years post-op. It truly is not easy to regain weight (unless you have mental issues with being non-compliant. Although, living with the DS is a very liberal and lenient lifestyle with hardly any restrictions or complicated regime). Simply stated, with the DS, you have options and it is up to you to what you want to eat if you want without harming your body through averse therapy or dealing with various dieting to lose or maintain weight. There is no drama eating food with the DS.

DS Lifestyle
DSer do not eat a lot of food per se. They may eat more frequently, but it is all basically portioned food every so often as needed. The VSG restricts the amount of food that you have in one sitting. DSers do not require to mandatory eat high fat food. It is an option, if you want. If a DSer is constipated, having the option to eat higher fat contents or even higher carb amount than usual, may help move things along. DSer do not have a lot of or more than normal, frequent daily bowel movement. On average, it is once to three times a day and all depends on what you eat. If you eat higher fat, there might be a possibility, you may go more. DSers do not pass gas all day. It all depends on what you eat.

Usually higher carbs or certain ingredients MAY cause gas to some (not the majority). Bowel and gas issues are the same as with all other WLS post-op individuals and not considered more or extreme. It is a fallacy. DSer are very much in tune to listen to their body and to its digestive system. Simple carbs, you have to moderate, as with all other WLS. Only thing is, you have the freedom to have it if you want, but know your limits.

Complex carbs are malabsorb, so enjoy that potato, corn, beans or favorite cereal. DSers on average malabsorb 40% of the complex carbs. One of the beauty of living the DS lifestyle is you are not freaking out, feeling guilty, having drama or need to count calories or fat from food because it will NOT cause weight gain as compare to other WLS.

You want fritters, that delicious savory sauce or gravy, that juicy marbled fat from a steak with all the au jus streaming down the side, the skin from a fried chicken, have creamy or flavorful oil based salad dressing or smear butter or mayo to your heart content to make whatever you are using it with taste good? Go ahead, it will not cause you to gain weight. If you want a fast food burger or fried chicken from KFC, no regrets. Both are high in protein, regardless of the amount of calories or fat it has because the DS is very forgiving to NOT allow your system absorb 80% of the fat, 50% of the calories and 40% of the complex carbs you eat.

It is all about protein and you more or less disregard the rest. You are also able to eat rice, bread, potatoes, raw vegetables, and because it is complex carb, do malabsorb some of the carbs from it. So, there is peace and no issues with food and most importantly, you want to drink that beverage, whether it is juice or carbonated with your food or meal, go ahead, it's all good (just make it low sugar, sugar free, best if it is caffeine free, too). If you are hungry, go eat and enjoy it. Your grehlin is removed, so you won't feel hungry all the times or have head hunger. If you are hungry, it means you are really hungry, so go eat. Food is no longer an issue because you will have the metabolism of a lean person. You eat because your body is signaling that you are truly hungry. You do not need to a plan a menu according to calories or fat (for yourself) because there is no cut off limit amount per day. Again, you won't be able to eat alot per serving. Food just doesn't become important that you think about it. You only think about protein. But remember, compare to calories, fat, complex carbs and simple carbs. You deal with one of them and that is knowing your limit or moderation to simple carbs. You can have it, including sugary stuff, just don't go buck wild exaggerating the intake amount every day.

Research, if you see any DSers having serious issues that they need to have a revision or having complications that it needs to be revised and especially to another surgery. The DS is very effective and rarely is there any failure due to its intestinal configuration to cause weight gain beyond your control.

Difference with RnY

RnYer have a 50/50 chance of having dumping syndrome and hope to have it to control their eating habits, needing that negative reinforcement for poor eating habits or "forced" to eat healthier or better quality of food. But it does not happen to all and 60% of the RNYers are left with the burden to be stuck on a low calorie, low fat, low carb diet for life on their own mental reinforcement because they did not get the gift of dumping syndrome to enable them to eat healthier with the contribution of their "tool".

This is why ther are some RnY post-ops who repeatedly, go over and over again to try to "recondition" themselves using the 5DPT (5 day pouch test) or the 3DLPT (3 day liquid protein test) as a sort of solution to help them out. But these options are not a weight loss regime or that they will lose weight on it if followed.

With the RNY, there are some side effects that can stop you from continuing on with your day and may even affect your health.

1. One is dumping syndrome, in which there are times the only solution is to go rest and sleep it off to get over the episode.

2. Second is reactive hypoglycemia, that affects your blood level, even if you never had diabetes in your life. It is also due to chromium, niacin, vitamin C and vitamin E not able to regulate the glucose level in their system due to the gastric bypass procedure. Vanadium may be helpful to normalize the metabolism and under a medical doctor supervision.

3. Third is food getting stuck or causing a stoma blockage (such as eating a raw carrot and didn't chew it down well), since you do not have a functional stomach that will grind food for you anymore. Some post-op sort to using meat tenderizer with some water to soften the bulk of food that is stuck or blocking the stoma for breakdown and does not remedy the condition right away.

4. Fourth is strictures, which may be painful and requires a trip to the hospital to have yourself dilated.

5. Fifth is marginal ulcers and especially in the blind stomach that can't be scope for evaluation.

6. Sixth is RnY should never use NSAID because they do not have the digestive acids to help prevent irritation inside the stomach lining.

If a person has a family history of arthritis, lupus, migraines or ulcers, this can be an important factor to decide on having the DS due to the need of NSAID and this means daily and for life.

Unlike the Gastric Bypass, the Duodenal Switch is an intestinal bypass and NOT a gastric bypass procedure. It is also a gastric restrictive procedure and again NOT considered a gastric bypass, since, digestion begins in the stomach breaking down food and it keeps the pyloric muscle between stomach and small intestine intact, allowing the stomach contents to start their digestive process before food enters the duodenum. This preservation eliminates the symptoms of dumping syndrome, marginal ulcers, strictures and blockages.

WLS World

Duodenal Switch

Wednesday, May 23, 2007

6 1/2 months post-op

Sarah'a WLS World

Normal Digestive System Anatomy

Blog Archive

DS medical studies, scientifc data and published research

What is the Duodenal Switch?

Gastric Bypass versus Duodenal Switch

Difference with RnY