Duodenal Switch FAQ's

FAQ's

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BEFORE SURGERY

Can't I just diet?
Do I qualify for the surgery?
What if my family is against me having the surgery?
Will my insurance plan cover this surgery?
What if my insurance company approves the wrong surgery?

DURING SURGERY

What are the differences between the DS and the RNY?
Why do they have to REMOVE part of the stomach in the DS?
What is the difference between the "distal gastric bypass/duodenal switch (DGB/DS)",
and the "biliopancreatic diversion/duodenal switch (BPD/DS)"?

What is a common tract and why is it significant?
Can the DS be performed laparascopically?

AFTER SURGERY

How can I minimize the risk of blood clots?
Will I experience hair loss?
Will I have a problem with foul gas and loose bowels?
Will my medications be properly absorbed after surgery?
Will malabsorption cause me to become malnourished?

POST-OPERATIVE EATING

How much protein will I need each day?
I can only eat tiny meals. How can I get all the protein I need?
I used to be able to eat dairy products, but now they give me gas and diarrhea. What's wrong with me?

BEFORE SURGERY

Can't I just diet?

You can! You can diet and diet and diet. There is a reason why the diet industry is making billions of dollars- DIETS DON'T WORK.

Don't get me wrong, weight loss surgeons want to make money too but most of them are serious about helping the obese live longer lives.

Many people will tell you that all it takes is willpower or "if you would just not eat seconds or dessert, etc". Of course, these are the people that never experienced how it feels to weigh 300+ pounds, be discriminated against, laughed at, unable to fit in seats, etc. If the obese don't have willpower, I don't think anyone does. It takes so much strength and so much power just to wake up everyday knowing how awful society makes you feel.

So, if you want to try another diet, do it. If you have questioning thoughts, then maybe the duodenal switch procedure is not right for you (yet!).

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Do I qualify for obesity surgery?

The National Institutes of Health (NIH) has set the criteria by which most surgeons and insurance companies abide when deciding who qualifies for obesity surgery. Click here for the NIH patient selection guidelines.

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What if my family is against me having the surgery?

Having any type of weight loss surgery is a serious undertaking. It is very important that you have support so you can have a stress free and uneventful recovery. So what do you do when your family is against the surgery?

Many family members are not actually against the surgery but are fearful of possible outcomes and need to be educated about the surgery. It is your job to fill them in on the benefits, possible risks, aftercare and other aspects of the surgery. Once you have decided to have the surgery, help your family realize that you are making the right choice.

What should you do if you have tried to convince them that it is a wise choice, but they are still against it? This is always tough, since it may mean not having the surgery if it's a husband or wife that refuses to go along with your decision. You need to stay firm in your decision and make it clear that it is your life that is in danger without the help of surgery. If possible, get a third party involved. A counselor, clergy or friend that will help your significant other in understanding your decision.

If you are going into the surgery without family or friends, find yourself an angel. On the duodenal switch email list, there are plenty of people that would be willing to help you while in the hospital and afterwards.

Never give up!

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Will my insurance plan cover this surgery?

Increasingly, insurance companies are beginning to recognize that obesity surgery is much more than a "cosmetic" procedure, and they are covering it more now than ever.

Generally, the first step in pursuing this type of surgery is to see your primary care physician and ask for a referral to a WLS surgeon. The surgeon's office will request authorization for surgery from the insurance company. From there, it's important to keep the lines of communication open, both with your doctors, and with the insurance company.

Note the exact name and phone extension of the people you speak with at your surgeon's office and your insurance company. Being able to ask for the same individual on subsequent calls should help make the process a bit easier for you.

If you are denied initially, do not hesitate to appeal! This surgery is often approved on appeal. Even if your policy has an exclusion against WLS, you may be able to get coverage by proving that the procedure is "medically necessary" to alleviate co-morbidities (health problems that are exacerbated by your weight, and which would be improved by losing weight -- such as hypertension, diabetes, degenerative joint disease, asthma, sleep apnea -- just to name a few).

If all else fails, you can contact a lawyer. Patients have reported success getting approvals for duodenal switch procedures with help from both Larry Slade and Gary Viscio.

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What if my insurance company approves the wrong surgery?

By Michelle R:

It happens!

Many insurance companies will approve weight loss surgery but not approve the duodenal switch procedure. It happened to me and it could easily happen to you.

There are many reasons why the insurance companies do this. The first reason is they want you to use a doctor within their network. Another reason is they are unfamiliar with the duodenal switch procedure and may even consider it experimental. Of course, they may want you to go for the cheaper surgery which is usually the RNY.

So what do you do when you've gotten the approval but not for the duodenal switch procedure? You fight! You've already won half the battle by getting the weight loss surgery approved but now you must convince them to allow you to have the duodenal switch procedure.

Here is how I got the DS procedure approved over the RNY:

My medical group approved weight loss surgery for me but only with a local surgeon that did the RNY. He was in the medical group's network and they didn't want me to go out of network. I didn't want the RNY and was determined to have the duodenal switch. I basically had to go to my medical group's office to educate the people on what the duodenal switch was and why I wouldn't settle for anything less. Of course, the insurance coordinator for my surgeon's office was excellent. I think I bugged her every half minute of every day about getting the approval.

My best advice is to be your own advocate. Educate yourself on why you want this procedure, what this procedure is and why it is better then other weight loss surgeries. If you are prepared with this information, you will be prepared with any excuse your insurance company gives you on why you shouldn't have it.

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DURING SURGERY

What are the differences between the DS and the RNY?

Please see the DS vs. RNY page for essays on this topic.

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Why do they have to REMOVE part of the stomach in the DS?

The idea of partial stomach removal is a stumbling block for some people who are considering the Duodenal Switch procedure. However, it needn't be as scary as all that. The DS stomach is left essentially as a smaller version of its former self, with all of the functionality of an unoperated stomach -- just as nature intended it, only smaller.

The DS procedure's partial gastrectomy divides the stomach along the greater curvature, and the part that is removed is nothing more than a mass of acid-producing tissue. Removal of that mass of tissue (and thus the acids it would create) eliminates the danger of ulcer formation, which would be difficult to diagnose and treat if that stomach tissue were stapled off or transected and not removed (left "blind", as in the RNY procedure).

In DS patients, the remaining stomach is very close to "natural". The pyloric valve continues to function normally, and the lower part of the stomach (the antrum) continues its function to churn food into the proper consistency for nutrient absorption in the gut. The DS stomach will eventually (after 18 months or so) expand to hold a small- to normal-sized meal, with weight loss being maintained by the malabsorption component of the procedure. The DS stomach will never go back to its original size.

By contrast, the RNY procedure transforms the stomach into a tiny ~1oz. "pouch" with an artificial outlet to the small intestine. The pyloric valve is excluded, along with most of the stomach and all of the duodenum. They are left, unfunctional, behind the rib cage. (Theoretically, in case of serious problems, the surgery could be reversed, and the natural stomach could be used again.)

After the DS procedure, there would never be a need for reversal of the stomach portion, since it retains all of its functional anatomy.

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What is the difference between the "distal gastric bypass/duodenal switch (DGB/DS)", and the "biliopancreatic diversion/duodenal switch (BPD/DS)"?

Both of these terms describe essentially the same operation. The duodenal switch procedure provides an enhancement to the original BPD surgery, so "BPD/DS" is probably the most accurately descriptive term in use. However, some surgeons prefer to use other terms; this is simply a matter of preference and not indicative of any significant difference in the procedure. As always, it is important to question your surgeon as to the specifics of the procedure he is performing on you.

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What is a common tract and why is it significant?

The common tract (or common channel) is the length at the end of the small intestine in which food and digestive juices are able to mix, after being initially kept separate by the intestinal "rerouting" of the gastric bypass procedure. Keeping food and digestive juices initially separate is what enables your body to absorb fewer calories and fats.

You can visualize the surgically rearranged intestine in the shape of a "Y": digestive juices travel from the liver and pancreas down one arm of the "Y"; food travels from the stomach down the other arm of the "Y". At the bottom of the "Y", these two paths are joined, allowing food and digestive juices to mix and continue on their path toward the large intestine.

Sugars, protein and nutrients are absorbed to a limited degree in the food tract. Fat absorption occurs only in the common tract. Therefore, the shorter the common tract, the less fat absorption can occur. In general, a shorter common tract means that patients might experience more of the side effects that can affect all distal bypass patients (eg. smelly gas, diarrhea, vitamin deficiencies).

When you are researching your surgeon, it is important to question him as to exactly what measurements and methods he will employ in your surgery, and how these might affect you post-operatively.

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Can the BPD/DS be performed laparascopically?

Yes, by a limited number of surgeons worldwide. Laparoscopic duodenal switch surgeons are indicated by an asterisk (*) on the Duodenal Switch Surgeons page.

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AFTER SURGERY

How can I minimize my risk of blood clots?

It is generally agreed that the most important thing a patient can do to prevent the formation of blood clots is to get up and walking as quickly as possible after surgery. You may have heard patients mention that they were helped out of bed mere hours after surgery -- this is why.

In addition, some (most?) patients are given heparin (blood thinner) shots before and/or after surgery to minimize the danger.

There are also leg stockings that can be placed over your lower legs, which are pumped up (sort of like a blood pressure cuff pumps up) repeatedly to keep the blood flowing in the lower extremities.

One other thing that is sometimes done is to have a Vena Cava filter placed in the artery leading to the heart. This is a fairly minor procedure, done in the doctor's office (or sometimes preoperatively at the hospital), where they put this filter into an artery near the heart which will catch and prevent blood clots from entering the heart. My understanding is that the Vena Cava (also called Greenfield filter), is generally only used if the patient has a history of blood clots or some other factor that would warrant it. The filter stays in place permanently once it is installed.

The bottom line is that most blood clots form in the legs, when patients are immobile and the blood pools up and clots there. Later, when the patient does finally get up and moving, the clot dislodges and becomes dangerous... so, getting up and walking early is the best thing you can do.

Talk to your physician about this risk factor, which can occur when undergoing any type of major surgical procedure.

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Will I experience hair loss?

For reasons that aren't completely understood, some patients will experience hair loss to varying degrees, usually starting from 4 to 6 months after surgery and continuing for several months. Some people speculate that this is due to the sudden change in nutrient absorption following surgery, or due to our having been put under general anesthesia. Most doctors say that the best way to avoid or minimize hair loss is to make sure you consume enough protein, and adhere strictly to your post-op vitamin regimen as advised by your surgeon. There is some recent research to suggest that taking zinc and folic acid supplements can minimize hair loss. Some people suggest that scalp massage might help to maintain hair growth, and many hairdressers recommend shorter hairstyles, to reduce the amount of weight on the roots of the hair.Regardless of how this issue affects you, the good news is that the hair will grow back!

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Will I have a problem with foul gas and loose bowels?

The infamous "intestinal bypass", first done in the 1950's, is no longer performed; this is the procedure that many people are referring to when we hear horror stories of severe diarrhea and malnutrition. Modern obesity surgery has progressed beyond the point of causing these very unpleasant effects.

It is true, however, that because of the reduced absorption of nutrients and fats after a distal gastric bypass, patients can experience loose stools and bad-smelling flatulence -- but this problem generally improves and resolves itself within 6 months after surgery. This doesn't just affect duodenal switch patients -- it can affect anyone who undergoes a distal bypass.

There are several remedies that you can use to minimize the problem:

  • Avoid high-fat foods. This is probably the most effective way to combat the problem. Many people report that they suffer from this problem most when they eat fatty foods. Through trial and error, you will learn what your system can and can't tolerate.
  • Devrom Chewable Bismuth Subgallate tablets. These "internal deodorant" tablets were initally devised for ostomy patients, but many gastric bypass patients report that they see great improvement in bowel odors with the use of this product. The manufacturer, Parthenon, Inc., accepts online orders for Devrom chewable subgallate tablets.
  • Chlorophyll tablets. Some patients report that taking these tablets on a regular basis helps to combat offensive intestinal gas odors. One brand that has been recommended is "ENNDS".
  • Activated charcoal tablets. These tablets are claimed to reduce the amount of intestinal gas produced. One brand that has been recommended is "Charco Caps." Warning: Activated Charcoal may absorb medications (such as heart medicine or birth control pills). Consult your physician before using these.
  • Ozium odor eliminator is widely reported to be very effective in erasing odors from the air around you. Ozium is sold in a tiny canister, small enough to hide in purse or pocket, and can usually be found in discount stores such as Wal-Mart and K-Mart, as well as in many car washes.

Too many people worry needlessly over this issue. You will learn how to minimize and cope (just as RNY patients must learn to minimize and cope with issues related to their tiny pouch). It's not as if we're all walking around, like Charlie Brown's Pig Pen, surrounded by a cloud of odor. :-) Really!

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Will my medications be properly absorbed after surgery?

Most medications, including birth control pills, will be completely absorbed. However, timed-release or coated medications may not be fully absorbed after a distal bypass. A good way to test your pill is to put one of them in a clear glass of water -- if it dissolves in 20-30 minutes, it should absorb well when you swallow it as usual.

Remember, as your weight decreases, so may your dosage requirements for some medications. It is important to talk to your primary care physician about all of your prescriptions, and to follow your surgeon's post-operative instructions regarding those, as well as over-the-counter medications.

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Will malabsorption cause me to become malnourished?

You will need to take daily multivitamins in order to maintain your health. You may also need extra calcium and iron. Extra protein is sometimes recommended early on, just after surgery. Your doctor may require occasional bloodwork to make sure that you are maintaining the proper levels of vitamins and minerals. If you follow these simple guidelines, malnourishment is very unlikely to occur.

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POST-OPERATIVE EATING

How much protein will I need each day?

The recommended daily allowance of protein for the general population is 60 grams. In order for DS patients to absorb an adequate amount of protein in our altered digestive tracts, it is generally recommended that we consume around 90 grams of protein each day. However, your surgeon may have specific guidelines that you should follow, and it is important that you follow those instructions.

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I can only eat tiny meals. How can I get all the protein I need?

Common sources of protein are lean meats, poultry, fish, eggs, cheeses, yogurt, legumes and nuts. As tempting as it is to eat that salad or potato, it is vital that you eat your protein first, then if you've any room left, eat the carbohydrates.

Protein is also available in the form of liquid concentrates, powders and bars. These can be found at most health food stores, like GNC. These items are a terrific way to boost your protein intake, and the liquids, and powders made into smoothies, may be easier for you to digest early on if you're not yet ready for more solid food.

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I used to be able to eat dairy products, but now they give me gas and diarrhea. What's wrong with me?

You may have become lactose intolerant, which means that your digestive system can't handle lactose (milk sugar). Try eating non-fat yogurt, cottage cheese and milk. If you don't like non-fat milk, try ½% milkfat milk, or Lactaid (or another Lactose-free) brand milk. These are much easier to digest if you're Lactose Intolerant.

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