By: Jamey Lancaster

Jamey Lancaster — Thu, 21 Jun 2007 19:13:09 +0000

Here is the information a friend of mine who had the DS sent on European
docs.

03803 - Alcoy
Alicante, SPAIN
Phone: +34-96-533.25.36 and +34-654-06.40.93
FAX: +34-96-533.25.36 and +34-96-533.04.00

Dr. Baltasars comments on scars (with pictures)

There is also a web page sponosred by his patients:

This is old stuff:

Date: Wed, 21 Feb 2001 11:00:03 -0500

Subject: Dr. Baltasar’s page on BPD/DS

DUODENAL SWITCH

Vertical Subtotal Gastrectomy/

Bilio-Pancreatic Diversion/

Duodeno-ileal Switch

WLS (Weight Loss Surgery)

For

MALIGNANT (MORBID) OBESITY

A patient information booklet

2001-01-01

Aniceto Baltasar, MD, FACS, FASBS

Cid 61

03808 - Alcoy. Alicante. Spain

Tel. & FAX +34-96-533.25.36

2nd FAX +34-96-533.04.00

Cedular +34-96-654-06.40.93

WHAT IS THE DUODENAL SWITCH?

The Duodenal Switch is a combination of two types of surgeries developed
over the last 45 years to treat obesity. Part of the operation is
restrictive, reducing the stomach size so the individual will eat less, and
the second is a malabsoptive component, reducing the small bowel’s ability
to absorb ingested foods. It is a mixed or hybrid type of surgery. Neither
of the procedures is extreme; it is designed this way to lessen the
undesirable side effects.

ANATOMY OF THE DIGESTIVE SYSTEM

1. Mouth: Entry point for food; teeth and tongue chew food and move it
to the back of the throat for swallowing. The enzyme amylase starts
digestion of starches and sugars (carbohydrates).

2. Esophagus: Carries food to the stomach. It has no digestive
function.

3. Stomach: Holds food and mixes it with acid and saliva. It has not
absorptive function!.

4. Pylorus: The valve that controls the emptying of the stomach. It
helps prevent "dumping syndrome".

5. Small bowel: This tube,5 meters (15-30 feet) in length, lies in
between the pylorus and the large bowel (the colon). 95% of all digestion is
carried out here and it is the most important part of the digestive system.
It is divided in 3 parts:

Ø Duodenum: Two feet long (60 cm). Bile from the liver and pancreatic
enzymes (the digestive juices) enter this segment.

Ø Jejunum: The middle portion of the small bowel.

Ø Ileum: The lower portion.

The jejunum and ileum are the sections where carbohydrates, proteins and
fats are absorbed, as well as vitamins and minerals. Iron and Calcium are
absorb in the duodenum.

6. Large bowel: Starts at the end of the small bowel. Its main function
is the absorption of water and holding the stools. Nutrients are not
absorbed here. The appendix joins the bowel at its beginning.

7. Liver: Nutrients absorbed from the small bowel go the liver via the
portal veins. Secretes the bile necessary for fat digestion.

8. Pancreas: Secretes the enzymes necessary to digest carbohydrates,
proteins and fats.

HOW DIGESTION WORKS

Digestion stars in the mouth with saliva’s amylase. Food travels to the
stomach where it is held, and mixed with acid, it starts to break down here.
Stomach emptying is regulated by the pylorus. Digestion and absorption
happen in the small bowel when food is acted upon by bile from the liver and
pancreatic enzymes. Water is absorbed in the colon and waste is excreted
through the rectum.

HOW THE BPD/DS IS PERFORMED

I. Vertical Subtotal Gastrectomy: The restrictive part:

To cut the stomach, we use surgical linear staplers. These are instruments
that apply staples and cut the bowel, both, at the same time. The staples
make the operation safe, so bleeding and leakage are prevented!.

The duodenum is cut at 1 inches (2.5 cm) past the pylorus with linear
staplers.

II. Duodenal Switch: The malabsoptive part.

The cecum is identified and the appendix removed. Starting from the end of
the ileum, where the small and large bowel meet, the whole small bowel is
measured. It is cut half way (eight to nine feet = 250 cm) with the stapler.

The free end of the ileum is joined by stitches or staples to the short
piece of remaining duodenum, 2.5 cm past the pilorous. This portion is now
called the Alimentary or Digestive limb.

This is where the term "switch" comes from; as the ileum is switched with
the duodenum just below the stomach

III. Biliopancreatic Diversion: The malabsoptive part; cont’d:

The remaining length of the duodenum and proximal small bowel, called the
Bilio-Pancreatic limb is attached to the ileum two and half feet (75 cm)
from the ileocecal valve. This last portion of the "new small bowel" is
called the Common limb.

The alimentary limb has the ability to digest sugars and proteins but the
full digestion takes place mainly in the common limb where all the
pancreatic and digestive enzymes and bile mix with food. This part of the
bowel is too short to absorb all of the ingested fat.

Advantages of this operation: The small stomach restricts the intake because
the patient easily feels full. But there is not any restrictive band to act
as a foreign body to make you vomit. Not one inch of the small bowel is
removed, so that portion of the operation is reversible. The removal of part
of the stomach is not reversible, but with time the stomach enlarges enough
to allow fairly normal intake and have no serious long-term consequences.
The bile and pancreatic juices are reabsorbed and not lost from the body.
The operation works by combining the restrictive and malabsorptive
components. Either method alone will not cause weight loss. However, if you
can’t eat as much as before and part of the food is not absorbed, you can’t
stay fat.

The operated patient will absorb less calories than she/he needs. The body
will use the accumulated fat within your body to compensate for the lack of
calories. Weight loss will occur. Stored fat is burned and the byproducts,
mainly cholesterol, are removed from your body by the liver and bile. With
rapid weight loss, there is a high risk that cholesterol stones will form in
your gallbladder. For this reason, we remove the gallbladder at surgery;
otherwise, the patient will very likely have biliary colic and
complications, that will require a gallbladder operation later on. A
prophylactic cholecystectomy prevents this occurring.

The full name of the operation should be "Vertical Subtotal Gastrectomy/
Bilio-Pancreatic Diversion/ Duodeno-ileal Switch". The short form is
BPD/Duodenal Switch. and the shortest BPD/DS or just DS. Strangely enough
the name of the operation has not been standardized and, still less, there
is not coding for this operation, so most Insurance Companies do not cover
expenses.

IMPORTANT FEATURES OF THE D.S.

Ø The stomach: It will be small, 2-4 oz. (60-120 cc) in size, like a
small juice glass (in the shape and size of a small banana); it will slowly
enlarge so you can eat a small normal meal. Not a large meal. The segment of
stomach removed is not reversible but it has very little clinical
significance.

Ø Reduced incidence of marginal ulcers: Ulcers occur when the small
bowel is joined to the stomach in the gastric bypass. Because the acid
production has been decreased by the removal of part of the stomach the
chances of ulcer formation is minimal.

Ø No dumping syndrome: This complication is caused by liquids and foods
high in sugar content emptying into the small bowel as in the gastric
bypass. It causes dizziness, sweating and such bad sensations that patients
tend to avoid eating sugars.

Ø The pylorus: It is not removed or bypassed. It continues to function
normally, controlling stomach emptying, preventing the "dumping syndrome"
that occurs with the gastric bypass. It also allows complete and effective
reversal of the small bowel no normal, if needed.

Ø The Alimentary limb: This is the distal small bowel, now joined to
the duodenum. It digest mainly sugars and some proteins and ends in the
common channel.

Ø The Bilio-Pancreatic limb: This is the first segment of the normal
small bowel that now has no contact with food. It functions by reabsorbing
bile salts and water as before the operation.

Ø The common channel: This is the last portion of the small bowel. It
is the only segment available now to absorb FATS. But the remaining length
is not enough. There is decreased amount of fat, cholesterol and
triglicerides absorbed. The fat-soluble vitamins - A, D, E and K may be
insufficiently absorbed as well. Patients are required to take supplements
of these nutrients for the rest of their lives.

SUPPLEMENTS REQUIRED AFTER SURGERY

VITAMINS:

Vit A is important for your eyes and skin.

Vit. D is important for calcium absorption and bone formation.

Vitamin E has not important clinical significance.

Vit. K helps in coagulating your blood. Let your doctor now if you have to
take "blood thinners".

Information on ADEKs:

ADEKs can be purchased online at scandipharm.com or ordered at the
pharmacy. I think they are superior to the Allergy A and D. Quite a few of
the American doctors are requiring their patients to take ADEKs. Just some
information from the instructions included:

"ADEKs is an oral multinutrient tablet specially formulated for use under
medical supervision to

provide nutritional supplementation in individuals with malabsoptive
conditions. ADEKs tablets

use water miscible form so the fat-soluble vitamins to improve absorption in
these individuals.

ADEKs are indicated in individuals who do not obtain sufficient fat-soluble
vitamins (A,D,E, and K)

from their diet, especially due to malabsoption of dietary fat, as in cystic
fibrosis. Each tablet contains:Vit.A9000IU,Vit.C 60mg, Vit. D 400 IU, Vit. E
150 IU, Vit. K 150mcg, Thiamin 1.3mg,

Riboflavin 1.2mg, Niacin 10 mg, Vit. B 6 1.5 mg, Folic acid 2 mg, Vit. B12
-12 mcg, Biotin 50 mcg,

Pantothenic Acid 10 mg, Zinc7.5mg."

The bottle says to chew two tablets daily. Because this supplement is not
only A,D,E,K vitamins and others, you may not have to take a supplemental
multi-vitamin.

MULTIVITAMINS

If you are not taking ADEKs you should take a Multivitamin each day, any one
over the counter. It will supply most of the other vitamins and trace
minerals.

CALCIUM

Since the proximal bowel is bypassed you will not absorb enough calcium. You
must take calcium supplements, about 1500-2000 mg a day. "Tums" will work
well in the 1st few weeks after surgery they are easy to take, help settle
your stomach and reduce gastric irritation. Later, when you can take pills
more easily start with "Cicatral" (Calcium citrate) or "Cal apatite" (the
microcrystalline hydroxyapatite is the most readily absorbed form of
calcium).

Calcium carbonate is the most common form of calcium supplements on the
market but it requires acid to dissolve, since your stomach acid output is
now low any other type of liquid or vitamins will be absorbed better. Skim
milk is a good source of calcium (300 mg per cup).

Calcium is the most important mineral for you after surgery. Most of the
body’s stores are in bones, which are very important for your strength,
function and body stability. Calcium plays a vital role in many basic
physiological processes, including blood coagulation, the sending of
messages along the nerves, skeletal and heart muscles function, preservation
of cell membrane integrity and permeability and certain glandular functions.
Less than one percent of the body calcium is in body fluids, and the rest
is in the bones.

If your blood calcium level becomes low, the body will take the needed
calcium from the bones, and in the long run your bones will become softer
(Osteoporosis) and easier to break. This is more common in post-menopausal
women. Cal apatite is 20% more absorbable than Tums and even more than
Cicatral.

After surgery there are three blood test your primary care physician should
include in the calcium follow up: Serum calcium, Alkaline Phosphatase and
PTH (a hormone that regulates calcium metabolism).

CHILDBEARING

Women of childbearing age who are having weight reduction surgery should use
some type of birth control during the period of rapid weight loss (18 to 24
months). Maternal malnutrition may impair normal fetal development. All
patients who are losing weight, at a rapid rate, are in some way suffering
some form of malnutrition. Pregnancy should be postponed until your weight
has become stable for some time. Women who become pregnant after WLS should
receive specific attention from the surgical care team along with their
obstetrician. Many patients have become pregnant after DS without any
difficulty, but they do need to be watched more closely and they also need
to make sure they are taking all necessary vitamins, minerals and proteins.

Folic acid, one of the B vitamins, has been found to prevent neural tube
defects (NTD). Increased intake of folic acid reduces the risk of NTDs such
as anencephaly and spina bifida (open spine) by as much of 50 to 70 % if
women take enough of it before conception and in the early months of
pregnancy. Take your multivitamins containing 400 mg of folic acid (the
standard in most multivitamins) every day.

Many morbidly obese patients also have fertility problems, but after WLS
they will frequently be able to become pregnant. Do not get pregnant until
your weight has stabilized.

RISKS AND COMPLICATIONS

Most patients do very well with the operation but there are risks.
Short-term risks are the one seen in the hospital or during the first month
after WLS. The risks of all surgeries are infection, blood clots, bleeding
and pneumonia. All of them are important to us.

The complication we surgeons are very concerned about is a possible "leak".
A leak is a perforation of the stomach or the bowel from any place where a
suture or staple is. The places where the stomach and small intestine are
sutured are tested during the operation for leaks using a special dye called
"methidine blue". No patients exits from the OR with a leak since we test it
several times. But leaks may occur thereafter. Not all leaks need
reoperation if they are well drained. But you may require reoperation,
prolonged hospital stay and important medical treatment. Fortunately this
complication is not common. One month after WLS the risk of this
complications is gone.

Wound abscess or pus is very uncommon unless you had a leak. Special
measures are used to prevent wound infection or drainage during surgery.
Some patients may develop a wound seroma made of the subcutaneous fat that
becomes oily after WLS; the treatment is partial opening of the wound and
drainage.

We cut stitches on the second or third day, and use strips of tape to hold
the wound closed to decrease scar formation.

Some patients have difficulty takings fluids in the very beginning because
there may be swelling around the operated areas. You will stay on liquids
the first 1 week, then 1 week on mashed/pureed food, and then after two
weeks you may go on a normal diet.

BLOOD LOSS

We never have needed to give blood transfusions in primary WLS; however we
do have blood in our bank. In WLS revisions there are more chances of
bleeding from previous scars and adhesions of the bowel. We do not think
that it is necessary for patients to store blood before surgery.

LONG -TERM COMPLICATIONS

Long-term complications are related to the malabsoption part of the
procedure. Since fat is not properly absorbed the fat-soluble vitamins have
to be checked, such as Vit. A, D & K. Take your ADEK vitamins. Plus calcium.
All of them should be taken for your lifetime, forever. Eat high quality
proteins such as fish, meat, eggs, milk and cheese.

Blood tests should be done every 3 months the first year, every 6 months the
second and yearly thereafter.

Premenopausal women need extra iron to prevent iron deficiency anemia.
Postmenopausal women may take estrogen to prevent osteoporosis. Consult your
physician regarding hormone replacement therapy.

Liver cirrhosis and liver failure are not inherent complications of this
operation such it was in the old jejuno-ileal bypass (JIB). When/if they
occur it is due to active B or C hepatitis or previous cirrhosis, plus some
form of malnutrition. In the DS there is not a blind loop of bowel and
bacterial overgrowth as there was in the JIB.

DIARRHE

Diarrhea is not universal to the DS. Some patients are even constipated. You
can have larger stools due to increased undigested food. Normally patients
have to go to the bathroom very early and then after breakfast. Some may go
once or twice more per day. It varies from patient to patient. Some patients
may need to slow the bowel’s pace by using Lomotil (prescription) or
Immodium (over the counter). Also you may need a antibiotic such as Flagyl
if diarrhea happens while traveling and bowel flora changes. For many
patients, diarrhea stops when they go on to clear fluids for a couple of
days. In severe cases of diarrhea, patients may need to enter the hospital
and have IV fluids to treat dehydration.

When diarrhea has occurred because of a change in the normal bowel flora
take "lactobacillus acidophilus", "bifidobacteria" or "Ultraflora" dairy
free. This may solve your problem completely.

Avoid sorbitol since this white, sweet, odorless, crystalline alcohol found
in berries, fruits used as a sugar substitute is not absorbed in the GI
tract; it gets into the large bowel, bacteria ferment it and form gas and
loose stools. Eat whole wheat, pasta and rolls made without sorbitol.

BAD BREATH

Some patients have the sweet smell of acetone on their breath and have good
results by taking 10 mg of Reglan (prescription) at bedtime or 5 mg (1/2
tablet) of Reglan during the day, 2-3 times a day as needed.

FLATULENCE

For most people gas is a problem because it causes (sometimes painful)
bloating and (often mortifying) odors. Everyone has gas. The average person
generates 1 to 3 pints of gas a day, but some people produce a lot more. The
average is 14 times a day. Most gas is odorless.

Gas is composed of hydrogen, nitrogen and carbon dioxide and some oxygen.
One third of the adult population produces copious quantities of methane,
while the rest little or none.

Less than one percent of the gas smells. But boy, does it ever. Several
sulfur containing compounds are responsible for most fecal odors. The human
nose detects hydrogen sulfide in concentrations as low as one-half pert per
million.

Certain foods are gassier than others. Beans, Brussels sprouts, raisins,
apple juice and prune juice are a few. But a gas producing foods for one
person may not be for the next. Extremely flatulent foods (more than 40
passages a day) vary from person to person. Carbohydrates are largely to
blame, due to sugars, starches, and fiber that reach the colon (large bowel)
without being digested or absorbed. Once in the colon, the colonies off
harmless bacteria eat them and give off byproducts of hydrogen, carbon
dioxide and in some people methane. These are the "good bugs" (bacteria)
that are wiped out with antibiotics and need to be replaced by taking
Ultradophilus, Ultrabifidus and lactobacillus acidophilus.

The most common sources of gas are: 1) lactose, a sugar that occurs in milk
product. Many people lack the enzyme (lactase) to digest lactose: 2) Soluble
fiber, like the pectin in fruits and the beta-glucans in oat bran: 3) Gas
producing bacteria feed off small amounts of starch that escape digestion by
enzymes in the small intestine. 4) The most infamous source of gas (in large
amounts) is beans, vegetables and grains. No one has the alphagalactosidase
enzyme required to break them down. When they hit the large bowel, our
bacteria have a feast.

FOLLOW UP

After surgery you will be given discharge information for your primary care
physician and your self. It is very important that you follow up with your
PCP, and your WLS doctor, who understands your type of surgery.

In our experience, DS is the operation that requires the lowest rate of
revisions due to failure of the technique to lose enough weight or long-term
secondary effects.

Patients should have blood tests every 3 months during the first year to
detect any possible side-effects of the DS such as:

1. Protein malnutrition: Monitor Total & Albumin blood tests.

2. Iron deficits: 7% incidence. Check Iron levels, anemia.

3. Calcium deficit: 8% incidence. Follow Ca levels, Alk.
Phosphatase & PTH.

4. Diarrhea: 2% incidence. Controlled with Lomotil or Flagyl
(Metronidazol).

5. Fat soluble vitamins: D25, D1,25, A, Carotene, K
(Quick index). Very low incidence (<2%).

6. Liver profile: SGOT & SGPT are normally elevated up
to 60 units for the first 6 months. Total & Direct Bilirubin.

WEIGHT REGAIN

BPD/DS patients may lose weight for 16 to 18 months. The lowest weight the
patients reaches it is called the nadir. Once the patient reaches the nadir
of their weight there is always the chance that a particular patient may
regain weight, but without any doubt this is the operation with the lowest
weight regain!.

Surgeons who have been doing this surgery for 12-14 years state that the
mean weight regain is about 4-5 Kg = 10 lbs. A patient who has lived a
lifetime with the terror of weight gain, it may call their doctors even, if
the weight regain is less than 2 lbs. This is understandable. So far, in my
experience, no DS patient has required surgical revision due to weight gain.
The phenomenon of weight regain and reoperation was very common with the
VBG.

FOOD AND NUTRITION

Protein: This is the most important food type. The body needs proteins for
the most important bodily mechanisms. Since the intestine is shortened by
half, and is the only place where proteins are absorbed, the patients should
eat as much protein as possible. You will not gain any weight by eating
proteins. Proteins are high in meat, tofu, meat substitutes, fish,
shellfish, eggs, milk and cheese. The more you eat of these protein sources
the better.

Fat: The purpose of the bowel bypass is to decrease fat absorption. But
there is little to no risk of deficiency of fat required for vital
functions. Some patients lose fat in the stools; some patients have
reported seeing fat vacuoles in their stools.

Carbohydrates: These foods are the cause of late weight regain, since simple
sugars are easily absorbed. Carbohydrates are mainly found in candy, soda
pop, cookies, pies, juices, sweetened drinks, ice cream, bread, potatoes,
pasta, fruits and deserts. Try to avoid them.

OUR EXPERIENCE WITH D.S.

We are publishing our experience with the DS in Obes. Surg. 2001, February
issue, Vol. 11 (1) a paper entitled "Duodenal Switch: An Effective Therapy
for Morbid Obesity. Intermediate results".

Among the open DS cases two patients died within a month after surgery, one
due to pulmonary emboli and a second one due to an intrathoracic esophageal
rupture and multiorgan failure. Our mortality rate is 1.37%; 65% of the
patients were superobese and 25% were conversions from failed VBG’s. There
was no mortality among the patients with primary operations.

We had 8 leaks , a 5.6% rate. Six of the patients required operations, and
two of them were cured by conservative means. The two patients who died and
six out of the eight leaks occurred in re-do WLS; we know that revision
surgery has a much higher complication rate.

Two patients died at long-term. Three patients required conversions
(replacing the small bowel into its anatomical position) due to : 1) to
alcoholic suicide attempts with liver impairment, 2nd) due to protein
malnutrition and a 3rd) due to diarrhea. All of them are now asymptomatic
and with minimal weight regain (from 10 to 50 lbs).

Long-term results: 97% of the patients lost at least half of their excess
weight. Mean %EWL (percentage of excess weight loss) was 75% and the drop in
the BMI was successful in both the Morbidly obese and the Superobese
patients.

By the BAROS classification that measures QOL (quality of life), weight loss
and cure of co-morbidities) 45% had excellent results, 40% very good
results, 12% good and 3% fair. There were no failures.

In a scale from 1 (perfect results) to 5 (poor results) measuring the type
of intake, vomiting, hunger, stool frequency and odors and abdominal gas
pain, the mean measure was 1.7, close to the perfect 1 and the only frequent
side-effect was foul odor of the stools in about 35% of the patients.

There is no perfect WLS. All operations have pros and cons.

After many years of using the different approaches to WLS (RNY in the 70’s,
VBG in the 80’s, LAP-RNY again in the 90’s) I recommend my patients the
BPD/DS since the weight losses and QOL are the best.

We want to remind to anyone who is considering WLS that this is not cosmetic
surgery, nor endocrine surgery. Many patients have severe preoperative
conditions that increase the risks of surgery; at the same time, those
comorbidities (high blood pressure, diabetes, sleep apnea syndrome,
cardiovascular disease, osteoarthritis, infertility) are costly, reduce the
morbidly obese QOL and increase heir chances of early death without surgery
as well.

Comments on: Pam

By: Jamey Lancaster

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By: Jamey Lancaster

By: Jamey Lancaster