Is the Dueodenal Switch experimental?

[Guest guest]

Dear Ds'ers,

After much seraching, I have finally found what I think is the source

of the insurance companies claim that DS is experimental. Please

read the section that follows.

Now we need to attack this point by point.

Hull

Ask the Experts on . . .

Biliopancreatic Diversion With a Duodenal Switch

----------------------------------------------------------------------

----------

Question

Is biliopancreatic diversion with duodenal switch an approved

procedure for the treatment of morbid obesity? If so, what are the

indications, success rate, and morbidity rate?

Response

from Walter J. Pories, MD, 03/08/01

The biliopancreatic diversion with duodenal switch is a relatively

new procedure that has yet to be shown as safe and effective in long-

term studies.[1] Proponents state that the operation is technically

easier than gastric bypass and is associated with an equal risk of

complications (1% to 10%) and mortality.[2-4] Advocates also report

weight loss rates ranging from 65% to 80% of excess initial weight

and deny that malnutrition is a clinically significant problem.[2]

However, anemia, hypocalcemia, and hypoalbuminemia have been reported

in patients undergoing this procedure.[3] Furthermore, diarrhea and

halitosis are common side effects.

My major concern is that the experience with this procedure is

limited to the short term. I have not been able to find a long-term

study with an acceptable follow-up rate. Accordingly, my bias is that

the enthusiasm for the procedure is premature and may not be well

founded at this time.

The indications for this operation are the same as for a gastric

bypass. Patients with a body mass index (BMI) > 40 who do not have

associated comorbidities and patients with a BMI > 35 who have

significant illnesses associated with the obesity are good candidates

for this procedure. In short, we are more likely to operate on

patients with a lower BMI if they have comorbidities such as sleep

apnea, diabetes, hypertension, and pseudo-tumor cerebri.

Contraindications for this surgery include uncontrolled depression or

other psychologic disease, substance abuse, alcoholism, failure to

agree to a long-term follow-up, inadequate intelligence to understand

the operation, and patients with unrealistic expectations.

Based on our experience and reports in the literature on other

surgical procedures for the treatment of morbid obesity, I am also

concerned about the long-term effects of this " malabsorptive

operation, " especially in regard to deficiencies of B12, B6, iron,

and folic acid.

Please do not interpret my remarks as a condemnation of the

procedure. It may turn out to be a fine alternative to gastric

bypass. At the present time, however, I and many other bariatric

surgeons consider the procedure experimental, interesting, and

perhaps even promising. Accordingly, I believe that until we have

better data on its efficacy and safety, the biliopancreatic diversion

with duodenal switch procedure should be performed only at

institutions that are conducting rigorous clinical trials.

References

Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch.

Obes Surg. 1998;8:267-282.

Ren CJ, E, Gagner M. Early results of laparoscopic

biliopancreatic diversion with duodenal switch: a case series of 40

consecutive patients. Obes Surg. 2000;10:514-523; discussion 524.

Lagace M, Marceau P, Marceau S, et al. Biliopancreatic diversion with

a new type of gastrectomy: some previous conclusions revisited. Obes

Surg. 1995;5:411-418.

Rabkin RA. Distal gastric bypass/duodenal switch procedure, Roux-en-Y

gastric bypass and biliopancreatic diversion in a community practice.

Obes Surg. 1998;8:53-59.

[Guest guest]

So guys - particularly those of us who have Dr. (who is referenced

below) - do you think we should bring this to Dr. P's attention and ask her

what her opinion of the article is?

dina

Dina in Aloha, OR

Age 37/BMI 61

Waiting for my consult with Dr.

Hoping my new insurance will cover it all....

Is the Dueodenal Switch experimental?

Dear Ds'ers,

After much seraching, I have finally found what I think is the source

of the insurance companies claim that DS is experimental. Please

read the section that follows.

Now we need to attack this point by point.

Hull

Ask the Experts on . . .

Biliopancreatic Diversion With a Duodenal Switch

----------------------------------------------------------------------

----------

Question

Is biliopancreatic diversion with duodenal switch an approved

procedure for the treatment of morbid obesity? If so, what are the

indications, success rate, and morbidity rate?

Response

from Walter J. Pories, MD, 03/08/01

The biliopancreatic diversion with duodenal switch is a relatively

new procedure that has yet to be shown as safe and effective in long-

term studies.[1] Proponents state that the operation is technically

easier than gastric bypass and is associated with an equal risk of

complications (1% to 10%) and mortality.[2-4] Advocates also report

weight loss rates ranging from 65% to 80% of excess initial weight

and deny that malnutrition is a clinically significant problem.[2]

However, anemia, hypocalcemia, and hypoalbuminemia have been reported

in patients undergoing this procedure.[3] Furthermore, diarrhea and

halitosis are common side effects.

My major concern is that the experience with this procedure is

limited to the short term. I have not been able to find a long-term

study with an acceptable follow-up rate. Accordingly, my bias is that

the enthusiasm for the procedure is premature and may not be well

founded at this time.

The indications for this operation are the same as for a gastric

bypass. Patients with a body mass index (BMI) > 40 who do not have

associated comorbidities and patients with a BMI > 35 who have

significant illnesses associated with the obesity are good candidates

for this procedure. In short, we are more likely to operate on

patients with a lower BMI if they have comorbidities such as sleep

apnea, diabetes, hypertension, and pseudo-tumor cerebri.

Contraindications for this surgery include uncontrolled depression or

other psychologic disease, substance abuse, alcoholism, failure to

agree to a long-term follow-up, inadequate intelligence to understand

the operation, and patients with unrealistic expectations.

Based on our experience and reports in the literature on other

surgical procedures for the treatment of morbid obesity, I am also

concerned about the long-term effects of this " malabsorptive

operation, " especially in regard to deficiencies of B12, B6, iron,

and folic acid.

Please do not interpret my remarks as a condemnation of the

procedure. It may turn out to be a fine alternative to gastric

bypass. At the present time, however, I and many other bariatric

surgeons consider the procedure experimental, interesting, and

perhaps even promising. Accordingly, I believe that until we have

better data on its efficacy and safety, the biliopancreatic diversion

with duodenal switch procedure should be performed only at

institutions that are conducting rigorous clinical trials.

References

Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch.

Obes Surg. 1998;8:267-282.

Ren CJ, E, Gagner M. Early results of laparoscopic

biliopancreatic diversion with duodenal switch: a case series of 40

consecutive patients. Obes Surg. 2000;10:514-523; discussion 524.

Lagace M, Marceau P, Marceau S, et al. Biliopancreatic diversion with

a new type of gastrectomy: some previous conclusions revisited. Obes

Surg. 1995;5:411-418.

Rabkin RA. Distal gastric bypass/duodenal switch procedure, Roux-en-Y

gastric bypass and biliopancreatic diversion in a community practice.

Obes Surg. 1998;8:53-59.

----------------------------------------------------------------------

[Guest guest]

Chris;

Where did you find this letter from Dr. Walter J. Pories?

Who is this guy?

In what context is he considered knowledgeable on the subject?

Is he a Bariatric Surgeon?

Moving on, I have an incredibly huge concern about his

footnotes. Do you realize he is actually citing the Bariatric

Surgeons who do the DS?

He is citing Dr. Hess' 10 year study as proof that there does not

exist any long term studies showing it is safe and effective. If he

got this from Dr. Hess' paper, what the heck did Dr. Hess say

anyway?

Please identify who this person is and in what context he was

answering this question.

Thanks,

gobo

> Dear Ds'ers,

>

> After much seraching, I have finally found what I think is the

source

> of the insurance companies claim that DS is experimental.

Please

> read the section that follows.

>

> Now we need to attack this point by point.

>

> Hull

>

>

>

> Ask the Experts on . . .

> Biliopancreatic Diversion With a Duodenal Switch

>

> ------------------------------------------------

----------------------

[Guest guest]

Dr. Pories' evaluation of the DS wasn't really bad. The negative in

his report was his allegation that it hasn't been studied long enough.

What is the good Dr. Pories wanting to find in terms of length of

study? I have read Hess' report and wasn't it something like 20

years? I have the durn thing but can't lay my hands on it. Also,

hasn't Rabkin been going at it including lap and open for somewhere

between 15 - 20 years? We'll be dead and in the grave by the time

this guy is satisfied with the length of time the DS has been

studied. One has to wonder if he read ALL of each and every one of

the reports he cited.

Nick in Sage

--- In duodenalswitch@y...,

> Walter J. Pories, MD Professor of Surgery Professor of

Biochemistry.

>

>

[Guest guest]

Walter J. Pories, MD Professor of Surgery Professor of Biochemistry. Mailing

Address:

East Carolina University School of Medicine Department of Surgery

His credentials and list of peer reviewed aqrticles are found at:

http://www.surgery.ecu.edu/pories.htm

his is also an associate editor of " OBESITY SURGERY

Including Laparoscopy and Allied Care " the

OFFICIAL JOURNAL OF THE INTERNATIONAL FEDERATION FOR THE SURGERY OF OBESITY

(IFSO)

He is a regular member of the ASBS

Greenville NC

Walter J. Pories M.D.

He may be dead wrong, but he has credentials.

in Seattle

>Chris;

>Where did you find this letter from Dr. Walter J. Pories?

>Who is this guy?

>In what context is he considered knowledgeable on the subject?

>Is he a Bariatric Surgeon?

>

>Moving on, I have an incredibly huge concern about his

>footnotes. Do you realize he is actually citing the Bariatric

>Surgeons who do the DS?

>

>He is citing Dr. Hess' 10 year study as proof that there does not

>exist any long term studies showing it is safe and effective. If he

>got this from Dr. Hess' paper, what the heck did Dr. Hess say

>anyway?

>

>Please identify who this person is and in what context he was

>answering this question.

>Thanks,

>gobo

>

>

>> Dear Ds'ers,

>>

>> After much seraching, I have finally found what I think is the

>source

>> of the insurance companies claim that DS is experimental.

>Please

>> read the section that follows.

>>

>> Now we need to attack this point by point.

>>

>> Hull

>>

>>

>>

>> Ask the Experts on . . .

>> Biliopancreatic Diversion With a Duodenal Switch

Web Mail services provided by http://www.aa.net

[Guest guest]

,

Thanks so much for the information. I sent the following

correpondence electronically to the good doctor:

Dear Dr. Pories,

I have a few questions regarding your opinion that BPD/DS is

experimental:

I am surprised that your refer to this as a new procedure since BPD

has been available since 1979 and BPD/DS since 1989. Regarding long

term studies, the very one you quote (Hess) is an eight year study,

and I understand that the definition of long term in medical circles

is > 5 years. In addition Dr. Scopinaro published a 21-year follow-

up report on a series of 2241 BPD patients

Scopinaro N, et al.: Biliopancreatic Diversion, World J Surg. 1998

Sep;22(9):936-46. PMID: 9717419; UI: 98383147.).

I think that qualifies as long term and is perhaps the most

comprehensive study of ANY weight loss surgery. Granted, it is

without the Duodenal Switch, but my understanding is that the basic

procedure is the same.

Regarding malnutrition and diarrhea, both Hess and Scopinaro a have

shown that with proper dietary supplements and adequate length of the

alimentary limb (>100cm) the incidence of malnutrition is quite low.

Hepatic liver failure is also extremely low (unlike the intestinal

bypass).

Anemia and bone loss have also been shown to be controllable with

proper Vitamin D, Calcium, and Iron supplementation. Hair loss has

been shown to be temporary. Hernia's are quite common (10-20%) but

are usually corrected with minor surgery (often done at the same time

as panelectomies). Lactose intolerance is quite common (50%) but also

manageable.

Anemia is not unique to the BPD/DS procedure, and in fact is quite

common in the standard gastric bypass (RNY). My own spouse is a case

and point. In addition, the standard gastric bypass induces

vomiting, dumping syndrome an inability to eat meat or other dairy

products. I have witnessed its affect on my wife for almost 4 years

and I consider akin to forced bulimia (in fact the outward symptoms

are the same). Also, weight regain is quite common with the

standard gastric bypass (though not as common as the banded

procedures). My father in law had to have his procedure converted to

a distal RNY, and suffers ALL of the disadvantages of BOTH the RNY

and the BPD/DS procedure! Even so he is still perhaps 70 lbs

overweight!

For these reasons I believe that the BPD/DS procedure is superior for

myself any many other obese patients.

However, statements like " I and many other bariatric surgeons

consider the procedure experimental " are great excuses for insurance

companies to deny coverage, and many are doing exactly that. You may

not have been aware of the profound implications of such a simple

statement, but statements like that are affecting the lives of

hundreds of people. Insurance companies are in the business of

denying care whenever possible, and we need to avoid giving them any

ammunition. I believe a procedure that is now 12 years old is far

beyond the experimental stage. I think that most of the authors in

the references you site would agree.

I would respectfully ask you to reconsider your position in light

this study and others recently published: e.g: by Dr. Aniceto

Baltasar

" Duodenal Switch: an Effective Therapy for Morbid Obesity—

Intermediate Results. " Obes Surg. 2001 Feb;11:54-59)

Thank You,

Hull, Ph.D.

chris.hull@...

chull1@...

> >> Dear Ds'ers,

> >>

> >> After much seraching, I have finally found what I think is the

> >source

> >> of the insurance companies claim that DS is experimental.

> >Please

> >> read the section that follows.

> >>

> >> Now we need to attack this point by point.

> >>

> >> Hull

> >>

> >>

> >>

> >> Ask the Experts on . . .

> >> Biliopancreatic Diversion With a Duodenal Switch

>

>

> Web Mail services provided by http://www.aa.net

[Guest guest]

At 14:07 -0800 6/28/01, Montgomery wrote:

>He may be dead wrong, but he has credentials.

I'm wondering if he only does RNY... you know, the industry " gold

standard " (which I've always wondered if just a euphemism for 'gold

on the bottom line').

--stella

[Guest guest]

I can probably answer this one from Gobo. Dr. Walter (all the cool guys are

named Walter) Pories is a renowed bariatric surgeon from East Carolina

University who has performed hundreds of gastric bypasses over many many

years. He and his collegues have published the most outstanding data

available in bariatric surgery with incredible follow-up and have

essentially " proven " that gastric bypass " cures " type 2 diabetes. He is the

President-elect of the ASBS....he speaks with authority, even if I think he

may be legally incorrect on this topic, his opinion is one to respect and

think about quite seriously. While his bias may be in the procedure he

does, there is no more respected bariatric surgeon out there in the world I

suspect - his quiet words speak loudly to his collegues and others at the

NIH and places of importance.

Hope that helps create some perspective.

Walter Lindstrom, Jr., Esquire

Obesity Law & Advocacy Center

www.obesitylaw.com

2939 Alta View Drive, Suite O-360

San Diego, CA 92139

Tel:

Fax:

Re: Is the Dueodenal Switch experimental?

> Chris;

> Where did you find this letter from Dr. Walter J. Pories?

> Who is this guy?

> In what context is he considered knowledgeable on the subject?

> Is he a Bariatric Surgeon?

>

> Moving on, I have an incredibly huge concern about his

> footnotes. Do you realize he is actually citing the Bariatric

> Surgeons who do the DS?

>

> He is citing Dr. Hess' 10 year study as proof that there does not

> exist any long term studies showing it is safe and effective. If he

> got this from Dr. Hess' paper, what the heck did Dr. Hess say

> anyway?

>

> Please identify who this person is and in what context he was

> answering this question.

> Thanks,

> gobo

>

>

> > Dear Ds'ers,

> >

> > After much seraching, I have finally found what I think is the

> source

> > of the insurance companies claim that DS is experimental.

> Please

> > read the section that follows.

> >

> > Now we need to attack this point by point.

> >

> > Hull

> >

> >

> >

> > Ask the Experts on . . .

> > Biliopancreatic Diversion With a Duodenal Switch

> >

> > ------------------------------------------------

> ----------------------

>

>

>

> ----------------------------------------------------------------------

>

[Guest guest]

Dude - EXCELLENT letter. Big time congratulations on a job extremely well

done!!!

Blessings,

dina

Dina in Aloha, OR

Age 37/BMI 61

Waiting for my consult with Dr.

Hoping my new insurance will cover it all....

[Guest guest]

Walter,

Thank you for that information. What a two edged swoard this guy has

turned out to be. Doubtless his proof of a cure for diabetes has

given you an avenue to pursue when exclusion clauses exist for WLS

(that is great). Unoftunately, his stance on BPD/DS is all the

insurance guys need to justify their denials. I posted a copy of a

letter I sent to him on this site earlier. It is a long shot since I

am not even a Doctor. While, actually I am a Doctor (of philosopy)

but not a medical doctor. I seriously considered using my proper

title as a prefix (Dr.) rather than a suffix (Ph.D.) but decided to

be fully honest.

Hull

> > > Dear Ds'ers,

> > >

> > > After much seraching, I have finally found what I think is the

> > source

> > > of the insurance companies claim that DS is experimental.

> > Please

> > > read the section that follows.

> > >

> > > Now we need to attack this point by point.

> > >

> > > Hull

> > >

> > >

> > >

> > > Ask the Experts on . . .

> > > Biliopancreatic Diversion With a Duodenal Switch

> > >

> > > ------------------------------------------------

> > ----------------------

> >

> >

> >

> > ------------------------------------------------------------------

----

> >

[Guest guest]

Ive always thought that if the RNY is the gold standard then the DS must be

the platinum......much more rare than the gold!

Jude

Re: Re: Is the Dueodenal Switch experimental?

> At 14:07 -0800 6/28/01, Montgomery wrote:

> >He may be dead wrong, but he has credentials.

>

> I'm wondering if he only does RNY... you know, the industry " gold

> standard " (which I've always wondered if just a euphemism for 'gold

> on the bottom line').

>

> --stella

>

>

> ----------------------------------------------------------------------

>