Fri 30 Apr 2010
Is the Duodenal Switch a viable surgery to consider for Lighterweight BMI’s?
Posted by satorijane under JournalThere are many very positive reasons to consider a Duodenal Switch surgery and I have spoken at length about them before. So in this blog I am going to focus purely on the weight loss aspect of choosing a DS. It’s not the B and end all of choosing a surgery, but imo it is a very important player.
I’ve often heard patients with other surgery types say to me that they only wished they’d known about the DS as they’d have definitely opted for it. When I ask them why they’d have chosen it, it is interesting that I’ve never heard anyone say ‘ because it would have helped me be healthier’. The answer without exception, is that they feel they’d have lost more weight with it.
I’ve given the same answer at times when I have been asked why I chose my DS.
People generally understand it much better than ‘I wanted to preserve my pylorus, keep my digestive system vagally intact and capitalise on the metabolic factors it offers ‘, for example. 
At the end of the day weight loss matters… it’s just as simple as that.
It’s at last becoming more common knowledge that the BPD/DS has the best percentage of excess weight loss of all surgery types. What data we have consistently shows this over the past years.
The link below also looks at some quite recent research that shows it has an excellent percentage of body fat loss over the other surgeries too (and that’s what we want to lose, not muscle!):
The duodenal switch has traditionally been thought of as the optimal surgery for those who have higher BMI’s. It’s something that I have read of over the years - the DS is for those with BMI’s that are greater than 45. And I agree.
But I don’t agree that it might not also be an excellent surgery for those in the 35 with co-morbs - 40 BMI range. I was over BMI 45 and nonetheless regarded as a DS lighterweight - but had I been BMI 35 with co-morbs I would still have fought tooth & nail to get my DS.
Why would I say this when it is clearly a major surgery?
- Because I have observed over the years that for lighterweights there seems to be a much better chance of losing beyond the frequently quoted excess weight loss percentages.
- Co-morbs such as high blood cholesterol and diabetes have the best track record of resolve with the DS .
Those that are involved with WLS might sometimes see super morbidly obese people as being in a worse off situation than those of us who are morbidly obese. This appears to sometimes justify reserving the DS for higher BMI’s only.
However - being at any stage of obesity is a very subjective thing and we do appear to have different ways of coping with wherever we are at on the scale. I don’t think we can quantify mental and emotional suffering. Even trying to quantify physical suffering is extremely difficult. I have friends who remain very large - much larger than I was. And they elect NOT to have surgery at all. When I look at them they appear to be coping and in much better health than I was, even though my obesity was not as developed as theirs. It’s very personal and very individual.
When it comes to deciding if someone is viable for a DS I don’t think it is right to just throw a generalized BMI blanket over it. To my mind this is very linear thinking. It still happens, although it seems to be getting marginally better in the UK. Some surgeons appear to refuse to give those below 40BMI even with co-morbs any consideration. Even getting it at 40BMI can be quite difficult for those who are determined and who, on the face of it, do seem to be very good candidates for a DS.
That said I do think we need to draw a rational line under it and my feeling is that the cut off point of 35BMI with co-morbs is sensible.
It’s vital to take into account what co-morbs someone may have and if the DS could have an effective impact on them over and above other surgery types, how they are coping emotionally, mentally and socially, whether they have a mature sense of realism about the surgery, whether they have a strong knowledge about the DS upfront, whether they personally feel they will cope with it’s nutritional demands, and how they intend to do this.
This is the truly important stuff.
To any Dser considering the surgery, lighterweight or not - I suggest strongly that you research and understand as much as you can about it. Search your own soul about it too, be honest about the possible hurdles you as an individual might face due to your own personal issues. This way you’ll give yourself more ability to change whatever it might be that needs changing for the future.
Another reason very frequently given to lighterweights struggling to get a DS, is that they risk ‘overshooting’ and ending up losing too much weight.
Perhaps giving people with BMI 35 with co-morbs to 40 BMI longer common channels might help prevent overshooting. There is also the possibility of leaving the stomach a little larger, but these are discussions for one’s surgeon.
As a pre-op I thought long and hard about the fact that I might overshoot into anorexic thinness and struggle to maintain a healthy weight. It seemed very unlikely to me. I felt I had much more chance of being left overweight as my obesity felt deeply entrenched and almost immoveable to me. Just prior to my surgery I had lived through a last ditch attempt to diet. I tried the Atkins diet which was harsh, and during which I lost almost nothing. It was as if my system had finally packed up and turned to stone. I saw a brilliant endo at the time who said it was likely my syndrome X was part of the reason the diet had not worked. I mentioned WLS and to my surprise he told me in my shoes he would consider it. I still consider him an evolved soul, way ahead of his time! 
In those days coming in just above 45 BMI was probably the equivalent of trying to get the DS at BMI 39 today. Surgeons seemed happier doing it at 50BMI plus. Of course I hoped my body would just slot into a good healthy weight and be done with it but I also had to play out possible scenario’s in my mind.
Given a choice of the two possibilities:
To potentially struggle with still being overweight? ( Rebound weight gain is not uncommon - even with the DS.)
Or - to potentially struggle with being underweight? … which could I live with better?
Call me fickle - but if I was not going to hit a perfect BMI - I’d plump for the underweight option everytime. I’d had a lifetime struggle of ‘overweight’. I was fed up with it.
I thought in the event I lost more rapidly I would control it by adding more carbs and sugars to my diet. That did not look like too much of a hardship to me at the time! As an obese person used to depriving diets, it had quite a luxurious ring to it - imagine being able to eat all the carbs I liked!
Oh little did I know! 
However before I came to the fine line of potentially slipping into excessive skinny-ness, I did have a little taster of what it feels like to have a rebound gain in weight. A few years into my DS, I had some weight gain. It was not a lot in the greater picture, but I panicked awfully. Each time I weighed myself I had an awful feeling in the pit of my stomach. I lived with anxiety and at times it depressed me. Luckily for me my regain stabilised and in the following year I began to lose weight again. Just the teeniest amount - here and there. This continued for several years adding up to a pretty substantial overall loss.
I still can’t quite work out why. It might have been that by then I had slotted into an eating pattern that was simple. I had got over my need for a daily small chocolate and lost interest in having it. I ate a diverse range of protein foods and healthy fats, lots of complex carbs and little else. But it might also just have been that my DS decided it was time to be on the metabolic move again!
The day did come when my weight kept threatening to slip into being overly thin. And eating carbs was quite a chore - I moaned about it a lot, to my own surprise! They unsettled my tummy and just tasted so awfully bland.
I’m afraid my carb eating approach did not last long. It was not the pleasurable activity I once imagined it would be. I became aware that it was going to be BIG effort time again. And effort - is effort. Whether one is working not to gain weight or not to lose weight!
Instead of flour based carbs I turned to simple sugars. I took to sucking boiled sweets throughout the day with my surgeons blessings.
However after a while I stopped doing it because I felt the sweeties could become very hard to stop at some stage. I was enjoying them way toooo much, justifiable or not, and my use of them was rapidly accelerating in quite an unconscious way. I had also begun to drink a lot of sugar in my tea - and I felt it was that or the sweets. Not both.
I think my sugar intake helps me not lose further weight - but I also worry about it from a health point of view. I have recently been a bit conflicted about it. I’ve been worrying that I might be playing a potentially dangerous game with my blood sugars. However I had my blood sugars tested last week and was very pleased to hear today that they are entirely normal, so at this point my body is coping with them.
I’m currently 8 stone 7.
Were it not that my DS check ups require getting on the scales, I’d be happy to never see one of those darned things ever again! Even at my current weight they make me momentarily and involuntarily anxious!
I’ve lost over 100% of my excess weight.
The thing is - I don’t have to be in a constant worry about weight gain. It has huge psychological implications for those of us who know the full impact of being uncontrollably obese. I have been there both before and after my DS - and I don’t like being there.
I was spot on about things pre-op. Even though I discovered that trying not to lose weight is as much an effort as trying to lose it and neither are ideal or easy - I definitely prefer to do battle with potentially being underweight than overweight.
I’d love more solid data about just how many DS lighterweights actually do overshoot, but there seems to be almost no data about it. Is it a danger that is over considered perhaps? I asked a doc who is very informed, what the percentage of the DSers overshooting in her care was. She said that they very loosely put all the surgery types together and say roughly 10% will regain, roughly 10% will overshoot. In the series of Hess, standalone DS figures were 3.8% - for both regain and too much weight loss. Again the figures remain lumped together and I’ve not been able to find any definitive figures for DS overshooting alone. Which makes me wonder if it is an insignificant enough figure(unless of course you are personally struggling with it) that it simply doesn’t form much of a priority in research?
Most of the data I have read on the DS speaks of losing iro 75 % EWL. I have also read data saying EWL is 40%…and various figures in-between. It doesn’t seem to hold a huge risk for overshooting based on these figures.
I have a hunch we might see more overshooting earlier in the DS - but longerterm? Do we find we can hold firm in a healthy BMI range? Do some of the initial overshooters find that with further adaptation of the gut they begin to have some gain in weight? As you can see, unfortunately as usual I have more questions than answers.
Over the years I have read a few horror stories about uncontrollable overshooting. There have been people who have been through hell with it and have had to resort to revisions to stop the loss.
So, if one is a lighter BMI opting for a DS must be thought through very carefully and discussed with one’s surgeon in the smallest detail. Overshooting can be quite alarming and I personally have at times found it quite difficult to be teetering on the brink…although I think,( hope) I am stable now. On the other hand some DSers I know who have overshot say they enjoy the complete freedom to eat loads of food and pretty much what they please, as they work to stabilise their weight loss.
All in all, I don’t think we should just dismiss out of hand that the DS for lighterweights could be an incredibly optimal surgery. For the right lighterweight candidates, it could bring not only the health benefits of weight loss but also the chance to lose an optimal and substantial amount of weight.
I think there is something to be said for that.
So at the risk of sticking out my neck - I am saying it! 
