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DS vs RNY:
The Differences Between the BPD/DS and the RNY Procedures
In researching which type of weight-loss surgery to pursue,
people often want to know the differences between the BPD/DS
procedure and the more common Roux-en-Y procedure. Several
people have written their own comparisons, which are listed
below. By reading these folks’ “take” on things, you may gain
a greater understanding of exactly how the BPD/DS works.
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By
Laura E. in Phillips Ranch, CA
It's not easy to understand the differences between these
surgeries! Hopefully, you've had a chance to read up on the
ASBS site -- they have a paper there that gives some good
info about the various surgeries that are done for obesity.
Also, Drs. Anthone and Rabkin have excellent information on
their websites that show diagrams and details of the Duodenal
Switch procedure. [See the
More Information page for these URLs.]
All weight loss surgeries work by making the stomach smaller
(restrictive procedures) and/or creating changes in the
digestive tract which do not permit the body to absorb all of
the fats in the food you eat (called malabsorptive
procedures).The DS is a combination restrictive and
malabsorptive surgery. The stomach is made smaller and the
intestines are rerouted so that you can't absorb all the food
you eat. Because of this malabsorption it's essential that you
monitor your vitamin levels and take your prescribed vitamins
for the rest of your life. It's also the malabsorption that
can cause diarrhea if you eat too much fat. The undigested fat
in your colon can cause gas problems, but they usually improve
in the first 6 months after surgery.
The DS is similar to the RNY with respect to the intestinal
bypass (malabsorptive) portion of the procedure. The lower
part of this surgery is basically the same as a distal RNY.
RNY's are done either proximal (with a shorter length of the
intestines bypassed) or distal (with more of the intestines
bypassed). Studies have shown that people who have distal
bypasses have greater success at losing large amounts of
weight and keeping it off.
The RNY and DS are very different with respect to what is done
at the top end of the surgery -- the portion involving the
stomach (the restrictive aspect of the surgery). The RNY
doctors do a variety of things to make the stomach smaller --
most create “pouches” or transect (divide) the stomach. They
then reroute the intestines by connecting them directly to the
new stomach pouch, bypassing the duodenum. In the RNY/pouch
procedures, the pyloric valve (which regulates the emptying of
stomach contents into the duodenum) is bypassed and therefore
doesn't function after surgery.
In the DS procedure, the surgeon creates a smaller stomach by
removing about 75% of the stomach (which is called a partial
gastrectomy). The top part of the gastric bypass is connected
below the duodenum which keeps the upper part of the digestive
process the same as before surgery (except that your stomach
is smaller). Your pyloric valve continues to regulate the
emptying of the stomach contents into the duodenum and all of
the hormones and secretions that occur in the duodenum
continue after surgery.
In RNY/pouch procedures, the duodenum and pyloric valve are
bypassed and the intestines are connected to the newly created
stomach pouch.
Dumping happens when the stomach contents (unregulated by
the pyloric valve which has been bypassed) dump directly from
the new stomach pouch into the intestine. Eating sugars can
cause dumping for many RNY/pouch patients. For this reason,
they must be very careful of sugars. Some feel that this type
of surgery with the dumping syndrome is the best option for
people who eat a lot of sweets, since the dumping acts as a
deterrent to eating sweets.
Since our pyloric valve and duodenum are left functioning as
before, we DS patients don't have dumping syndrome, nor a risk
of staple line problems, clogging of the anastamosis, ulcers
at the stoma, etc. (remember, we don't have pouches or
stomas). So, we don't have the problems with "stretching" the
pouch or getting something stuck in the stoma -- because what
we have is our real stomach, connected the same way it was
before surgery to the duodenum.
Good luck in sorting all of this out!! Of course, I'm biased
but I believe the Duodenal Switch is the best surgery for
morbid obesity!
Laura E. in Phillips Ranch, CA.
DS/DGB 3-5-99 Dr. Anthone, USC, Los Angeles
Pre-op wt. 418 lbs, 5'7" age 45
Lost 75 pounds as of 4 months post op.
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By
Craig in San Francisco
There are always a lot of questions about the difference
between the Distal Gastric Bypass with Duodenal Switch (DS)
and the more common Roux-en-Y (RNY) procedure. I have done a
fair amount of research for myself and can tell you why I have
chosen the DS procedure. The following is just my
understanding and opinion.
Probably foremost is that the DS avoids altogether the
complications with the RNY "anastamosis" -- that is the
artificial outlet from the "stomach" pouch into the intestine.
Some RNYers have had this opening "close up" on them,
sometimes several times. At the very least, this means a very
painful trip to the emergency room to have the opening "roto
rootered" open again. Unable to eat or even drink water, you
can get into trouble quickly.
In the regular RNY, a small pouch is created where the stomach
meets the esophagus, and made into a new artificial stomach.
The remaining stomach is either stapled off or separated from
the pouch. A hole "about the diameter of a pen" is then made
in the pouch, and a fresh-cut piece of small intestine is
brought up and sewn to that hole.
The opening between the pouch and the intestine is called the
anastamosis. Food can block this small opening, or scar tissue
can swell it closed. It is also prone to ulcers and bleeding
(and internal bleeding is serious), because the "cast iron"
tough stomach tissue both is largely impervious to, and itself
produces acid, while the tender intestinal tissue sewn to it
is neither. [The stomach tissue is a naturally acid
environment, while the intestinal tissue is alkaline -- which
can make for less-than-chummy bedfellows.]
Another concern is that because the exit from the stomach to
the intestine is simply a "hole," from which the stomach
contents empty directly into the intestine, it is like a sink
whose drain is always open. For this reason, RNY patients
sometimes have trouble regulating blood sugar, which causes
the very unpleasant "dumping
syndrome."
The Duodenal Switch procedure is essentially a newer, arguably
more advanced version of the RNY, which avoids all of the
above-mentioned problems. DS surgeons are still few and far
between. Most DS surgeons have done a many RNYs and have been
ultimately dissatisfied with the procedure, which led them to
perform the DS.
The DS procedure includes a “distal” gastric bypass, which
means that more of the small intestine is by passed than in a
"proximal" bypass, which some may worry about. (The RNY can be
done with either a distal or a proximal bypass.) The DS’s
distal bypass means that fewer nutrients and calories are
absorbed than with a proximal bypass. This results in more
successful weight loss, but it also means more vigilance is
necessary in taking your vitamins and calcium supplements.
[After the DS procedure, patients will continue to absorb
sugars completely, so it is important that we consume
high-sugar foods in moderation. Proteins and carbohydrates
will be absorbed incompletely at first, but the body will
acclimate and absorb more of these nutrients with the passage
of time.] Fats will never be completely absorbed following the
DS, which means that eating high-fat foods can mean smelly and
loose bowel movements. (But whose having surgery to keep
eating lots of greasy foods?).
The biggest advantage of the DS is that you keep an
honest-to-goodness stomach, [which is usually 150-200cc is
size (as opposed to the 15-30cc pouch of the RNY)]. The
pyloric valve remains intact and functioning just the way God
intended it. The pyloric valve is a sphincter muscle that
opens and closes to regulate the release of stomach contents
into the digestive tract. The retention of the pyloric valve
eliminates the dumping syndrome that is experienced by many
RNY patients. The DS patient’s stomach can also "churn" food
like it is supposed to. DS patients do not have problems with
bleeding ulcers or blocked "anastamosis." They are also less
likely than RNY patients to vomit unexpectedly.
The bypass portion of the operation is essentially the same as
a regular RNY - the top part of one side of the "Y" brings the
food down, but has been disconnected from the pancreatic juice
and bile. The other top half of the "Y" brings down only that
pancreatic juice and bile. They food and digestive juices mix
only in the bottom part of the "Y," which results in a greatly
abbreviated digestion time.
The RNY is a great operation. It is the one performed by the
greatest number of surgeons, and I would not hesitate to
undergo it if the DS were not available to me for whatever
reason. These surgeries are the best kept secret in medicine,
saving lives both figuratively and literally.
Craig in San Francisco
Duodenal Switch 2-9-99, Dr. Rabkin
Pre-op, 410 pounds, 5'13" tall
-100 in 5 months!!!
Top
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Gastric Reduction Duodenal Switch (GRDS) (LGRDS-DS)
This surgical procedure was originated
by Douglas Hess, M.D. of Bowling Green, Ohio. In the
restrictive component of the LGRDS, 65% of the stomach is resected (removed). The size of the
stomach after
resection has the volume for approximately 4-6 oz.
The
small bowel (intestine) and duodenum (first segment of
small intestine) is divided and new
connections are made.
This procedure bypasses approximately 60-65 % of the small
bowel. The part of the intestine where the digestion and
absorption of fat and proteins is taking place after
surgery is
called the common channel.
A calculation
regarding the length of the common channel is very
important in this procedure. It
determines how much malabsorption should be created. The length of the small
intestine varies
for each individual. There are other
factors that are also taken into consideration within this
calculation. These factors include patient's age, weight,
BMI and goals. Each patient has a
different length of
common channel and alimentary loop designed in order to
achieve the best
results.
Routinely the gallbladder
and appendix are removed. There is a 80 % chance of
gallstones
forming following weight loss. The gallbladder
is removed to eliminate this possibility. The
appendix is
removed to avoid future confusion of questionable
abdominal symptoms of
appendicitis or necessity for an
appendectomy in the first months following surgery.
This type of
surgery (LGRDS) is the most successful
Bariatric procedure at this time. It is designed to be themost physiological and have the best long term results.
PLEASE NOTE
• no part of the bowel (intestine) is
removed in surgery.
• although the stomach is restricted, it will stretch in
time. approximately 12 months following
surgery patients
are able to eat 60 % the amount of food eaten prior to
surgery.
• the length of the surgical procedure is 2.5 to 5 hours.
• average hospital length of stay is 3 days.
• weight loss will level out in approximately 12 to 24
months.
RESULTS
Patients are losing 85 % to 95 % of the
excess body weight within one to two years following
surgery. A patient's weight and BMI prior to surgery does
have an effect on the weight loss as
well as the
compliance of a patient to follow post operative
instructions.
Studies have shown that the long term
success in this surgical procedure for morbid obesity is
approximately 85% of the excess body weight loss. This
weight loss has proven to be the most
successful for the
treatment and alleviation of hypertension, Type II
diabetes, sleep apnea, hypercholesterolemia, pain
associated with arthritic changes in joints, asthma and
urinary stress
incontinence as well as improving
psycho-social activities.
POSSIBLE SURGICAL COMPLICATIONS
INTRA-OPERATIVE
• bleeding
• blood transfusion
• injury to liver, spleen, esophagus, large bowel
IMMEDIATE POST-OPERATIVE COMPLICATIONS
• perforation involving small bowel, duodenum, stomach
• bleeding
• obstruction
• pancreatitis
• evisceration
• pulmonary emboli
• deep vein thrombosis
• abscess
• pneumonia
• perioperative mortality rate (approximatey 0.5%)
SUBSEQUENT POST-OPERATIVE LONG TERM COMPLICATIONS
• hernia
• excessive weight loss
• osteopenia / osteoporosis
• anemia
• obstruction
SYMPTOMS TO
RECOGNIZE
Side effects following this surgery are
very rare, however, patients sometimes do experience
various symptoms. The most typical symptoms are distorted
taste and smell, dry mouth,
diminished appetite,
occasional nausea, dizziness and hot flashes. Most
patients discover these
symptoms are gone within 2 - 4
weeks after surgery.
The symptoms patients need to be
aware of that are of most concern are frequent nausea with
vomiting, diarrhea, temperature above 100 degrees,
drainage from incision, unexpected
abdominal pain,
shortness of breath, chest pain or swelling of the legs.
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Roux-en-Y / Gastric By-Pass
(Open or Laparoscopic)
Roux en Y (RNY) or gastric bypass is a restrictive
procedure that staples off an approximate 5-35cc stomach
pouch at the upper portion of the stomach. A section of
small bowel is then attached to the pouch via a small
opening.
Narrowing and or blockages can take place at this small
opening. Ulceration can also happen at the area where the
small bowel and the stomach tissue are attached.
Due to the small pouch size vomiting can take place if
food is not properly chewed or food is eaten too fast or
in too large a volume.
Dumping syndrome also takes place when consuming high
sugar food.
When the opening in between the pouch and
the small bowel is stretched patient begins to regain weight.
This generally occurs approximately 2 years after surgery
