Gas, diahrrea (sp), and foul smelling stooles, is it as bad as it sounds?

I've read the info on duodenal switch and i would like to know from those of you that have had this type done is it as bad as it seems it could be? I mean do you pass gas a lot? Does the diahrrea(sp) come often and severe? Are you in the bathroom all the time? And what other complications has anyone had with this type of surgery?

Oy -- more of the same misinformation gets promulgated all the time. Let me guess -- did you hear this from your RNY surgeon's office? Your PCP's? Here is a repost of something I post from time to time on the main message board, and in fact what I reposted just this evening -- my comments on my bathroom habits are most of the way down: DS FACTS: It is a sad truth that there is a lot of misinformation being circulated about the duodenal switch (DS) procedure. Even more sadly, much of it comes from RNY surgeons and their patients, who have various degrees of vested interest in promoting their surgery (or in certain cases, dissing WLS altogether). I would hope that each and every potential WLS patient who is researching what to do about treating his or her morbid obesity has access to the FACTS before making the decision about which surgery to have. For a number of years, insurance approval has been the vehicle by which access to the DS procedure has been limited -- most of the largest insurers, including Blue Cross, Blue Shield, Aetna and Cigna, have cited misleading information and each others' policies to claim that the DS is "experimenal," "investigational" or "unsafe and inadequately studied." However, the papers cited by these insurance companies to support this allegation are often not even related to the correct procedure. When the DS was introduced, it was an improvement over the Biliopancreatic Diversion procedure, or BPD -- unfortunately, this led to the procedure being called the BPD/DS, which is a misnomer. While the intestinal part of the BPD is essentially the same as the DS, the stomach part is VERY different. The problems with the BPD are much more like a distal RNY than the currently practiced DS, as the BPD involves removing much of the lower part of the stoma*****luding the parts that absorb vitamin B12 and iron, and the pyloric valve, and BPD issues include potentially serious malnutrition issues. What insurance companies often do is to cite papers discussing the very real problems with the BPD (which is rarely performed anymore) against the DS, which is quite inappropriate. In addition, they completely ignore the growing body of scientific evidence that is approaching 20 years of study on the DS and the wonderful results that have been established. Over the past several years, and due in no small part to the steady pressure exerted by patients demanding the DS procedure, there have been numerous inroads made into educating both the insurance companies and the external reviewers who end up ruling on the appeals of die-hard DS wannabees. The tide appears to finally be turning, as one after another insurance company is beginning to acknowledge the beneficial effects and safety of the DS. Blue Cross of California has recently changed their official policy to permit the DS, and it seems from recent legal challenges that Blue Shield will not be far behind. The national Blue Cross/Blue Shield Technology Evaluation Center assessment of the DS is currently being reviewed as well, and there is a good possibility that they will reclassify the status of the DS. The most recent CPT Code book for 2005 has given the DS a new, Category I, code number, indicating that it is now a generally recognized procedure and not still being evaluated for safety and efficacy. In addition to the many published articles that have come out recently praising the DS procedure (available on request), there is now an almost astonishing new source of analysis and validation of the procedure -- the external reviewers of the Center for Health Dispute Resolution of Maximus. This organization has been contracted to perform external reviews for 25 states, Federal government employees and Medicare/Medicaid appeals. They now appear to be taking the position that essentially ANY patient (including those with a BMI under 50) should qualify for the DS, and that insurers are improperly refusing to acknowledge this. One of the most available sources of information about this sea change is the published decisions of the California Department of Managed Health Care, which is the agency to whom California HMO participants appeal denials of coverage. Needless to say, organizations such as CHDR are inclined to be very conservative, since they are hired by politically influenced state agencies -- as you can imagine, it is likely that the insurance companies will have SOME input to how such state reviews are conducted. In addition, these organizations are also performing PRIVATE external medical reviews for insurance companies which are able to chose who will perform the external reviews of their own decisions. So it is in my opinion a significant fact that CHDR is now supporting the DS and overturning almost every denial that comes their way, at least in California (which is the only source of published opinions I have found -- I will be happy to provide the link to it on request, because putting it here will make this posting difficult to read, since it will stretch out the entire posting and all posts in response sideways to accommodate the entire link). Here are some quoted comments on the DS in these published decisions by CHDR, which has NO vested interest whatsoever in seeing this procedure being more commonly performed, other than their own intellectual honesty: * Techniques in duodenal switch have been available since the 1980s. There is now sufficient data to show that duodenal switch has a superior long-term outcome when compared to gastric bypass. * In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. * Long-term studies of the duodenal switch procedure demonstrate equal effectiveness with less need for a highly restrictive diet than with gastric bypass. * There is a significant risk of marginal ulceration with the standard gastric bypass that does not appear to be present in the duodenal switch procedure. * The data strongly supports the high failure rate of Roux-en-y gastric bypass in patients who are super morbidly obese. * Review of the medical literature indicates revisional weight loss surgeries have a high complication rate. A patient who has failed a restrictive operation (Lap-Band) is more likely to fail another restrictive operation longer-term unless a malabsorptive element is added. The study cited above reported high incidence of protein and nutritional deficiency after revision of gastric bypass to distal gastric bypass. Furthermore, a patient with a BMI of 48 may have a high failure rate after a restrictive procedure. A more suitable option may be a hybrid procedure such as duodenal switch. * The duodenal switch procedure has a track record greater than 15 years. The anticipated complications associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch. * At the 2003 American Society of Bariatric Surgeons meeting held in Boston, Massachusetts, scientific papers were presented, which indicated there is growing evidence that protein malnutrition is a much larger problem post gastric bypass than was initially suspected. * Techniques in duodenal switch have been available since the 1980s. With duodenal switch, patients lose weight in the range of 69% to 80%. * Complications have been reported to be comparable to other operations. Multiple vitamin deficiencies, mineral deficiencies, bacterial overgrowth issues seem all to be comparable and less than other alternative surgeries. Hundreds of duodenal switch operations have been performed on patients in California and they appear to have a good track record of positive results. * The duodenal switch procedure is designed to avoid dumping syndrome and prevent peptic ulcers. * The duodenal switch combines the restrictive gastric pouch with the malabsorptive components of biliopancreatic diversion. * It has been reported that the retention of the pylorus results in fewer problems with bowel movements, including dumping syndrome, marginal ulcers, anemia and other complications. * The pouch results in excess weight loss of 70-80% with good to excellent success rate of 93% and no difference between patients with BMI scores above or below 50. * Duodenal switch is an accepted method of weight loss surgery and is appropriate for treatment of this patient's obesity. * There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. * The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. In addition to this clarifying information about the safety and efficacy, I also want to make people understand that the "socially unacceptable" side effects of the DS surgery are often exaggerated in the extreme by those who don't have actual information from real patients to be making such statements. Again, sometimes this is confabulation of the problems associated with the BPD to apply to the DS, which is inappropriate. Sometimes, it is purely to steer patients from a surgery the surgeon doesn't perform (the DS) to one they do (the RNY or LapBand). Here is my experience, which I have substantially in common with most DSers: * I have a bowel movement every morning as soon as I wake up. Sometimes, I have another one after breakfast, IF I am still at home. Sometimes, I have another one shortly before bedtime. I NEVER have to go poop outside my house (except when I'm traveling, of course, and then only at the hotel). I do not have diarrhea, uncontrollable need to poop, or anything like that. In fact, my post-op issues with IBS have significantly improved, and my bathroom habits are BETTER than they were pre-op. It smells somewhat worse then it did pre-op, but not that much worse, and a quick spray of Ozium takes care of any lingering smell. * I fart, and it stinks, IF AND ONLY IF I have eaten some of the foods that disagree with me, such as white bread, most pasta, onions, beans and broccoli. This will happen 4-6 hours after eating such foods, so I can still eat them if I know I will not be around people (other than my family) when it kicks in. I can also take Gas-X and smell-reducing agents such as Beano, Devrom or Innermint with the meal to ameliorate the gas. It is entirely dealable with, and not really worse than it was pre-op with my IBS issues. The gas WAS more of a problem in the first 2-3 months after surgery, but it has gotten a LOT better since then, both because I have learned how to manage my diet and because my body has accommodated. Plus, I take a probiotic every day to help maintain my internal flora. * I take the following vitamins at 16 months out, and my one year labs were perfect: One prenatal vitamin, and 4 calcium citrate pills. That's it. No malnutrition or protein or vitamin deficiencies. I don't even need to supplement the fat soluble vitamins A, D, E or K. * I don't diet anymore. I eat what I want, starting with protein. I can eat about 2/3 of what I used to eat and I feel full -- comfortably -- when I'm done. * I don't barf, ever, even if I overeat (which I'm less inclined to do, though sometimes I eat reflexively while watching TV). At worst, I get a little uncomfortable, and I immediately stop. No nausea, ever, either. There's more, but you get the picture? The so-called "socially unacceptable problems" that you probably have heard about the DS are for the most part, scare tactics, a myth and I daresay a LIE. Other facts that should be understood (from a preprint of an ongoing study by Hess et al.): * The DS is a CURE for type II diabetes. In Europe, the intestinal part of the DS is being performed on people who are not obese to cure type II diabetes. There is data going out over 10 years now demonstrating the cure rate is 98%. * The average excess weight loss at ten years is 76%. * 94% of 10 year out patients are in the satisfactory category (50% or more excess weight loss). * There are no foreign materials used. * The pylorus is retained and controls the stomach emptying. * There is no small stoma that could dilate causing failure, allowing the patient to eat normal meals. * There is no dumping syndrome. * If the patient takes vitamins and minerals as instructed, as well as eats sufficient protein as instructed, which is easily accomplished eating normal food and without "protein shakes" or other supplementation, they will have little or no malnutrition issues. * The average lab results on a ten year cohort are all within the normal range. * Long-term studies have shown little or no serious or irremediable nutritional squellae, contrary to frequently expressed - but unsubstantiated - concerns. * It is certainly no longer considered an experimental or investigational procedure, either by the American Society for Bariatric Surgery (ASBS) or by the surgeons who perform it. It is still true that there are not that many surgeons offering the DS as compared with the RNY. It is a more difficult procedure to learn and to perform properly, as the tissue of the duodenum is harder to stitch. You ONLY want an experienced surgeon performing this procedure on you (but that's true for ANY surgery). Many insurance companies are still balking at covering it, but if pressed, they often will cave in, and more of them are now accepting it. But you must ask yourself, which surgery can I live with for the rest of my life -- which will give me the BEST quality of life, as well as ability to maintain my hard-earned weight loss without constant dieting? For me, there was only one answer, and that was the DS. Good luck to everyone in making the best and most informed choice you can.

Thank you so much for that information. That has helped a lot.

Yikes! No, it's nothing like what you have heard. Immediately post-op there is an adjustment period when your body is getting used to it's new plumbing. It was about 5 weeks for me and I did have diarrhea. As time passes you adjust. You learn what not to eat. At 16 mos post-op, I can now eat anything but cooked cabbage and FF SF gummy bears. Some people have a hard time with bread and refined sugar but we don't need those things anyway. You can treat diarrhea. Lot's of folks say a high fiber diet really helps. Post-op poop smells worse than pre-op poop. Some people carry air freshener or take pills like Devrom or Innermint. To me, poop is poop and none of it smells like roses! I don't have any more gas now than I did pre-op. Unless I eat the cabbage and gummy bears!

I am 7 weeks out, so my experience is very limited. I had very very runny stools for the first week or so, now they are almost "normal". If I eat something new, than it might change for a day. However, I have never had and accident or any real troubles. The gas is not any worse than preop and less "smelly" than some "normal" people. Maybe I am not typical???? Anyhow, I had heard those same things before I had surgery, and I was a bit hesitant at first. I decided that it was worth the risk for me since most people I had spoken to did NOT have the troubles I had feared. Robin G 10/26/04 down 40 pounds in 7 weeks

After two weeks post-op, normal stools ... I can actually get constipated and may not go but every other day. Like Robin, when I'm having something new or it has a higher concentration of fats, I spend a little more time in the bathroom. All "immediate urgency" to get to the potty stopped after week two as well. And gas ... unbelievably, spectacularly, I've farted maybe 3 times in 4 weeks! (Honest!!) I was prepared for gas, was prepared product-wise for gas, and NO GAS to speak of!!

Crystal, after the 2nd week, I have had diarrhea maybe 3 times and each of those was after dairy or high fat or high carb meals. I can tell you that pre-op I had a whole lot more diarrhea than I do now! Normally, I go once a day as soon as I get up in the morning, before work. Sometimes I will go again at night, but it's like a normal BM--not urgent you just know you need to go! I admit, my poop and gas smell very bad and that's why I use Devrom and Gas X. Gotta laugh, but my college age son says my gas smells like "red hot chili farts mixed with old cauliflower." But again, the gas is not uncontrollable--I just hold it until I'm out of the car or the meeting or until I can go for a walk or find a restroom. I haven't had accidental gas in public yet, so gas doesn't affect my social activities at all. Pre-op, I worried about DS bathroom issues. Post-op, they are non-issues. I wish now I'd saved my worries for the ones that really matter like "Where am I going to get money to replace all my clothes including underwear?!" I have had no complications at all so far. Good luck to you. -joanne s

My poop does smell worse than it did pre-op. As for gas---sometimes it stinks, sometimes it doesn't---and it's NEVER as stinky as that of a non-op friend of mine. (Talk about clearing a room FAST!) I've also noticed that I don't pass gas as often now as I did pre-op, and I haven't had ANY diarrhea post-op. While I was in the research stage, I found a website that said the 'average' person passes gas 14 times daily. Yesterday I farted ONCE.

5 weeks out here, and no bowel or smell problems since about weeks 2-3. I have a bowel movement maybe twice a day; it smells differently than it used to, but not really worse. Sometimes it smells very little. I rarely have gas, and in fact I think I had much more gas pre-op, although I was never particularly gassy. I was in the bathroom a lot the first two weeks, but that eased up and I actually spend less time in there now than pre-op. I almost NEVER have a bowel movement during the main part of the day. Only in the morning (1-2) and evening. Oh, one other thing, kind of disgusting maybe, but "clean up" after my bowel movements now is SO much easier, not nearly as paper-consuming. I love that! Shelley

Believe it or not, someone who had the RNY surgery sued and was awarded damages in a lawsuit because she would have to live with foul-smelling bowel movements, flatulence, etc after the RNY (see November 16 story from the Medical Post below). She sued because she had asked for VG not RNY. Now, just because a lawyer says it is so, doesn't mean it's true, but I find it astounding that people say this about DS when it apparently goes both ways. Good luck on your decision. Nancy Operation successful-but not what she signed up for After a patient receives the wrong weight-loss surgery, she sues for damages By Bill Rogers A bizarre twist of fate in a Vancouver operating room has led to an unusual court case. It began when Melody Cochran, a 29-year-old resident of Kitimat, B.C., went in for gastric weight-loss surgery. It was, in a sense, remarkably successful. She lost 125 lbs. She has kept the weight off. People say she looks great. The problem? It was the wrong operation. Cochran was awarded $145,000 in damages. Judge Wendy Baker, in a decision called Cochran v. Hunter, refused to reduce the monetary award just because the weight-loss outcome was spectacular. After all, the judge reasoned, although Cochran had indeed lost an enormous amount of weight and kept it off, the mistaken operation has exposed her to unpleasant side-effects that are worse, and more permanent, than would have been the case had she received the operation she thought she was going to get. She wanted a "Vertical Banded Gastroplasty" (VBG). Instead, surgeon Dr. James Hunter performed a "Roux en Y Gastric Bypass" (RNY). He admits the error. The judge found that Dr. Hunter simply forgot Cochran had chosen the less-popular VBG procedure and did not review her chart or consent form. And because she was already anesthetized, he did not speak to her before surgery. The VBG and the RNY are similar operations. They both rearrange the digestive tract, creating a smaller stomach that makes the patient feel full after ingesting only a small portion of food. The difference is that the VBG is reversible, whereas the RNY isn't. Furthermore, the RNY can lead to peculiar side-effects because--unlike the VBG--it not only makes the stomach smaller, it actually diverts the digestive route. This means food doesn't pass through the pyloric valve but rather goes straight to the small intestine. This can cause, for example, "dumping syndrome." As food passes quickly into the intestine, bypassing the pyloric valve, the body anticipates a large meal and produces an abundance of insulin. This results in blood-sugar drop, clammy feelings, trembling, light-headedness and finally, severe diarrhea. Other symptoms the judge attributed to the RNY include bloating, gas, flatulence, spasms and bowel movements that are "particularly malodorous." Moreover, said the judge, the RNY procedure prevents the body from absorbing certain nutrients in a normal fashion, and therefore the patient must take supplements of calcium, iron, zinc and vitamin B12, for life. This was particularly important for Cochran when she was pregnant and concerned about the possibility that her unborn child might not receive sufficient nutrients. "Ms. Cochran did not choose these side-effects," said the judge. "She is entitled to be compensated for them." What makes this case unusual is that the medical error may have led to a better outcome. The judge noted that the RNY is actually the preferred procedure among patients who have weight-loss surgery. It offers a somewhat better chance of success than a VBG. Some patients who have a VBG and don't lose weight go back in for the RNY. Having said that, the bottom line here is that Cochran didn't get the operation she asked for, and she's now stuck with worse and permanent side-effects she never planned on. Moreover, the judge said, she "may well have been equally successful" in losing weight with the VBG, the operation she actually wanted. Cochran was one of a new breed of patient: extremely well-informed, thanks to Internet research. She knew the pros and cons and wanted the less-aggressive VBG because, among other things, she was interested in simpler, more gradual weight loss, which she thought would be easier on her gallbladder and skin tone. For several days following the operation, Cochran was unaware of the mistake, as was Dr. Hunter. It was one of Cochran's Internet obesity message board pals who ended up being the one to tell her about the medical error. It happened that the two had the same anesthesiologist, who happened to tell the message board pal that Cochran had just had an RNY. This came as a surprise. When the news got back to Cochran, she was shocked, as was Dr. Hunter. He tried to make Cochran feel better by telling her she had nothing to worry about. She had had the better procedure. But she told him that it was not the procedure she asked for. She was upset. Dr. Hunter, said the judge, was "truly remorseful" about the error and "displayed sensitivity" toward Cochran. Therefore, no punitive damages were awarded. "There is nothing about Dr. Hunter's conduct in the making of the error or in the aftermath of it that warrants an award of punitive damages, and nothing in his conduct towards Ms. Cochran following the discovery of the error that could remotely be considered high-handed or outrageous." Dr. Hunter's lawyer, David Pilley of Harper Grey Easton in Vancouver, is "very pleased" with the result. "Often," he says, "when people are faced with their mistakes, they may not react in the best way possible. But here, the judge found that Dr. Hunter did." Cochran's lawyer, Shelley Henshaw of Sliman, Stander & Company in Chilliwack, B.C., is also pleased with the result, although she says she "wanted more for the loss of income-earning capacity." She had asked for $75,000 to $100,000 under that rubric, based on the argument that Cochran wanted to pursue a career in forensic science with the RCMP, but felt the job would be too difficult because of her need for proximity to a washroom. The judge rejected this claim as "too speculative," and awarded a mere $20,000 on the basis that "it is likely that there are some jobs for which Ms. Cochran is now unsuited, or which she would find difficult and embarrassing, due to the fact that she must monitor the type of food she can eat very carefully, and must be in reasonable proximity to a washroom immediately after she consumes food, especially in the morning." The decision will not be appealed, so what we're left with here is a good surgical outcome and a legal liability to go with it. Yes, the patient lost weight. But, as her lawyer points out, the operation she had, with its unpleasant, irreversible side-effects, was "not what she signed up for." Bill Rogers (LL.B.) is a law journalist who covers medical and pharmaceutical matters. Readers with legal news can contact him care of this publication or at [email protected]. © Copyright 2003 The Medical Post. All rights reserved.