Question:
Should people pursuing DS surgery be concerned with their stomachs stretching?

Ive read a lot about RNY postops concerns over whether their stomachs would stretch over time and allow them to eat too much. Im really confused now because this hasnt been discussed as a problem for DS patients. Since with the DS surgery your stomach starts out as 1/4 its original size (as opposed to much smaller with RNY) wouldnt that eventually stretch to twice that or more given time? Wouldnt it make sense just to leave the stomach alone and focus exclusively on the intestine? — [Anonymous] (posted on April 9, 2000)

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April 9, 2000
The BPD/DS is a combination malabsorbtive and restrictive procedure, much like the distal RNY. Increase in stomach size is a built-in feature of both surgeries. In the beginning, the main reason you lose weight is because you can't eat much, in addition to the malabsorbtion. Over time, the amount you can eat increases, which slows your weight loss. If you didn't have the restriction, you wouldn't lose as much or as fast, and if the stomach didn't stretch, you wouldn't stop losing. The greater malabsorbtion in the DS is balanced by the larger stomach. The lesser malabsorbtion in the distal RNY is balanced by the smaller stomach. You basically get to choose between eating more and absorbing less, or eating less and absorbing more. In the end, they both work out about the same, but the BPD/DS seems to have a higher statistical success rate than the other surgeries. Hope this clarifies things for you.
— Kim H.

April 10, 2000
Would you please clarify the statement "BPDS seems to have a higher statistical success rate than the RNY" i.e. - source of info - who did the study? Where was this published? # of study participants - etc.
— Toni B.

April 10, 2000
Toni, I'd be happy to clarify that statement. In a study entitled "Multidisciplinary Management of Obesity", written by Mark Bessler, MD (who is an RNY surgeon), it states: "The weight loss associated with BPD or DS BPD is likely greater than either VBG or even GB, although no prospective randomized trial has been published." Dr. Bessler, with whom I've exchanged e-mail, made this statement based on analysis of statistics provided by both RNY and DS surgeons, since no direct comparitive study has been published (although two surgeons who perform both the RNY and DS are preparing reports for publication, and from what I understand, their findings support his statement). The full text of the article has been posted here on AMOS, along with the URL for the source information - which includes the hard data for the studies referenced. Happy reading!
— Kim H.

April 10, 2000
Kim: I agree Dr. Bessler Report is very enlightning and the full text warrants posting to those with slow browsers. Multidisciplinary Management of Obesity by Mark Bessler, MD Introduction Obesity is now an epidemic in the United States. According to the Third National Health and Nutrition Examination Survey, an estimated 97 million adults in the US are either overweight or obese, and the prevalence of obesity has increased markedly during the last decade. The combination of historic selection for genetic traits that promote storage of fat, an environment that has high-carbohydrate, good-tasting food readily and constantly available, as well as an increasingly sedentary lifestyle for many may in part explain this epidemic. Although it is estimated that 40% to 70% of the variation in body mass and body fat is heritable, environmental factors also determine body weight. More likely, obesity is influenced by the interaction of genetic and environmental factors. The National Institutes of Health defines overweight as a body mass index (BMI) of 25.0 to 29.9 kg/m2 and obesity as a BMI of 30 kg/m2 or higher. By this definition approximately 22% of adults in the United States are obese. Obesity is second only to smoking as a cause of preventable death in the United States. Analysis of data from five prospective cohort studies and one published study in conjunction with 1991 national statistics on BMI distributions and overall deaths estimated that the number of annual deaths attributed to obesity in US adults is approximately 280,000. Overweight and obese individuals are at higher risk for developing type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke, dyslipidemia, osteoarthritis, and some cancers. A review of the literature confirms that weight loss may mitigate or prevent obesity-related disease. The majority of this symposium addressed various treatment modalities used to care for obese and especially morbidly obese subjects. Basic Principles and Medical Management of Obesity Samuel Klein, MD, presented the basic principles of obesity management. Obesity is a chronic disease that requires long-term treatment. Behavioral principles that aid patients' success in long-term life change include small attainable goals, frequent follow-up, and a focus on the positive. Dietary changes should include a decrease in fat as a percentage of total calories, a decrease in total calorie intake, and an increase in fruits and vegetables. Since dietary changes should be long-term, they must be safe and palatable so they can be more easily maintained. Specific low-calorie diets and even prepared liquid very low-calorie diets are often used to obtain an initial boost in weight loss but are not proven beneficial in the long term if not associated with lifestyle and dietary changes. Increased exercise is critical to overall health as well as weight loss and maintenance. A decrease in metabolic rate has been associated with weight loss and is likely a homeostatic mechanism that exercise helps to counteract. Thirty-five minutes of vigorous activity or 80 minutes of moderate activity was associated with weight maintenance in a long-term study. Medication has a role for some obese patients, but studies have shown moderate benefits at best and the drugs that must be taken for the expected duration of weight loss are sometimes poorly tolerated by patients. Phenylpropanolamine (in Dexatrim) can have adverse effects if overused. Sibutramine (Meridia) has a CNS effect on norepinephrine and has been shown to produce a 10% loss in body weight in 40% of patients vs an 8% body weight loss in a placebo group. Two thirds of patients achieved 5% initial weight loss in the treatment group. Adverse effects including tachycardia and hypertension are not usually problematic. Orlistat (Xenical) prevents absorption of 30% of dietary fat by blocking lipase in the gut. Forty percent of patients lose 10% of initial body weight in most studies, but in diabetics only 20% of patients achieved this degree of weight loss. Diarrhea and flatulence are frequent adverse effects but decrease within 3 to 6 months, similar to the rate of these adverse effects in control groups. A weight-management program combined with medication is more effective than medication alone in most studies and consists of nutritional education, exercise, and behavior modification. Surgical Treatment of Obesity Three types of surgical treatments are available that have a proven track record of weight loss and safety. These include gastric restrictive procedures, malabsorptive procedures, and combination procedures. In general, purely restrictive procedures such as vertical banded gastroplasty (VBG) have the lowest complication rates but also are associated with lower weight loss and higher failure rates than the others. Malabsorptive procedures such as biliopancreatic diversion (BPD) with or without duodenal switch produce the highest weight loss and success rates but are associated with the highest rates of metabolic complications as well as chronic diarrhea and flatulence in some groups of patients. Gastric bypass (GB), which combines a significant gastric restrictive component with a mild malabsorptive component, has shown good weight loss with a very low rate of metabolic complications. The following presentations are devoted to a discussion of these procedures. Morbidity of Obesity and Resolution With Surgery Surgery for the treatment of obesity has been limited for the most part to patients suffering from morbid obesity (MO). MO is defined as a BMI of 40 or greater and also includes patients with a BMI of 35 to 40 if associated comorbid conditions are present that would increase the surgical benefit to the patient. For a 5'4" woman, MO begins at just under 240 pounds. The comorbidities of obesity are protean and the most significant and common include diabetes, hypertension (HTN), gastroesophageal reflux disease, sleep apnea, and osteoarthritis. The etiology of the comorbid conditions associated with obesity is unclear. Harvey Sugerman, MD, presented data that suggest a chronic abdominal compartment syndrome exists in patients suffering from morbid obesity and that this is in part responsible for many of the comorbid conditions. The weight loss associated with GB surgery alleviates many of the comorbidities by reducing the elevated intra-abdominal pressure in these patients. Pickwickian syndrome, or obesity hypoventilation syndrome (OHS), is characterized by hypoxia and hypercarbia during the day and is usually a late manifestation of severe obesity. Sleep apnea syndrome (SAS) is clinically suspected in obese patients who snore loudly, are tired during the day and fall asleep frequently, or who awake tired even after adequate length of sleep. A sleep study can confirm SAS, which should be treated with continuous positive airway pressure or biphasic positive airway pressure via nasal mask to decrease hypoxia at night. Sleep apnea is one of the contributing factors to OHS. The resolution of obesity-related problems is common after the weight loss associated with surgery. Most patients have resolution or significant improvement of respiratory difficulties after the weight loss associated with GB. Eighty-five percent of noninsulin-dependent diabetes resolves and most of the remaining patients have better control with less medication. Improvement in hyperlipidemia and HTN is frequently seen; this is likely the mechanism by which coronary artery disease is reduced with weight loss. A prospective randomized study of VBG and GB reported by Dr. Sugerman showed a better weight loss after GB and especially poor results for VBG patients who ate sweets. Gastroplasty and Gastric Bypass GB and VBG are currently the two most common operations in the United States for the treatment of MO. GB is performed more commonly. In 1967, loop gastrojejunostomy to a transected stomach pouch was proposed by Mason, and with the implementation of staplers in the late 1970s, this operation began to gain acceptance. Gastroplasties initially were not successful until reinforcement of the outlet of a vertical pouch was used in the early 1980s. Four randomized studies comparing VBG and GB have shown improved weight loss in the short and intermediate follow-up periods after GB. Henry Buchwald, MD, presented retrospective data from his own institution comparing VBG and GB, which showed increased weight loss for GB at all times, but this was only statistically significant for women at 1 year and the entire group at 2 years. Thereafter, no significant differences between the two treatments were found. Dr. Sugerman questioned the poor follow-up in this group of patients. In choosing a surgical procedure to control MO, the following factors are important to consider. Death and major complication rates following surgery are approximately equal for both procedures. Operative mortality is less than 0.5%, morbidity is approximately 5%, incisional hernia rate is approximately 5%, and small bowel obstruction occurs in 2% of cases. Dumping, iron deficiency, B12 deficiency, and the inability to access the distal stomach are all problems with GB. On the other hand, while VBG does not have these problems, it takes a long time to adjust to, the stoma cannot be dilated, and occasionally food impaction becomes a problem. In addition, the percentage of patients who consider the operation a failure is likely higher after VBG than after GB. Malabsorptive Procedures While many surgeons are reluctant to change normal physiology in a procedure for weight loss, malabsorptive procedures avoid severe food restriction, which can decrease quality of life. Picard Marceau, MD, presented the variety of procedures available in this category. BPD is a principle that reduces the mixing of bile and pancreatic secretions with food by diverting these secretions into the distal bowel. The distal gastrectomy of BPD is necessary to reduce the acid production that leads to marginal ulcer. Classic BPD often results in diarrhea, flatulence, and a significant incidence of protein malnutrition. Duodenal switch (DS) BPD uses a sleeve gastrectomy and keeps a portion of the duodenal bulb with the stomach. A 250-cm alimentary limb with bile return at 100 cm proximal to the ileocecal valve leads to significant weight loss; diarrhea occurs in 8% and flatulence is more common. There was not a significant discussion regarding the incidence of protein malnutrition. Benefits of the operation include normalization of cholesterol, triglycerides, and insulin metabolism. The weight loss associated with BPD or DS BPD is likely greater than either VBG or even GB, although no prospective randomized trial has been published. Protein malnutrition is a significant problem and may be more in evidence after classic BPD than after DS BPD, relating in part to the ability to eat protein without restriction as well as having the stomach portion of protein digestion preserved. In part because of this serious problem as well as the chronic diarrhea and flatulence associated with significant protein malabsorption, the National Institutes of Health consensus conference did not recommend BPD and suggested that most medical centers in the United States not offer it as a primary treatment option. Complications of Bariatric Procedures Robert Brolin, MD, presented the variety of possible complications in surgery for severe obesity. The rates of occurrence of some of these complications are listed in Table 1. Other complications include tachycardia (a heart rate of 120 beats per minute or higher is often the cardinal sign), tachypnea (which may indicate the need to rule out pulmonary embolus), fever, and abdominal tenderness. Possible wound complications include fascial dehiscence, skin dehiscence, infection, hernia, and seroma. Seromas should be drained early and kept draining but do not require opening the wound. Bleeding from ulcers or gastritis in distal stomach can be difficult to diagnose. Direct puncture of the distal stomach may allow study. Pneumonia is unusual and atelectasis, while frequent, is usually easily treated. Emesis is common, but severe or intractable vomiting is rare. Often, emesis is related to adjustment to a restrictive component and a patient eating too much or too fast. Stomal stenosis after gastric bypass almost always responds to balloon dilation but after VBG reoperation is frequently necessary. Early dumping is usually not a problem because it is associated with specific foods. Late dumping is more problematic but can be treated with increased protein and planned carbohydrate snack 1 to 1.5 hours after meals. Incidence of iron, B12, or folate deficiencies increases with time and therefore iron and B12 supplements should be given. Folate can be replaced with multivitamins. Vigilant follow-up is required indefinitely to prevent complications from nutritional deficiency. Preoperative and Postoperative Psychopathology The psychopathology of preoperative and postoperative patients was presented by Patrick O'Neil, PhD.[16] Mild to moderate obesity is not associated with increased psychopathology. Morbid obesity in patients seeking treatment is associated with higher lifetime prevalence of Axis I disorders such as anxiety and depression than in the general population (48%-57% vs 26%-35%).[16] The morbidly obese may have a higher incidence of a history of sexual abuse and symptoms of posttraumatic stress disorder. Impaired self-esteem is common in this population. Eating disturbances are also common, especially binge eating, which is present in 21% of MO patients. Bulimia and night eating syndrome are two other eating disorders frequently seen. Significant discrimination against people with MO is a barrier to employment, college admission, and even medical care. Postoperative patients report significant declines in the amount of discrimination they experienced. Other psychosocial benefits of surgery include improvement in body image, less binge eating, greater sense of control over eating, decreased feelings of depression, and improved self-esteem and sense of adequacy. Improved quality of life was dramatically documented by a study in which many formerly obese patients stated that they would rather be deaf, blind, or lose a limb than return to being morbidly obese. Occasionally, however, postoperative patients may experience worsening of relationships or difficulty dealing with other psychological stresses. There are no known psychological predictors of good or poor weight loss outcome and therefore treatment of an identified problem is the most frequent action after a psychological evaluation in morbidly obese patients seeking surgical treatment. Laparoscopic Gastric Bypass and Laparoscopic Banding Laparoscopic gastric bypass and laparoscopic banding are bariatric -- not just laparoscopic -- procedures; however, they do require advanced laparoscopic skills and should not be taken on without adequate training or preparation. Because these operations do not cure obesity, patients require long-term follow-up to monitor for possible metabolic complications, according to Alan Wittgrove, MD. Hiatal hernias, superobesity, and revisional surgery are all relative contraindications for laparoscopic gastric bypass and laparoscopic banding, but many of these may relate to experience and equipment issues, which will change with time. Laparoscopic banding with the Lap Band is currently investigational in the United States. Weight loss is in the range of 50% of excess weight, although early results of the US trial have not entered this range. VBG is rarely performed laparoscopically, but a few small series have been reported. Approximately 2000 laparoscopic GBs have been performed in the United States with positive weight loss results. Some other benefits are likely to be shown, especially in wound complications and recovery time. Leak rates and stricture of the gastrojejunostomy may be more common after the laparoscopic procedure. The details of the operation should not be changed just to accomplish this operation with limited access. Dr. Wittgrove's technique is very similar to the standard open technique and results bear this out. A summary of results shows: 75% excess weight loss with laparoscopic gastric bypass, 1 incisional hernia in 500 cases or 0.2% (not all patients were examined in follow-up), and wound complications reported as less problematic (numbers not presented); anastomotic leaks and stomal stenosis rates were not discussed. All patients should agree to laparotomy if needed, and since there is a steep learning curve, mentoring should be considered unless advanced laparoscopic skills are available and training has been adequate. Plastic Surgery for Body Contouring After Weight-Loss Surgery It is currently the standard to defer body contouring procedures such as abdominoplasty in morbidly obese patients until after they have stabilized their weight following weight-loss surgery. Austin Merhof, MD, presented results of a personal series of 185 consecutive patients with body contouring after weight-loss surgery. Age range was 23 to 70 years with a mean of 47 years, average preoperative weight was 329 lb, with an average postoperative weight loss of 141 lb. The interval between weight-loss surgery and body-contouring surgery was 2 years. A mean of 2.5 procedures per patient included abdominoplasty, hernia repair, and breast, arm, and thigh reduction. Only 9 patients required transfusion, but 43% of patients had complications, including seroma, tissue necrosis, and infection. Previous incisions, especially a subcostal incision, increase the incidence of flap necrosis after abdominoplasty. The mons and suprapubic areas are especially problematic and require lowering the inferior incision. A 2% recurrence after hernia repair sometimes requires resection of the umbilicus; mesh was frequently used for large defects. Arm reduction has a low complication rate but medial excision is not as satisfactory as posterior excision. Breast reduction is associated with a low complication rate but specific issues with loss of tissue during weight loss can result in difficulty obtaining good contour. Axillary excess is dealt with as secondary procedure. Thigh reduction is associated with the highest rate of complications, including lymphedema, seroma, and lymphocele. Life-threatening complications are possible and, though infrequent, must be taken into consideration. The Role of Liposuction in the Treatment of Obesity Initially liposuction was not used to treat obesity, but recently many physicians have performed large-volume liposuction. It is not yet clear if the weight removed is ultimately regained in many or most patients. Deaths have been reported and George Commons, MD,[19] described five guidelines for safe surgery that have been developed: (1) a well-trained surgeon, (2) a well-trained anesthesia team, (3) adequate facility, (4) proper patient selection, and (5) proper medical management of the patient. Large volume indicates aspirate of 5 liters or more; the largest volume removed was 46 lb in three procedures. The aspirate consists of fat and fluid, which is injected to provide vasoconstriction. Complications include excess skin, skin loss, seroma, and infection. Whether this weight loss will be definitive or an encouragement or initial boost to begin a weight-loss program is still in question. Certainly this procedure can be complementary to other weight-loss procedures. Only a small number of patients with more than 100 lb excess weight were presented in Dr. Commons's. Patients are encouraged to lose weight in addition to what is removed and not to count removed weight as weight loss. Patients who gain weight usually have it dispersed, but it can be in a limited region, including the original liposuction site. The technique of "superwet" (infiltration of fluid in a 1:1 ratio with tissue to be resected) is used in large-volume resection. Keys to a successful procedure include keeping fluid warm to maintain normal body temperature and avoiding overwetting, which can lead to death, or underwetting which can lead to excessive bleeding. Epinephrine and often lidocaine are used in the wetting solution. Pressure garment should be worn for 2 days continuously and for 2 weeks as often as possible. The anesthesiologist does not administer much fluid to avoid overhydration. Residual fluid should be between 90 to 120 mL/kg. A temporary decrease in renal function is often seen and is possibly due to the epinephrine. The use of this procedure in morbidly obese patients has not been well evaluated and, if applicable, will likely be an adjunct to other weight-loss procedures. Weight regained after these procedures, especially in the morbidly obese, is not well studied but probable. The upper volume limit that can be removed remains to be defined; the current limit is 25 lb and only after extensive experience with lesser resection. Truncal Circumcision A modification of abdominoplasty, the technique of truncal circumcision was developed to deal with additional areas of skin excess not addressed by the classic abdominoplasty, and was discussed by Charles Horton, MD.[20] The back, thighs, and buttocks, which are frequently problematic after significant weight loss, are addressed by circumferential extension of the abdominoplasty tissue excision. Increased blood loss and the need to turn the patient to the prone position during the procedure are potential disadvantages to truncal circumcision. However, the benefits can be marked for the patient since difficult-to-address skin excess in the thighs and flanks is managed in a single procedure. Meticulous surgical technique, strong suture material in layers, and an excision of a portion of the mons is recommended for optimal results. Complications were described as limited. While this is a technique that clearly requires more work and effort than standard abdominoplasty, it appears that the advantages may render this procedure worthwhile. It is clear from the above discussion and summary of talks that morbid obesity is a chronic disease that is not easily treated medically. A multidisciplinary approach to treatment with lifelong follow-up and monitoring is necessary for successful surgical treatment, which is best performed by a dedicated and expert team. Plastic surgery procedures can improve the functional and cosmetic outcome of gastrointestinal weight loss procedures and should be available for appropriate candidates. 
— Victoria B.

April 10, 2000
So, 1) to clarify, there was a misquote here - Bessler did NOT say that the "BPDS seemed to be statistically superior to the RNY" but in fact was actually comparing the BPDS to the VGB. I think its important that we present accurate info, as people depend on this site. 2) Anyone know anything about the eating disorder Bessler speaks of - "Night Eating Syndrome" or where I can find more info?
— Toni B.

April 10, 2000
Toni, please allow me to clarify: 1) I never stated that the BPD was statistically superior to the RNY, but rather said "In the end, they both work out about the same, but the BPD/DS seems to have a higher statistical success rate than the other surgeries." 2) Bessler refers, in his statement, to both the VBG and the GB (gastric bypass), which is the term he uses to describe a proximal RNY. So yes, he does state that the BPD and BPD/DS have a higher rate of weight loss than either the VBG or the proximal RNY. Thanks for giving me the opportunity to clear that up!
— Kim H.

April 10, 2000
To further clarify, Dr. Bessler wrote this paper as a summary of information presented at a 1999 bariatric surgery conference. The offer stands for the URL which includes his reference papers, most of which have been published in peer-reviewed journals prior to their presentation at the conference. If anyone is interested in actually reviewing the source information, I would be happy to provide the list of documents used to write this paper.
— Kim H.

April 10, 2000
If anyone is interested in reviewing Dr. Bessler's source material, please e-mail me. It's an extremely long list, and I don't want to take up room here with something that may not be of interest to more than one or two individuals.
— Kim H.

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