by Wesley Clark, MD
co 2003 - reprinted by permission. Please contact author for reprint permission
(it is permissable to link to this site)
Dear SueW,
You raise the issue of the value of the DS/BPD vs the RNY. We have had
considerable experience with both procedures, beginning in 1986, when we began
doing the BPD. By about 1992, we had one of the largest series in the United
States, and were strong proponents of the operation. We then began to offer the
RNY also, after associating with Dr. Richard Catlin, who was one of the pioneer
proponents of the small-pouch RNY (15cc volume, vs 60cc with the older style).
For a while, we offered both procedures, according to the preference of the
patient, but within about 2 years, without any conscious decision to favor one
procedure over the other, we found we were doing almost exclusively the RNY.
The reason was simple: our RNY patients got equally good weight loss, with much
less side-effects, and risk, than the patients who had a BPD. When observed
side-by-side, RNY patients had better skin color and looked healthier. BPD
patients tended to look pale and sallow, often appeared weaker, and sometimes
even tended to smell bad. Until recently, two of our BPD patients worked in our
office, and both observed the results of the two operations, from the standpoint
of someone who owns one. Both stated emphatically, that they would prefer to
have had an RNY. And both were very careful to do everything we told them, to
get the best results. Patients who did not follow instructions, and did not
return for regular checkups, sometimes became very ill.
WHY?
The DS/BPD causes weight loss primarily by impairing the absorption of certain
foods, namely fats and starches, as well as some vitamins and minerals. They are
called "malabsorptive procedures", because interference with normal absorption
of food is the way they operate. Although there is some decrease in the capacity
to eat, caused by reduction in the size of the stomach, the re-arrangement of
the bowel, with a short segment of "common channel", in which absorption is
fully empowered, causes most of the fat consumed to be wasted, and about 75 -
80% of starch as well. Patients can eat fairly normal meals, and absorb only a
small fraction of the total calories that pass thru their mouths. Most persons
who are hearty eaters are captivated by the concept that they can continue to
eat large amounts, without suffering the adverse health consequences.
Althought this seems superficially to be a great solution, it is an illusion.
The physiology of digestion and absorption of the many nutrients we need is a
very complex process, of which we really understand very little. Surgical
tinkering with this complex process is a bit like letting a 5 year-old pull
parts out of the back of one's color TV. The downside and risks are
considerable:
The Duodenal Switch (DS) attempts to solve some of these problems, although
the success of this modification has not yet been clearly demonstrated. Neither
the BPD nor the DS are easy to reverse, but in most instances a reversal is well
within the capability of the experienced surgeon. However, reversal should
seldom be necessary, so I don't see this as a major liability. Revision is more
often needed, and if serious malnutrition has occurred, the risk of that surgery
may be much increased by the underlying poor health.
The RNY works by limiting the volume of food which one can eat, and
simultaneously producing a sense of satisfaction after eating just a small
amount. Almost all of the food which is eaten is absorbed, and nutritional
deficiencies are quite rare, provided that a simple food regimen is followed.
Even though the amount of food that can be eaten is very small, the early sense
of satisfaction (which I call the "Who Cares?" feeling) means that there is no
sense of loss or deprivation, such as occurs with dieting and eating small
portions.
It is necessary, as with the DS/BPD, to take a broad-spectrum vitamin and
mineral supplement every day, and there are some basic rules to follow, for best
results, the most important of which is to avoid eating between meals, which can
slow down weight loss, or lead to weight regain (the surgeon changes your
stomach -- you have to change your mind). Although there can be some bumps in
the road, during the first few months of the recovery process, RNY patients very
rarely suffer any metabolic problems over the long term, and can live a normal
life in a normal-sized body, without abnormal gas, irritable stools or diarrhea,
and with a very healthy and happy lifestyle. Compared to the DS/BPD, their
existence seems so much more happy and normal, that I am thrilled to do the RNY,
and reluctant to even consider a BPD any more.
After all, every surgeon wants the satisfaction of a successful operation and a
happy patient.
I hasten to add that some very eminent and experienced surgeons have a different
view than I do. I had the privilege of debating this very issue at the annual
June meeting of the American Society for Bariatric Surgery. Although about 75%
of my colleagues agreed with my position and arguments, many very significant
figures in Bariatric Surgery did not. I respect them and their views. We agree
to politely disagree, and I'm sure we will continue to debate and argue for many
years to come.
G. Wesley Clark, MD
http://www.gastricbypass.com/
| Confused about Weight loss surgery? |