“Obesity Week,” the annual meeting of the ASMBS, which was held the first week of November 2015, included the very first session dedicated to duodenal switch. The casual meeting of the DS surgeons followed this. What follows is a mix of what I have heard and my opinion.
The official DS surgeons’ meeting ended up mostly being about DS “look-alikes” - and even including distal gastric – bypass rather than about the conventional DS. Surprisingly, there was little discussion about science, physiology, pre- and post-op care, or technical issues about the DS; instead, it mostly had to do with insurance, politics, etc.
There was a second open DS meeting that was announced during a packed general ASMBS meeting, and about 40-50 people showed up. Some of the same surgeons who try to sell the SADI/SIPS/loopDS as the same as the conventional DS again started touting their single-anastomosis procedure to this larger and more general audience. There was overall consensus (not surprising, given that they had all attended the DS meeting) that it is important to preserve the function of the pyloric valve. What was interesting that this discussion included a handful of surgeons who had been critical of the duodenal switch for years, or even worse, offer all procedures but now suddenly portray themselves as the leader of the movement for the “duodenal switch”. But instead of the DS, these surgeons are touting the single anastomosis variations variously known as SADI/SIPS/loopDS – the easier procedures with no substantial track record.
However, by the end of the meeting the following topics had been mentioned (not confirmed):
Further discussion made it clear (perhaps an “I told you so moment”?) that DS is going to be done more frequently in the future, because the majority of sleeves are plateauing at too high of a BMI, and many are having weight regain a few years out, as well as lapbands and RNYs having to be converted more and more often.
Some surgeons at the meeting defended single anastomosis surgery, using language such as “more complicated or aggressive” to denigrate the conventional DS. However, as we know, the first surgery for a patient should be the best surgery for that patient (Think Twice, Cut Once), and it is not in the patient’s best interest for the surgeon to plan on doing incremental surgeries, with repeated revisions as the insufficient surgeries fail.
One of the attendees also indicated “I change my procedures every five years.” Why would a surgeon do that?
We all realize that the science and our understanding of biochemistry, physiology, etc., are evolving all the time. The surgical instrumentation and the surgical staplers all continue to evolve. The DS however has not changed in principle. If some surgeons are looking for quick fixes and what is easy to do today, they will probably start placing the gastric balloon! Does this suggest a bariatric business plan that is based on having to repeatedly operate on patients – gastric balloon to lapband to VSG to SIPS to DS, with a separate cholecystectomy that could/should have been done in the first place thrown in for good measure?
It is also significant to note that as of today there are no codes for any of the single anastomosis procedures, and there is only one proper code for the DS - CPT 43845, which includes two anastomoses. In addition, because there are no CPT codes for them and likely won’t be one anytime soon, these single anastomosis variant procedures are being done with a lot of variability and under unbundled codes (e.g., coding for the SIPS procedure as a sleeve gastrectomy, with an enteroenterostomy, or including “unspecified” codes).
In many people’s opinion, it is not appropriate for experimental procedures to be misleadingly coded, clearly when the surgeon performing the experimental procedure under unbundled codes is simultaneously conducting a clinical trial on that very procedure: see, e.g.,
https://clinicaltrials.gov/ct2/show/NCT02275208?term=pylorus+sparing+obesity&rank=1 (it is interesting to note which surgeons are involved in this clinical trial by looking at the locations where it is offered).
Finally, what is clear from all of this (including, apparently, based on a discussion among some of the conventional DS surgeons) is that the DS patients who have been advocating for fully informed consent for these new single anastomosis procedures should not back off and in fact, if anything, should increase their informed consent advocacy even further. Prospective patients should be made aware (by their SURGEONS!) that there is no long term outcome for the single anastomosis procedures.
The “real” DS surgeons endorsed the DS veterans continuing to take an active role in spreading this information. In addition to sharing the factual information about the differences between the procedures that are minimized or glossed over, we can provide prospective patients with exemplary language to use for dealing with surgeons who are trying to pass off one of these variant procedures as being “just like the DS, only safer/cheaper/faster/better/new-and-improved,” for example “If you are not planning to give me a duodenal switch as described in CPT 43845, with two anastomoses, please let me know, and I will go elsewhere for my surgery.” That should be put IN WRITING. Moreover, patients should be warned that a surgeon saying in response to this demand (remember – you are the customer!) “OK, I will try; however, please be aware that if I cannot do the DS for some reason, then I will do a variation at my discretion" should be a red flag and serious warning sign to the patient. It is almost NEVER necessary to do less than a full DS because of unexpected findings during surgery according to the skilled DS surgeons. In the rare case that the DS can’t be done, then given the elective nature of the operation, the patient should be able to decide which procedure to have instead, rather than a blanket release.
More and more people are going to need DS in the future. We as veteran patient advocates have a moral obligation to help ensure that these patients – many of them already traumatized by failing their first (inadequate) surgeries – understand the implications of the often slick sales pitches of some, touted with disingenuous language not supported by long-term data, such as “it’s just like the DS, only safer/cheaper/faster/better/new-and-improved,” when these statements are untrue or irrelevant for the patient’s long-term health; that they know that the procedure cannot be coded as a DS and thus may end up not being covered by insurance (especially if the patient knew or should have known that they were not getting a proper DS); that bile reflux is a real possibility; that they cannot follow the high fat DS eating guidelines but still have substantial issues with nutrient malabsorption; and that there are NO long-term studies evidencing how durable SIPS weight loss and comorbidity remission will be.
If after receiving and comprehending this information, they still want consent to an unproven operation, possessed of information sufficient to give fully informed consent to this experimental procedure, which is unlikely to be covered by insurance (and perhaps retrospectively, after the op report is submitted), which may not give them the promised durable weight loss, nor the freedom of dietary limitations of the DS, it’s on them. (Though why anyone would pay full-price for an experimental procedure as a self-pay, I will never understand. At least it’s better than either RNY or lapband?)
Please link this to all the bariatric groups of which you are a member, and where pre-ops are researching.
The official DS surgeons’ meeting ended up mostly being about DS “look-alikes” - and even including distal gastric – bypass rather than about the conventional DS. Surprisingly, there was little discussion about science, physiology, pre- and post-op care, or technical issues about the DS; instead, it mostly had to do with insurance, politics, etc.
There was a second open DS meeting that was announced during a packed general ASMBS meeting, and about 40-50 people showed up. Some of the same surgeons who try to sell the SADI/SIPS/loopDS as the same as the conventional DS again started touting their single-anastomosis procedure to this larger and more general audience. There was overall consensus (not surprising, given that they had all attended the DS meeting) that it is important to preserve the function of the pyloric valve. What was interesting that this discussion included a handful of surgeons who had been critical of the duodenal switch for years, or even worse, offer all procedures but now suddenly portray themselves as the leader of the movement for the “duodenal switch”. But instead of the DS, these surgeons are touting the single anastomosis variations variously known as SADI/SIPS/loopDS – the easier procedures with no substantial track record.
However, by the end of the meeting the following topics had been mentioned (not confirmed):
- There may be a number of patients who have contacted lawyers about consent issues related to these variant EXPERIMENTAL procedures (presumably, based on failure of the patient to receive sufficient factual information to allow them to give fully informed consent).
- There was also a suggestion of at least one state licensing agency investigating a surgeon related to performing a single anastomosis procedure and calling it a DS.
- At least one surgeon may have received a demand to refund payments made for a SADI surgery from insurance companies
- In addition, there were a number of surgeons who have been personally told by third party payers that SADI or other single anastomosis procedures are not the DS, and 43845 cannot be used for coding for these variant procedures..
- If there is any doubt why, just look at what the descriptor for the code says – it CLEARLY has two anastomoses! “Biliopancreatic Bypass with Duodenal Switch: CPT code 43845—gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileosteomy [50 to 100 cm common channel] to limit absorption [biliopancreatic diversion with duodenal switch]”
Further discussion made it clear (perhaps an “I told you so moment”?) that DS is going to be done more frequently in the future, because the majority of sleeves are plateauing at too high of a BMI, and many are having weight regain a few years out, as well as lapbands and RNYs having to be converted more and more often.
Some surgeons at the meeting defended single anastomosis surgery, using language such as “more complicated or aggressive” to denigrate the conventional DS. However, as we know, the first surgery for a patient should be the best surgery for that patient (Think Twice, Cut Once), and it is not in the patient’s best interest for the surgeon to plan on doing incremental surgeries, with repeated revisions as the insufficient surgeries fail.
One of the attendees also indicated “I change my procedures every five years.” Why would a surgeon do that?
We all realize that the science and our understanding of biochemistry, physiology, etc., are evolving all the time. The surgical instrumentation and the surgical staplers all continue to evolve. The DS however has not changed in principle. If some surgeons are looking for quick fixes and what is easy to do today, they will probably start placing the gastric balloon! Does this suggest a bariatric business plan that is based on having to repeatedly operate on patients – gastric balloon to lapband to VSG to SIPS to DS, with a separate cholecystectomy that could/should have been done in the first place thrown in for good measure?
It is also significant to note that as of today there are no codes for any of the single anastomosis procedures, and there is only one proper code for the DS - CPT 43845, which includes two anastomoses. In addition, because there are no CPT codes for them and likely won’t be one anytime soon, these single anastomosis variant procedures are being done with a lot of variability and under unbundled codes (e.g., coding for the SIPS procedure as a sleeve gastrectomy, with an enteroenterostomy, or including “unspecified” codes).
In many people’s opinion, it is not appropriate for experimental procedures to be misleadingly coded, clearly when the surgeon performing the experimental procedure under unbundled codes is simultaneously conducting a clinical trial on that very procedure: see, e.g.,
https://clinicaltrials.gov/ct2/show/NCT02275208?term=pylorus+sparing+obesity&rank=1 (it is interesting to note which surgeons are involved in this clinical trial by looking at the locations where it is offered).
Finally, what is clear from all of this (including, apparently, based on a discussion among some of the conventional DS surgeons) is that the DS patients who have been advocating for fully informed consent for these new single anastomosis procedures should not back off and in fact, if anything, should increase their informed consent advocacy even further. Prospective patients should be made aware (by their SURGEONS!) that there is no long term outcome for the single anastomosis procedures.
The “real” DS surgeons endorsed the DS veterans continuing to take an active role in spreading this information. In addition to sharing the factual information about the differences between the procedures that are minimized or glossed over, we can provide prospective patients with exemplary language to use for dealing with surgeons who are trying to pass off one of these variant procedures as being “just like the DS, only safer/cheaper/faster/better/new-and-improved,” for example “If you are not planning to give me a duodenal switch as described in CPT 43845, with two anastomoses, please let me know, and I will go elsewhere for my surgery.” That should be put IN WRITING. Moreover, patients should be warned that a surgeon saying in response to this demand (remember – you are the customer!) “OK, I will try; however, please be aware that if I cannot do the DS for some reason, then I will do a variation at my discretion" should be a red flag and serious warning sign to the patient. It is almost NEVER necessary to do less than a full DS because of unexpected findings during surgery according to the skilled DS surgeons. In the rare case that the DS can’t be done, then given the elective nature of the operation, the patient should be able to decide which procedure to have instead, rather than a blanket release.
More and more people are going to need DS in the future. We as veteran patient advocates have a moral obligation to help ensure that these patients – many of them already traumatized by failing their first (inadequate) surgeries – understand the implications of the often slick sales pitches of some, touted with disingenuous language not supported by long-term data, such as “it’s just like the DS, only safer/cheaper/faster/better/new-and-improved,” when these statements are untrue or irrelevant for the patient’s long-term health; that they know that the procedure cannot be coded as a DS and thus may end up not being covered by insurance (especially if the patient knew or should have known that they were not getting a proper DS); that bile reflux is a real possibility; that they cannot follow the high fat DS eating guidelines but still have substantial issues with nutrient malabsorption; and that there are NO long-term studies evidencing how durable SIPS weight loss and comorbidity remission will be.
If after receiving and comprehending this information, they still want consent to an unproven operation, possessed of information sufficient to give fully informed consent to this experimental procedure, which is unlikely to be covered by insurance (and perhaps retrospectively, after the op report is submitted), which may not give them the promised durable weight loss, nor the freedom of dietary limitations of the DS, it’s on them. (Though why anyone would pay full-price for an experimental procedure as a self-pay, I will never understand. At least it’s better than either RNY or lapband?)
Please link this to all the bariatric groups of which you are a member, and where pre-ops are researching.
