Duodenal Switch

Food Restriction Plus Malabsorption

The duodenal switch (DS) surgery enables patients to eat a normal meal in much smaller quantities. This operation restricts food consumption by removing the most stretchable portion of the stomach, similar to a sleeve gastrectomy. Additionally, calorie absorption is limited by bypassing roughly one-half to three-fourths of the upper small intestine.

How Duodenal Switch Weight Loss Surgery Works

A sleeve gastrectomy is performed to remove the stretchy upper and outer 85 percent of the stomach, leaving a small, vertically-oriented tubular stomach. Stomach capacity is reduced from about a quart (1,000 ml) to roughly 4 – 6 ounces (120 ­– 180 ml). Depending on the size of the tube (bougie) that is created, patients generally report feeling full after eating 4 – 6 ounces of solid food.

The important structural elements of the stomach — such as the antrum, the pylorus and the nerves that control stomach function — are preserved. The result is a much smaller stomach that functions similarly to a normal one. This allows patients to enjoy a relatively normal diet (albeit in much smaller quantities) without side effects like “dumping” syndrome.

During duodenal switch surgery, the small intestine is rerouted to significantly reduce calorie absorption. The duodenum (the first section of the small intestine) is divided and connected to the last 8 ­– 13 feet (250 – 400 cm) of small intestine through which the food passes (alimentary limb or AL). The top half of the intestine carries only digestive (bile and pancreatic) juices and is called the bilio-pancreatic limb (BPL). This section is reconnected to the food stream 3.5 – 10 feet (100 – 300 cm) from the colon (large intestine). The last segment of the intestine —where the food and digestive juices mix — is referred to as the common channel (CC). Absorption of nutrients and calories from complex carbohydrates and fats is determined by the length of the CC. Absorption of calories from simple carbohydrates, such as starches, occurs in the alimentary limb. The shorter the AL the more the weight loss. The longer the CC the lesser the risk for nutritional problems.

The removal of the upper and outer stretchable portion of the stomach results in a decrease in the level of ghrelin, the “hunger hormone,” which reduces the appetite. In addition, bypassing the upper intestine helps bring food to the lowest portion of the small intestine earlier than usual, releasing important appetite-suppressing hormones such as glucagon-like peptide 1 (GLP1) and polypeptide YY (PYY). This accounts for the superior weight loss, weight maintenance and diabetes resolution associated with this surgery.

Duodenal Switch Outcomes

Weight Loss

Approximately 75 to 80 percent excess weight loss has been reported.1,2 

Improvement / Resolution of Comorbidities

Improvement or resolution of all major comorbidities has been documented, including type 2 diabetes, sleep apnea, hypertension and high cholesterol. A very high cure rate for diabetes has been reported with this surgery. 3,4

Advantages

The risk of “dumping” syndrome is very low. The symptoms of dumping syndrome are nausea, cramping, diarrhea, sweating, vomiting and heart palpitations, and it can occur when a patient (who has had gastric bypass) consumes sugar or carbohydrates, or eats too quickly.

Medication Tolerance

This pill-friendly procedure offers a high level of tolerance for medications, including aspirin and other NSAIDS.

Suited For

This surgery  is a good option for patients with higher BMI, diabetes or metabolic syndrome. 5,6,7,8,9  

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References
  1. Strain GW, et al. Comparison of effects of gastric bypass and biliopancreatic diversion with duodenal switch on weight loss and body composition 1–2 years after surgery. Surgery for Obesity and Related Diseases. 2007;3(1):31–36.

    http://www.soard.org/article/S1550-7289(06)00779-9/abstract

  2. Nelson DW, Blair KS, Martin MJ. Analysis of Obesity-Related Outcomes and Bariatric Failure Rates with the Duodenal Switch vs Gastric Bypass for Morbid Obesity. Arch Surg. 2012;147(9):847–854. doi:10.1001/archsurg.2012.1654.

    http://www.ncbi.nlm.nih.gov/pubmed/22987179

  3. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA. 2004;292(14):1724–1737. doi:10.1001/jama.292.14.1724.

    http://jama.jamanetwork.com/article.aspx?articleid=199587

  4. Hedberg J1, Sundbom M. Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass--a randomized controlled trial. Surg Obes Relat Dis. 2012 May-Jun;8(3):338-43. doi: 10.1016/j.soard.2012.01.014. Epub 2012 Feb 1.

    https://www.ncbi.nlm.nih.gov/pubmed/22425057

  5. Hilde Risstad, MD1,2; Torgeir T. Søvik, MD, PhD3; My Engström, RN, PhD4; et al. Five-Year Outcomes After Laparoscopic Gastric Bypass and Laparoscopic Duodenal Switch in Patients With Body Mass Index of 50 to 60A Randomized Clinical Trial. JAMA Surg 2015;150(4):352-361

    https://jamanetwork.com/journals/jamasurgery/fullarticle/2107252

  6. Skogar ML1, Sundbom M2. Duodenal Switch Is Superior to Gastric Bypass in Patients with Super Obesity when Evaluated with the Bariatric Analysis and Reporting Outcome System (BAROS). Obes Surg. 2017 Sep;27(9):2308-2316. doi: 10.1007/s11695-017-2680-z.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5562774/pdf/11695_2017_Article_2680.pdf

  7. Topart P1, Becouarn G, Ritz P. Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients. Surg Obes Relat Dis. 2013 Jul-Aug;9(4):526-30. doi: 10.1016/j.soard.2012.02.006. Epub 2012 Mar 3.

    https://www.ncbi.nlm.nih.gov/pubmed/22498360

  8. Marceau P et. al. Long-term metabolic outcomes 5-20yrs after BDP. Obesity Surgery 2015 DOI 10.1007s11695-015-1599-5

    https://www.ncbi.nlm.nih.gov/pubmed/25676155

  9. Anthone GJ et.al. The Duodenal Switch Operation for the Treatment of Morbid Obesity. Ann Surg 2003; 238. 618-628

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360120/

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