Duodenal Switch Procedure: The Ultimate Guide to Transform Your Weight Loss Journey

The duodenal switch (DS), also known as biliopancreatic diversion with duodenal switch (BPD-DS), is a weight-loss surgery combining restrictive and malabsorptive principles. It reduces stomach size and reroutes the intestines, leading to significant weight loss and improvement in obesity-related health conditions. The name "duodenal switch" comes from the fact that in this operation the intestinal bypass starts at the duodenum.

What is the Duodenal Switch Procedure?

Duodenal switch surgery is a complex procedure involving two main parts:

Sleeve Gastrectomy: Approximately 75-80% of the stomach is removed, creating a small, tubular pouch, similar to the gastric sleeve procedure. This small stomach restricts the amount of food you can eat at one time. The valve at the outlet of the stomach remains, which allows for the normal process of stomach-emptying and the feeling of fullness. After surgery, the stomach is roughly the size and shape of a banana and can hold approximately 3 ounces of food, as compared to the average stomach which can hold up to 4 cups of volume.
Intestinal Bypass: The small intestine (first part or duodenum) is then divided. A very short length of the last part of the small intestine is brought up and attached to it (duodenum). This is the duodenal switch. The food empties directly into the duodenum, bypassing about ¾ of the small intestine. When you eat, the food then only goes through the new stomach pouch. It empties into the last part of the small intestine. This goes around (bypasses) a large section of the small intestine, so that less of the food is digested. You absorb fewer calories and nutrients. The part of the small intestine that has been separated is reconnected to the last part of the small intestine. This changes the normal way that bile and digestive juices break down food. This is the biliopancreatic diversion. This cuts back on how many calories you absorb, causing still more weight loss.

The malabsorptive portion of the surgery reroutes a lengthy portion of the small intestine, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive loop, takes food from the stomach to the common channel. The common channel is the portion of small intestine, usually 75-150 centimeters long, in which the contents of the digestive path mix with the bile from the biliopancreatic loop before emptying into the large intestine. The principle measured length with a duodenal switch is the common channel. The common channel distance is important and can vary based on individual patients. The objective of this arrangement is to reduce the amount of time the body has to capture calories from food in the small intestine and to selectively limit the absorption of fat.

Read also: Revising Sleeve Gastrectomy

How Effective is the Duodenal Switch?

Duodenal switch surgery is one of the most successful bariatric surgeries. It results in a higher BMI loss (decreasing your BMI) when compared to gastric bypass. Patients can expect to lose 80 to 90 percent of excess weight in the first year after a duodenal switch operation. Most patients are able to lose up to 80 percent of their excess weight.

Who is a Good Candidate for Duodenal Switch Surgery?

To be a candidate, you must be morbidly obese or superobese (have a BMI greater than 50) and be healthy enough to tolerate surgery. Those who have comorbid conditions, like diabetes, are good candidates as well.

Healthcare providers may advise BPD/DS to people who are obese. This means a body mass index (BMI) of 35 or greater. It is usually an option for obese patients that have struggled to lose weight using diet and exercise.

Advantages of Duodenal Switch Surgery

Duodenal switch helps you lose weight and reduces your risk of serious obesity-related health problems. By losing excess weight, other illnesses associated with obesity can greatly improve. It can significantly improve your quality of life but requires that you make changes to your lifestyle.

Some more specific advantages are:

Read also: Understanding the Duodenal Switch

Greatest overall weight loss results
Most effective weight-loss procedure for people with Type 2 diabetes
Allows for slightly larger meals when compared to other gastric bypass procedures
Rarely causes dumping syndrome
Type 2 diabetics have had a 98% "cure" (i.e. became euglycemic) almost immediately following surgery, which is due to the metabolic effect from the intestine switch.
Because the pyloric valve between the stomach and small intestine is preserved, people who have undergone the DS do not experience the dumping syndrome common with people who have undergone the Roux-en-Y gastric bypass surgery (RNY).

Disadvantages and Risks of Duodenal Switch Surgery

Duodenal switch surgery is not reversible, and some people may have complications after the surgery. Duodenal switch surgery is a highly complex procedure. In fact, it is the most complex type of bariatric surgery and carries the most risk of complications.

One of the main disadvantages of the surgery is that it relies on malabsorption, which can help you lose weight. But it also requires you to follow a specific eating plan and take specific supplements to get the nutrition you need. You need to follow the eating plan to avoid loose bowel movements, as well.

Other risks may include:

Protein, vitamin and mineral deficiencies.
Infection, such as pneumonia, intra-abdominal abscesses, or C. diff colitis, which can lead to septic shock.
Acid reflux (heartburn) and esophagitis. This is irritation of the esophagus, the tube from your mouth to your stomach.
BPD/DS makes it hard for the body to absorb vitamins and minerals.
Low level of thiamine. This is rare but can damage the nervous system. You will need to take vitamin and mineral supplements for life. You will also need to have blood tests regularly. This is to prevent severe malnutrition and related problems. Even if you take supplements, you still may have nutrition problems and need treatment.
Longer term risks include the possibility of vitamin and mineral deficiency, hernia and bowel obstruction.
Gastroesophageal Reflux (GERD) - Because the procedure reduces the size of the stomach, it may also increase pressure on the esophagus.

Preparing for Duodenal Switch Surgery

If your healthcare provider believes you’re a good candidate for surgery, you’ll enter a screening process. This could involve:

Standard medical testing to make sure you’re in good health
Screening for alcohol, tobacco and drug use and therapy to help you quit, if necessary
Psychological counseling to make sure you’re prepared for the big life changes that your new digestive system will bring
Enrolling in a seminar so you understand the surgery
Get counseling to discuss emotional health and disordered eating habits.
Read educational material that will be given to you or attend classes about the procedure, expected results, and possible complications.
Ask a family member or friend to take you home from the hospital. You can’t drive yourself.
Bring your CPAP or BiPAP machine to the hospital on the day of your surgery.

Once you’ve met these benchmarks and scheduled your surgery, your healthcare provider will put you on a preoperative eating plan for a couple of weeks. This typically consists of eating meals that are low in fat and carbohydrates and high in protein. Patients are typically placed on a Low carbohydrate diet before surgery to shrink the liver as much a possible before surgery.

Tell your healthcare provider about all the medicines you take. This includes over-the-counter medicines, vitamins, herbs, and other supplements. You may need to stop taking some medicines before the procedure, such as blood thinners and aspirin.

Follow any directions you are given for not eating or drinking before surgery. Ask which medicines you should stop taking before surgery and for how long, and which medicines should be taken the day of surgery.

You will be asked to sign a consent form that gives your healthcare provider permission to do the procedure. Read the form carefully. Ask questions if something is not clear.

How is the Duodenal Switch Performed?

Duodenal switch surgery is a laparoscopic surgery. The laparoscopic method is less invasive and uses small incisions instead of making a larger incision in your abdomen. You receive general anesthesia so you’re asleep for the entire procedure. Some surgeons use robotic tools to help do part of the surgery. In some cases, BPD/DS may be done as open surgery. For this method, the surgeon makes one larger incision instead of several smaller ones. They see and use tools through this incision.

There are two surgical methods to the duodenal switch: the traditional duodenal switch (biliopancreatic diversion) and the SADI-S. The first step in both methods involves removing part of your stomach and shaping what’s left of it into a narrow sleeve. The differences are in the second part of the surgery - the intestinal bypass. Both versions begin the bypass by dividing your small intestine near the top, in the section called the duodenum. Then, they bring a lower section of your small intestine up to attach to the top, bypassing the middle. The original duodenal switch surgery bypasses most of your small intestine, making it significantly shorter. The modified version bypasses a little more than half of your small intestine.

Surgery takes about an hour and a half and patients have a similar recovery to other bariatric procedures. The surgery typically takes between two and four hours.

What to Expect After Duodenal Switch Surgery

After the surgery, you will spend 2 nights in the hospital. A hospital stay after a duodenal switch procedure is typically 24 to 48 hours. You’ll stay in the hospital for one to two days after surgery. It takes two to four weeks to make a full recovery. Many patients return to normal activity within one to two weeks.

You will wake up in a recovery room. You will be given medicine to control pain. You will be moved to a hospital room. You will be asked to get out of bed to move around within the next day. This helps prevent blood clots in your legs.

Your diet will start with clear liquids, and you will then transition to soft foods until your body can adjust to solid foods again. At first, you may have stomach or bowel cramping, or nausea. Tell your healthcare provider if pain or nausea is severe or doesn’t improve with time. Take pain medicines as prescribed.

Your healthcare provider will give you instructions to follow during your recovery. This will include a list of what activities to avoid and what foods you can eat. You’ll have frequent follow-up appointments with your healthcare provider in the first two years and periodic appointments for the rest of your life. The first two years will be your most dramatic weight-loss period. During this time, your provider will continuously monitor your progress and health.

You will get instructions about how to adapt to your new diet after your surgery. You will likely be on liquid nutrition for a few weeks after surgery. Over time, you’ll start to eat soft foods and then solid foods. If you eat too much or too fast, you will likely have stomach pain or vomiting. You’ll learn how to know when your new stomach is full. Your healthcare provider or nutritionist will give you more instructions about your diet. You’ll need to learn good habits like choosing healthy foods and not skipping meals.

Long-Term Follow-Up and Lifestyle Changes

Duodenal switch surgery requires a very strict diet and vitamin supplementation after surgery to avoid malnutrition. You will need to take vitamin and mineral supplements for life. You will also need to have blood tests regularly. This is to prevent severe malnutrition and related problems. Even if you take supplements, you still may have nutrition problems and need treatment. Bariatric surgery will change your eating habits for the rest of your life.

Because there’s a risk of malnutrition, you’ll need to take nutritional supplements for the rest of your life. You’ll also need to give blood samples at regular intervals to make sure you’re getting enough nutrients.

Your healthcare provider or nutritionist will also need to screen you for low levels of nutrients. Follow the nutrition plan set up by your dietitian. Get regular physical activity. Start slowly and build up to more activity. Talk with a counselor or weight-loss surgery support group to help you adjust. It is important that patients who have had a duodenal switch procedure make a lifelong commitment to making the necessary changes in their diet. How well you comply with diet recommendations and exercise will greatly contribute to your final weight.

Hormonal Impact of Duodenal Switch

Important hormones that are directly impacted by bariatric surgery that have a significant impact on patients' weight loss and outcomes are leptin, incretins (GIP and GLP1), ghrelin, and insulin.

Ghrelin: Ghrelin is a peptide hormone produced by ghrelinergic cells in the GI tract and functions as a neuropeptide in the central nervous system. Ghrelin plays a significant role in regulating the rate and distribution of the use of energy. Ghrelin levels rise with prolonged fasting and drop after ingestion of food. Bariatric procedures have variable effects on ghrelin production. Patients who underwent a sleeve gastrectomy had reduced ghrelin levels, which were likely due to the removal of that part of the stomach where ghrelin-secreting cells are located.
Leptin: Leptin is a hormone that is made by adipose cells and enterocytes. White adipose tissue is the main source of circulating leptin and adiponectin. Leptins' main function is to regulate energy balance by controlling hunger and fat storage. Leptin circulates at concentrations proportional to fat mass and inhibits food intake. Roux en y Gastric Bypass surgery has been shown to decrease leptin resistance, however, this has been shown to be proportional to the amount of body fat mass in patients.
Incretins: Incretin hormones such as glucose-dependent insulinotropic polypeptides and glucagon-like peptide 1 are secreted respectively from the upper duodenum K cells and the ileum L cells. Both are responsible for approximately 50% of postprandial insulin secretion. Besides the insulinotropic effects, GLP-1 and GIP delay gastric emptying, decrease appetite, promote weight loss, inhibit glucagon, and improve insulin sensitivity. Incretin levels have been shown to increase following biliopancreatic diversion and gastric bypass.
Insulin: Insulin is an amino acid peptide hormone produced by the beta cells of the pancreatic islets. Insulin regulates the metabolism of carbohydrates, fats, and protein. It is the main anabolic hormone of the body. Decreased insulin sensitivity leads to diabetes mellitus and obesity. It has been shown that insulin sensitivity improves with all types of bariatric surgery.

Contraindications

The indications for biliopancreatic diversion are mainly for bariatric procedures, with a few exceptions:

Pregnancy
Severe psychiatric illness
Eating disorders
Patient-related contraindications to undergo surgery (cardiovascular risk, anesthetic risk)
Substance misuse (alcoholism)
Severe coagulopathies

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