Duodenal switch surgery is a powerful weight-loss procedure combining restriction and malabsorption principles to help individuals achieve significant and lasting weight loss. This article provides a detailed overview of the duodenal switch, covering its mechanisms, benefits, risks, candidacy, the surgical process, recovery, and long-term considerations.
What is Duodenal Switch Surgery?
Duodenal switch surgery, or biliopancreatic diversion with duodenal switch (BPD-DS), is a bariatric procedure designed for individuals with morbid obesity or super obesity (BMI greater than 50) who have struggled with weight loss through diet and exercise. It is also an option for obese patients who have a BMI of 35 with an obesity-related condition. The duodenal switch is a weight loss operation that has been done for over 20 years, and has become more common in the last several years. It has the greatest weight loss potential of all the available operations. The name duodenal switch comes from the fact that in this operation the intestinal bypass starts at the duodenum.
Restriction and Malabsorption
Duodenal switch surgery works through two primary mechanisms:
- Restriction: The procedure reduces the size of the stomach, limiting the amount of food a person can eat.
- Malabsorption: The surgery reroutes the intestines, decreasing the absorption of calories and nutrients.
How Duodenal Switch Surgery Works
Biliopancreatic diversion with duodenal switch (BPD-DS) surgery is a 2-part procedure:
- Sleeve Gastrectomy: The first part involves creating a tube-shaped stomach pouch, similar to a sleeve gastrectomy. Approximately 75-80% of the stomach is removed, leaving a small, tubular stomach pouch, roughly the size and shape of a banana, which can hold approximately 3 ounces of food. The smaller stomach allows patients to eat less food and promotes a feeling of fullness or satiety. The valve at the outlet of the stomach remains, which allows for the normal process of stomach-emptying and the feeling of fullness.
- Intestinal Bypass: The second part involves rerouting the small intestine. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures, resulting in a significant decrease in the absorption of calories and nutrients. With this procedure, the food empties directly into the duodenum, bypassing about ¾ of the small intestine. For the intestinal bypass portion of the operation, the lower intestine is divided so that two thirds or more of the intestine is bypassed. The reconnected intestine also causes the food to bypass part of the intestine so some of the nutrients and calories in food will not be absorbed.
Surgical Techniques: Traditional Duodenal Switch vs. SADI-S
When changing the path of your intestine, your surgeon may make two connections (the traditional approach) or a single connection. The single-connection option is called single-anastomosis duodenoileostomy, or SADI.
Read also: Revising Sleeve Gastrectomy
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.
Benefits of Duodenal Switch Surgery
Duodenal switch surgery offers several advantages for individuals struggling with severe obesity and related health issues:
- Significant Weight Loss: Patients can expect to lose 80 to 90 percent of excess weight in the first year after a duodenal switch operation. You can expect to lose up to 80% of your excess body weight after duodenal switch surgery.
- Improved Health Conditions: By losing excess weight, other illnesses associated with obesity can greatly improve. More than just a cosmetic change, weight loss surgery can drastically improve high blood pressure, diabetes complications and more. The surgery also changes how your body absorbs the nutrients in food and turns them into energy. This change reduces hunger, increases fullness and improves blood sugar control.
- Effective for Type 2 Diabetes: Most effective weight-loss procedure for people with Type 2 diabetes. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control. Ghrelin also plays a role in blood sugar metabolism.
- Allows for Slightly Larger Meals: Allows for slightly larger meals when compared to other gastric bypass procedures.
- Rarely Causes Dumping Syndrome: Rarely causes dumping syndrome.
Risks and Considerations
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. Like any surgery, a duodenal switch carries some risk for complications; the risk for these complications are increased for obese patients. It is important that patients who have had a duodenal switch procedure make a lifelong commitment to making the necessary changes in their diet.
- Malnutrition: 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. Duodenal switch surgery requires a very strict diet and vitamin supplementation after surgery to avoid malnutrition. 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.
- Dietary Changes: 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.
- Non-Reversible: Duodenal switch surgery is not reversible, and some people may have complications after the surgery.
Candidacy for Duodenal Switch Surgery
You might be a good candidate for duodenal switch if you have:
- BMI of 50 or more
- Type 2 diabetes
- Tried other bariatric surgery options in the past
If you have a BMI of 40 or higher or a BMI of 35 with an obesity-related condition, you probably qualify for bariatric surgery. If you have tried diet and exercise to lower your weight but can’t keep it off, bariatric surgery can help. 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.
Read also: Understanding the Duodenal Switch
Pre-Surgical Screening Process
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
After your first meeting with the surgeon, we take a series of steps to make sure your surgery is as safe as possible. This process includes blood tests, imaging of your stomach and a heart screening. You also visit a psychologist who specializes in working with bariatric patients. Our dietitians also meet with every single patient, building the foundation for successful weight loss after your procedure. This process can take three to six months to complete.
Preoperative Eating Plan
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.
The Duodenal Switch Surgical Procedure
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. At Rush, duodenal switch is usually performed robotically. This means the surgeon will only make small cuts in your abdomen. As a result, you will have less pain when you wake up, a smaller chance of postsurgical infections and a shorter recovery time.
First, the sleeve is created with a surgical stapler along the outside curve of the stomach. After the new stomach is created, the excess stomach is removed. Next, your surgeon changes where food enters your small intestine from your stomach. Your surgeon may use two new connections when reconnecting your stomach and your intestine (the traditional approach to duodenal switch). They can also use only one connection in a SADI procedure. Both approaches result in up to 75% of the intestine no longer coming into contact with food.
Read also: Is Duodenal Switch Right for You?
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.
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.
Recovery After Duodenal Switch Surgery
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. After the surgery, you will spend 2 nights in the hospital. Many patients return to normal activity within one to two weeks. Most people who have duodenal switch surgery return to work after about two weeks. It takes two to four weeks to make a full recovery. 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.
Your diet will start with clear liquids, and you will then transition to soft foods until your body can adjust to solid foods again. For the first few weeks after surgery, you will need to follow a carefully monitored diet, starting with a liquid diet and slowly reintroducing specific types of food. Initially, you will feel full very quickly after eating a small amount of food.
To check on your recovery and your weight loss progress, you will have follow-up appointments regularly. The first will be two weeks after surgery, then again at three months, six months and a year after surgery. During your recovery, your surgeon, dietitian and nurses will be available for any questions or concerns you have.
Long-Term Follow-Up and Lifestyle Changes
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.
- Dietary Compliance: You need to follow the eating plan to avoid loose bowel movements, as well. Your surgeon will give you specific instructions to help make your procedure more successful.
Duodenal Switch vs. Other Bariatric Procedures
Duodenal switch surgery results in a higher BMI loss (decreasing your BMI) when compared to gastric bypass.