Bariatric surgery offers a pathway to effective and sustained weight loss for individuals seeking to improve their health and quality of life. Among the various bariatric procedures available, the duodenal switch (DS) stands out as a highly effective option, particularly for those with significant obesity or type 2 diabetes. However, primary bariatric procedures like sleeve gastrectomy may sometimes necessitate revision to achieve optimal outcomes. This article provides a comprehensive overview of sleeve revision to duodenal switch, covering its history, techniques, benefits, risks, and long-term considerations.
Historical Context and Evolution of the Duodenal Switch
The duodenal switch (DS) is a complex bariatric surgery that combines sleeve gastrectomy (SFG) with a biliopancreatic diversion (BPD). The procedure was initiated by Doug Hess in 1988, who described its key components. Marceau further developed the DS technique, publishing the first results and comparing it to the standard BPD. These early pioneers laid the foundation for the modern DS, which has since undergone refinements to improve safety and efficacy.
Key Figures in DS Development
- Doug Hess: Initiated the DS in 1988, outlining its core components.
- Marceau: Published the first DS results, comparing it to BPD.
- Lagacé: Reported positive DS outcomes with a modified gastrectomy technique.
- Ren: Performed the first completely laparoscopic duodenal switch (CDL) in 1999.
- Baltasar: Described the first CDL in Europe in 2000.
Understanding the Duodenal Switch Procedure
The duodenal switch (DS) surgery is comprised of two main components, Sleeve-forming Gastrectomy (SFG) plus a Biliopancreatic diversion (BPD). It is considered the most complex technique in bariatric surgery (BS).
Components of the Duodenal Switch
- Sleeve Gastrectomy (SFG): This involves removing approximately 80% of the stomach along the greater curvature, creating a smaller, tube-shaped stomach. This reduces gastric volume but allows normal emptying. Hess used a suture to invert the gastric serosa to cover the SFG staples and avoid leakage at the staple-line.
- Biliopancreatic Diversion (BPD): This involves dividing the duodenum post-pylorus [D1] to allow emptying into the small bowel through a Duodeno-ileal anastomosis (DIA). The BPL starts at the first part of the duodenum (D1) and joins at the union of AL-CL as end--lateral Roux-Y (RY) jejunal-ileal anastomosis (JIA) with a continuous monoplane resorbable suture.
Laparoscopic Duodenal Switch (LDS) Technique
The Laparoscopic CD (LDS) is typically performed by a team of three surgeons, utilizing six ports. The Optical Trocar or “main port” is Ethicon # 12 and enters the abdomen under vision at the lateral edge of the right rectus, three fingers below the costal margin. A 10 mm central supraumbilical port is used for the mid-line camera. There are four 5 mm ports, two sub-costal located on the right and left, one in the left hypochondrium and the other in the epigastrium used to retract the liver.
The entire small intestine is measured from the ileocecal valve to Treitz ligament with forceps at 5 cm steps to avoid lesions of the intestinal serosa. The CL is marked with a clip, and the upper AL is divided with a linear stapler. A retro-duodenal tunnel is created in D1, distal to the right gastric artery, which allows the duodenal division with a linear stapler before the Oddi sphincter. The proximal AL passes retro-colic, on the right, and a Duodenum-Ileal Anastomosis (DIA) is performed. All anastomoses are hand-sutured with a monolayer continuous suture, starting with the sliding and self-blocking knot of Serra-Baltasar and ending with Cuschieri one. The stomach is removed without a protective bag. A Maxon suture closes the 12 mm port fascia to prevent hernias.
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Why Consider Sleeve Revision to Duodenal Switch?
While sleeve gastrectomy is an effective primary bariatric procedure, some patients may experience inadequate weight loss, weight regain, or complications that necessitate revision surgery.
Common Reasons for Revision
- Inadequate Weight Loss: Patients may not achieve their desired weight loss goals after sleeve gastrectomy.
- Weight Regain: Some individuals may experience weight regain after initial success with the sleeve.
- Gastroesophageal Reflux Disease (GERD): Sleeve gastrectomy can exacerbate or cause GERD in some patients.
- Enlarged Gastric Pouch: Over time, the gastric pouch may stretch, reducing the restrictive effect of the sleeve.
- Other Complications: Disrupted staples or other mechanical issues may require surgical intervention.
The Duodenal Switch as a Revisional Option
Converting a sleeve gastrectomy to a duodenal switch can address these issues by providing additional weight loss and resolving complications like GERD. The duodenal switch begins with a sleeve gastrectomy and then involves a small bowel bypass. Converting an existing sleeve gastrectomy to a duodenal switch simply involves doing the small bowel bypass. This procedure is low risk and can be done as a single anastomosis, meaning with one connection, which minimizes the risk of the operation.
Benefits of Converting to a Duodenal Switch
The duodenal switch offers several advantages over other bariatric procedures, particularly in terms of weight loss and resolution of comorbidities.
Superior Weight Loss
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 who have had duodenal switch surgery can lose 70 to 80 percent of their excess weight within 2 years. Studies have consistently shown that patients undergoing DS experience greater and more sustained weight loss compared to those undergoing GBP.
Effective for Type 2 Diabetes
DS is a very effective operation to treat diabetes. 98% of our patients are normoglycemic with normal glycosylated hemoglobin. DS and BPD have diabetes resolution rates that exceed 90%.
Read also: Guide to Pureed Foods Post-Surgery
Other Advantages
- Allows for slightly larger meals when compared to other gastric bypass procedures
- Rarely causes dumping syndrome
Risks and Complications
As with any surgical procedure, sleeve revision to duodenal switch carries potential risks and complications. Patients should be fully informed of these risks before undergoing surgery.
Surgical Mortality and Morbidity
Surgical mortality: At 30 days occurred in six ODS patients (1.38%). Two LDS patients died (0.38%) due to pulmonary emboli. The DS is a long and difficult procedure that requires experienced and experienced surgeons. Operative mortality should be <1% and morbidity <5%.
Common Complications
- Leaks: Leakage in his angle of His, Leakage of the duodenal stump, DIA Leakage, RY leak.
- Pulmonary embolism: Two patients with IBMI-70 and IBMI-65 had embolism despite prophylactic therapy and died.
- Liver: a) Hepatic Disorders. Twelve patients underwent early liver function alterations with significant elevations of bilirubin (up to 15 and 29) that resolved with medical treatment. b) Hepatic Failure. Two patients suffered liver failure (0.2%). A patient died 13 years after ODS due to alcoholism.
- Caloric-protein malnutrition (CPM). Thirty-three patients (3.3%) developed CPM and 24 required CL elongation. Multiple hernias were found in the weak muscular wall between the mesentery vessels. These types of hernias have not been previously reported.
- Pancreatic-cutaneous fistula
- Hypoglycemia Two patients had recurrent episodes of hypoglycemia that required BPD reversal.
- Evisceration in four cases without consequences after proper repair.
- Delayed bowel obstruction: 7 cases (incidence of 0.73%).
- Beriberi. Three patients had vitamin B1 deficiency with neurological symptoms, changes in gait and spontaneous fall, all successfully corrected.
- Fractures due to the bad absorption of Ca that required Vitamin D25 plus Ca.
- Toxic megacolon 16 years after surgery due to pseudo membranous colitis.
- Miscellaneous: Pneumonia-4. Seroma-4, wound infection-15. Digestive bleeding-5 (3 requiring laparotomy).
- Long-term Mortality: An acute appendicitis not diagnosed at two years. Intestinal necrosis by internal hernia at 3 years.
Nutritional Deficiencies
The DS is not associated with extensive nutritional deficiencies. However, because 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.
Preoperative Evaluation and Preparation
Prior to undergoing sleeve revision to duodenal switch, patients undergo a comprehensive evaluation to assess their overall health and suitability for surgery.
Screening Process
- Standard medical testing to ensure good health
- Screening for alcohol, tobacco, and drug use, with therapy if necessary
- Psychological counseling to prepare for lifestyle changes
- Enrollment in a seminar to understand the surgery
Preoperative Diet
Healthcare providers typically prescribe a preoperative eating plan for a couple of weeks, consisting of meals low in fat and carbohydrates and high in protein.
Read also: Comprehensive Sleeve Diet
Postoperative Care and Recovery
Following duodenal switch surgery, patients require close monitoring and long-term follow-up to ensure optimal outcomes and address any potential complications.
Immediate Postoperative Period
Patients typically stay in the hospital for one to two days after surgery and require two to four weeks for full recovery.
Dietary Progression
Following a duodenal switch procedure, you will initially be on a liquids-only diet. This will allow your stomach and intestines some time to heal from the surgery. Gradually, you will transition from liquids to pureed foods. As your body adapts, you’ll then introduce soft foods and eventually advance to firmer foods based on your tolerance level.
Long-Term Follow-Up
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.
Nutritional Supplementation
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.
Long-Term Outcomes and Quality of Life
Patients who undergo sleeve revision to duodenal switch can experience significant improvements in their weight, health, and quality of life.
Weight Loss Results
Patients who have had duodenal switch surgery can lose 70 to 80 percent of their excess weight within 2 years. How much weight you lose will depend on what changes you make to your lifestyle habits.
Improvement in Comorbidities
Additional benefits of the duodenal switch include effective improvement or remission of the following health conditions related to a high body mass index:
- Type 2 diabetes
- High blood pressure
- Heart disease
- High cholesterol
- Obstructive sleep apnea
- Stroke
- Gastroesophageal reflux disease
- Infertility
Quality of Life
Changes after surgery included: self-esteem, physical activity, social activity, work activity plus sexual activity on a scale of-1 to 1.
The Role of Experienced Surgeons and Multidisciplinary Care
The duodenal switch is a complex procedure that requires experienced and skilled surgeons. Patients should seek out bariatric centers with a multidisciplinary team, including surgeons, dietitians, psychologists, and other healthcare professionals, to ensure comprehensive care and support.
Training and Expertise
We trained 72 bariatric surgeons and we have interacted live in several national and international congresses.
Multidisciplinary Approach
"Our care team includes several bariatric endoscopists who provide revisional treatment. They might insert a stent or repair tissue endoscopically," says Dr. In addition to collaborating with endoscopists, Dr. Ghanem works with expert radiologists skilled in detecting anatomical changes that can happen after bariatric surgery. His team also includes endocrinologists, psychologists, advanced practice professionals, residents and fellows.