For individuals grappling with severe obesity, the duodenal switch (DS) surgery presents a powerful intervention. This article delves into the intricacies of the duodenal switch procedure, exploring its mechanisms, benefits, risks, and long-term considerations, providing a comprehensive understanding for those considering this life-altering option.
Understanding the Duodenal Switch
The duodenal switch is a laparoscopic surgery designed to facilitate weight loss through a combination of food restriction and malabsorption. It is usually an option for obese patients that have struggled to lose weight using diet and exercise. The name duodenal switch comes from the fact that in this operation the intestinal bypass starts at the duodenum. The procedure is generally reserved as an option for patients with a BMI of 50 or higher. It involves two key steps: reducing the size of the stomach and rerouting the intestines.
How Does a Duodenal Switch Work?
The duodenal switch, also known as biliopancreatic diversion with duodenal switch (BPD-DS) surgery, is a two-part procedure:
1. Gastric Sleeve Resection: The first step is sleeve gastrectomy in which about 80% (in some cases 85%) of the stomach is removed, similar to the gastric sleeve procedure. The stomach is divided vertically with the portion intact, shaped like a banana. This reduces the stomach to a smaller, tube-shaped pouch, roughly the size and shape of a banana, limiting the amount of food it can hold. The valve that releases food to the small intestine, called the pyloric valve, remains. When the smaller stomach fills with food, a feeling of fullness or satiety occurs. The smaller stomach also produces fewer “hunger-causing” hormones, including ghrelin, thus patients are tempted to eat less. Ghrelin also plays a role in blood sugar metabolism.
2. Intestinal Rerouting (Duodenal Switch): The second step changes the digestive tract to bypass most of the intestine by connecting the end part of the intestine to the duodenum near the stomach. The small intestine is then cut below the duodenum, the portion responsible for chemical digestion. Once the top part of the small intestines is detached, the surgeon will then make a second cut to the small intestine several feet down, near the large intestine. The surgeon makes one cut through the part of the small intestine just below the duodenum. A second cut is then made farther down, near the lower end of the small intestine. Then the surgeon brings the cut end near the bottom of the small intestine up to the other cut end, just below the duodenum. The remaining portion of the small intestine, attached to the colon, is then connected to the duodenum, allowing the digestive juices produced to mix with the food entering from the stomach. The objective of a Duodenal Switch is to reduce the amount of time the body has to capture calories from food in the small intestine and selectively limit its absorption of fat. As a result of these changes, food bypasses most of the small intestine, limiting the absorption of calories and nutrients. For the intestinal bypass portion of the operation, the lower intestine is divided so that two thirds or more of the intestine is bypassed.
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The separated section of the intestine isn't removed from the body. Instead, it's reattached to the end of the intestine, allowing bile and pancreatic digestive juices to flow into this part of the intestine. This is the biliopancreatic diversion.
Minimally Invasive Techniques
Your surgeon may use different devices, such as magnets or robotic surgery, to reduce the number of incisions needed to perform a duodenal switch.
Loop Duodenal Switch Alternative
Unlike the traditional duodenal switch, the loop duodenal switch, or SADI surgery, requires only one cut of the duodenal. A loop is created and attached to the stomach.
Candidacy and Evaluation
Duodenal switch surgery can help you lose excess weight and reduce your risk of other life-threatening health problems. It is usually an option for obese patients that have struggled to lose weight using diet and exercise. 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. To be considered a candidate for the SADI-S procedure, your BMI (calculated using your weight and height) must be at or above 50.
The Screening Process
If your healthcare provider believes you’re a good candidate for surgery, you’ll enter a screening process. This could involve:
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- 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
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.
Contraindications
But a BPD/DS isn't for everyone who is severely overweight. You also must be willing to make permanent changes to lead a healthier lifestyle both before and after surgery.
The Surgical Procedure
The Duodenal Switch is an inpatient surgical procedure takes approximately 2 to 3 hours to complete. BPD/DS is done in the hospital. The length of your hospital stay will depend on your recovery and which procedure you're having done.
The First Step of a BPD/DS
The first step in a BPD/DS involves removing part of the stomach. After making the cuts with the open or laparoscopic technique, the surgeon removes a large portion of the stomach and forms the remaining portion into a narrow sleeve. The surgeon leaves intact the valve that releases food to the small intestine, known as the pyloric valve.
The Second Step of a BPD/DS
During the second step, the surgeon makes one cut through the part of the small intestine just below the duodenum. A second cut is then made farther down, near the lower end of the small intestine. Then the surgeon brings the cut end near the bottom of the small intestine up to the other cut end, just below the duodenum. Each step of the surgery usually takes a few hours.
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Two-Stage Procedure
Duodenal switch surgery is sometimes performed in two stages: stage one involves gastric sleeve surgery and stage two involves rerouting the small intestine.
Post-Operative Care and Recovery
Now is a good time to plan for your recovery after surgery. With the extent of the Duodenal Switch procedure, patients should plan to remain in the hospital for 2 to 3 days. Patients are generally able to return to work after 2 weeks and can expect a full recovery within 4 to 6 weeks, once the incisions have healed completely. Immediately after a BPD/DS procedure, you may have liquids but no solid food as your stomach and intestines begin to heal.
Dietary Progression
As far as eating goes, your stomach will be sensitive at first so you will start on a liquid diet and slowly transition back to solid foods. 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. Before surgery, you’ll need to follow a specific weight-loss diet for about two weeks. After surgery, you’ll need to follow specific diet levels provided by your bariatric surgery team-starting from an all-liquid diet and eventually moving to soft foods.
Nutritional Supplementation
The American Society for Metabolic and Bariatric Surgery recommends that patients take plenty of supplements following the Duodenal Switch procedure in order to help prevent nutritional deficiencies. Therefore, you will be taking several vitamins post-op, including a daily multi-vitamin and plenty of vitamin A, D, E and K supplements. You'll also have frequent medical checkups to monitor your health in the first several months after weight-loss surgery.
Lifestyle Adjustments
Patients are then encouraged to implement a restricted diet and begin a regular exercise regimen as part of their daily routine. 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.
High-Protein Diet
You will be asked to embark on a high-protein diet that consists of small, nutritious meals that also include fruits, vegetables, whole grains and omega-3 fatty acids. You also be tasked with avoiding sugar as much as possible.
Follow-Up Care
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.
Benefits of the Duodenal Switch
Patients who choose to undergo Duodenal Switch lose most of their excess weight quickly. Duodenal switch results in greater, more rapid weight loss than other weight loss procedures and less chance of regaining weight. In fact, patients will see most of their weight loss within the first year following surgery. And by the second year, individuals will lose, on average, approximately 70 to 80 percent of their excess weight. After a BPD/DS, it may be possible to lose 70% to 80% of your excess weight within two years.
Resolution of Co-morbidities
Duodenal Switch patients are more likely to maintain a healthier weight long-term, and as a result, experience significant improvements to their overall health and more complete resolution of obesity-related conditions. By losing excess weight, other illnesses associated with obesity can greatly improve.
Curing obesity, through either surgical or non-surgical weight loss, can lead to the reversal of or relief from a number of health concerns. This happens for a number of reasons, each unique to various bodily systems. And studies show that consequential weight loss reduces these issues in many patients by a significant percentage:
- 57% resolution of migraines
- 80% resolution of metabolic syndrome
- 83 %resolution of type 2 diabetes
- 95% resolution of venous stasis disease
- 72% resolution of gout
- 55% resolution of depression
- 74-98% resolution of obstructive sleep apnea
- 82% resolution of asthma
- 82% resolution of cardiovascular disease (including lower blood pressure)
- 72-98% resolution of acid reflux/GERD
- 41-76% resolution of degenerative joint disease
There is also a 95% improvement in the quality of life for patients, while five-year mortality rates drop by 89%.
Tolerable Diet and Reduced Dumping Syndrome
The diet following the Duodenal Switch is also very tolerable and considered more “normal” than with some other bariatric procedures. And since the pyloric valve between the stomach and small intestine is preserved, patients who have undergone the procedure will not experience “dumping syndrome,” which is what happens when food moves too quickly from the stomach into the first part of the small intestine. Dumping syndrome can produce a number of unpleasant symptoms, including nausea, vomiting, abdominal cramping, diarrhea, bloating, weakness, dizziness, sweating and even rapid or irregular heartbeat.
Advantages of Duodenal Switch
Some more specific advantages are:
- 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
Risks and Considerations
Like any surgery, a duodenal switch carries some risk for complications; the risk for these complications are increased for obese patients. Duodenal switch surgery is not reversible, and some people may have complications after the surgery.
Malnutrition and Vitamin Deficiencies
The duodenal switch has more potential than other bariatric surgeries to cause vitamin, mineral and protein deficiencies. One of the complications of duodenal switch surgery includes protein, vitamin and mineral deficiencies. That’s why following dietary and vitamin supplementation guidelines from our bariatric team is critical to avoid serious nutritional complications over time. 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.
Other Risks
Other risks may include:
- Having several bowel movements a day.
- Dumping syndrome, when food moves too quickly through the digestive system. This can lead to nausea, vomiting and diarrhea.
- Gastroesophageal Reflux (GERD) - Because the procedure reduces the size of the stomach, it may also increase pressure on the esophagus.
- Loose Bowels and Foul-Smelling GasCan occur if dietary guidelines are not followed.
Higher Technical Complexity
This complex surgery requires the skills of an experienced surgeon to minimize the risk of complications.
Disadvantages of Duodenal Switch
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.
Long-Term Commitment
As impressive as the Duodenal Switch sounds it is not a shortcut or cheat code to magically restore your health. No matter how much weight the surgery may help you to lose, patients must still stick to a regimented diet and health plan post-surgery. Failure to do so can derail whatever gains made and lead patients right back to weight increase - no matter how much they lost in the first few years following the operation.
Lifestyle Changes
The long-term success of bariatric surgery depends on your ability to make permanent changes in your diet, behavior, and exercise.
The Importance of Support
That’s why we ensure that our patients understand that bariatric surgery is just one part of a total approach to health. A Duodenal Switch is a powerful weight loss tool, but in order to experience a lasting positive outcomes, the patient must make a choice to change his or her mentality and stick with the program we outline.
SADI-S Procedure
SADI-S-which stands for single anastomosis duodeno-ileostomy with sleeve gastrectomy-is the newest and most aggressive of the 5 bariatric surgeries that Virtua offers. The first procedure is a restrictive surgery known as a gastric-sleeve surgery or sleeve gastrectomy. It’s minimally invasive-using only 4-5 tiny incisions. The second step is a malabsorption surgery called an intestinal bypass. The procedure bypasses all but 10 feet of your small intestine and strictly limits the amount of calories and nutrients you can absorb from food.
Advantages of SADI-S
The SADI-S weight-loss surgery can help you lose a significant amount of weight. Previous versions of this bariatric surgery procedure removed more of the intestine, which made it difficult for patients to get all the nutrients they needed to maintain their health. Additionally, Virtua is one of the only hospitals in the area to perform the SADI-S procedure laparoscopically, using several small incisions instead of one large incision in your abdomen.
When Weight-Loss Surgery Doesn't Work
It's possible to not lose enough weight or to regain weight after weight-loss surgery. This weight gain can happen if you don't follow the recommended lifestyle changes. If you frequently snack on high-calorie foods, for instance, weight loss can stall. It's important to keep all of your scheduled follow-up appointments after weight-loss surgery so your doctor can monitor your progress.