Duodenal switch

Last updated
Duodenal switch
ICD-9-CM 43.89, 45.51 45.91 [1]

The duodenal switch (DS) procedure, gastric reduction duodenal switch (GRDS), is a weight loss surgery procedure that is composed of a restrictive and a malabsorptive aspect.

Contents

The restrictive portion of the surgery involves removing approximately 70% of the stomach (along the greater curvature) and most of the duodenum.

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 much longer pathway, the biliopancreatic loop, carries bile from the liver 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 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. As a result, following surgery, these patients absorb only approximately 20% of the fat they consume.

Comparison to other surgeries

Advantages

The primary advantage of duodenal switch (DS) surgery is that its combination of moderate intake restriction with substantial calorie malabsorption results in a higher percentage of excess weight loss versus a purely restrictive gastric bypass for all individuals [2] In a Systemic Meta Analysis of the weight loss surgical procedures Buckwald et al. [3] Type 2 diabetics have had a 98% "cure" [4] (i.e. became euglycemic) almost immediately following surgery which is due to the metabolic effect from the intestine switch. The results are so favorable that some surgeons in Europe are performing the "switch" or intestinal surgery on non-obese patients curing diabetes. Novel operations are geared toward the treatment of diabetes and not necessarily to induce weight loss. Among the most prominent of these operations are the duodenal-jejunal bypass and ileal transposition where duodenal switch is a part of the operation. [5]

The following observations were reported on the resolution of obesity related comorbidities following the duodenal switch: type 2 diabetes 99%, hyperlipidemia 99%, sleep apnea 92%, and hypertension 83%. [6]

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've undergone the Roux-en-Y gastric bypass surgery (RNY). Much of the production of the hunger hormone, ghrelin, is removed with the greater curvature of the stomach.

The summarized data can be found on a poster: comparative poster

Diet following the DS is more normal and better tolerated than with other surgeries. [7]

The malabsorptive component of the DS is fully reversible as no small intestine is actually removed, only re-routed.

Disadvantages

The malabsorptive element of the DS requires that those who undergo the procedure take vitamin and mineral supplements above and beyond that of the normal population, as do patients having the RNY surgery. Commonly prescribed supplements include a daily multivitamin, calcium citrate, and the fat-soluble vitamins A, D, E and K. [8]

Because gallstones are a common complication of rapid weight loss following any type of weight loss surgery, some surgeons may remove the gall bladder as a preventative measure during the DS or the RNY. Others prefer to prescribe medication to reduce the risk of post-operative gallstones.

Like RNY patients, DS patients require lifelong and extensive blood tests to check for deficiencies in life critical vitamins and minerals. Without proper follow up tests and lifetime supplementation RNY and DS patients can become ill. This follow-up care is non-optional and must continue for as long as the patient lives.

DS patients also have a higher occurrence of smelly flatus and diarrhea, although both can usually be mitigated through diet, including avoiding simple carbohydrates.

The restrictive portion of the DS is not reversible, since part of the stomach is removed. However, the stomach in all DS patients does expand over time, and while it will never reach the same size as the natural stomach in most patients, some stretching does occur.

Risks

All surgical procedures involve a degree of risk however this must be balanced against the significant risks associated with severe obesity.

Some of the surgical risks or complications for this procedure are: perforation involving small bowel, duodenum, or stomach causing a leak, infection, abscess, deep vein thrombosis (blood clot), and pulmonary emboli (blood clot traveling to the lungs).

Longer term risks include the possibility of vitamin and mineral deficiency, hernia and bowel obstruction. There is little information as to the longer-term risks (greater than 15 years), as this procedure was very rarely performed prior to the year 2000.

The traditional biliopancreatic diversion with duodenal switch (BPD-DS) led to persistent malnutrition in a subset of patients. However, the loop duodenal switch reduces this risk because it bypasses a smaller portion of the small intestine, but there is no long term information for the loop duodenal switch to fully and accurately compare. [9] Malnutrition is an uncommon and preventable risk after duodenal switch. [10]

Qualifications

The National Institutes of Health state that for patients who meet the following guidelines, [11] weight loss surgery may be an appropriate measure for permanent weight loss:

Costs

Compared with the other three generally accepted bariatric surgery procedures (gastric bypass, gastric banding and gastric sleeve), duodenal switch surgery is the most expensive procedure to perform due to its more complicated nature and longer operating times. Because it is more complicated and is performed less often than the other common procedures (lower demand), it is also performed by a relatively small percentage of surgeons which further drives up the price due to lack of competition.

Patients without insurance (also called "self-pay" patients by most bariatric practices) can expect to pay an average of about $27,000 in the United States, although this varies widely across states and clinics. For example, surgical practices in the least expensive state (New Jersey) average about $24,000 while practices in the most expensive state (Nebraska) charge about $32,500. [12] This surgery is also performed by some surgeons in Mexico at a much lower cost than in the United States.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Gastric bypass surgery</span> Type of bariatric surgery

Gastric bypass surgery refers to a technique in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different gastric bypass procedures (GBP). Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.

<span class="mw-page-title-main">Gastrectomy</span> Surgical removal of the stomach

A gastrectomy is a partial or total surgical removal of the stomach.

<span class="mw-page-title-main">Vertical banded gastroplasty surgery</span>

Vertical banded gastroplasty (VBG), also known as stomach stapling, is a form of bariatric surgery for weight control. The VBG procedure involves using a band and staples to create a small stomach pouch. In the bottom of the pouch is an approximate one-centimeter hole through which the pouch contents can flow into the remainder of the stomach and hence on to the remainder of the gastrointestinal tract.

<span class="mw-page-title-main">Duodenal cancer</span> Medical condition

Duodenal cancer is a cancer in the first section of the small intestine known as the duodenum. Cancer of the duodenum is relatively rare compared to stomach cancer and colorectal cancer. Its histology is usually adenocarcinoma.

<span class="mw-page-title-main">Adjustable gastric band</span> Inflatable silicone device

A laparoscopic adjustable gastric band, commonly called a lap-band, A band, or LAGB, is an inflatable silicone device placed around the top portion of the stomach to treat obesity, intended to decrease food consumption.

<span class="mw-page-title-main">Sleeve gastrectomy</span> Surgical weight-loss procedure involving reduction of stomach size

Sleeve gastrectomy or vertical sleeve gastrectomy, is a surgical weight-loss procedure, typically performed laparoscopically, in which approximately 75 - 85% of the stomach is removed, along the greater curvature, which leaves a cylindrical, or "sleeve"-shaped stomach the size of a banana. Weight loss is affected not only through the reduction of the organ's size, but by the removal of the portion of it that produces ghrelin, the hormone that stimulates appetite. Patients can lose 50-70 percent of excess weight over the course of the two years that follow the surgery. The procedure is irreversible, though in some uncommon cases, patients can regain the lost weight, via resumption of poor dietary habits, or dilation of the stomach over time, which can require gastric sleeve revision surgery to either repair the sleeve or convert it to another type of weight loss method that may produce better results, such as a gastric bypass or duodenal switch.

Bariatric surgery is a medical term for surgical procedures used to manage obesity and obesity-related conditions. Long term weight loss with bariatric surgery may be achieved through alteration of gut hormones, physical reduction of stomach size, reduction of nutrient absorption, or a combination of these. Standard of care procedures include Roux en-Y bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, from which weight loss is largely achieved by altering gut hormone levels responsible for hunger and satiety, leading to a new hormonal weight set point.

<span class="mw-page-title-main">American Society for Metabolic & Bariatric Surgery</span> Organization

The American Society for Metabolic & Bariatric Surgery (ASMBS) is a non-profit medical organization dedicated to metabolic and bariatric surgery, and obesity-related diseases and conditions. It was established in 1983, and its stated vision is “to improve the public health and well being of society by lessening the burden of obesity and obesity-related diseases throughout the world.”

StomaphyX is an endoscopic suturing system designed to treat patients who have had previous Roux-en-Y gastric bypass surgery. Following this surgery, the stomach pouch and stomach outlet (stoma) becomes enlarged in some patients. The StomaphyX device can be used to restrict the size of the stoma without exposing the patient to further surgical risk.

Jejunoileal bypass (JIB) was a surgical weight-loss procedure performed for the relief of morbid obesity from the 1950s through the 1970s in which all but 30 cm (12 in) to 45 cm (18 in) of the small bowel were detached and set to the side.

Revision weight loss surgery is a surgical procedure that is performed on patients who have already undergone a form of bariatric surgery, and have either had complications from such surgery or have not achieved significant weight loss results from the initial surgery. Procedures are usually performed laparoscopically, though open surgery may be required if prior bariatric surgery has resulted in extensive scarring.

Henry Buchwald is an Austrian-American surgeon and academic. He is the Professor of Surgery and Biomedical Engineering and the Owen and Sarah Davidson Wangensteen Chair in Experimental Surgery Emeritus at the University of Minnesota, Minneapolis, Minnesota.

<span class="mw-page-title-main">SADI-S surgery</span>

SADI-S is a bariatric surgical technique to address metabolic disorders and to lose weight. It is a variation on the Duodenal Switch surgery, incorporating a vertical sleeve gastrectomy with a gastric bypass technique.

A duodenal-jejunal bypass liner, commonly called an EndoBarrier, is an implantable medical device in the form of a thin flexible 60 cm-long tube that creates a physical barrier between ingested food and the duodenum/proximal jejunum. The duodenal-jejunal bypass liner prevents the interaction of food with enzymes and hormones in the proximal intestine to treat type 2 diabetes and obesity. The duodenal-jejunal bypass liner is delivered endoscopically and has been tested on the morbidly obese as well as obese patients with a BMI less than 40, particularly those with difficult-to-manage type 2 diabetes. Despite a handful of serious adverse events such as gastrointestinal bleeding, abdominal pain, and device migration — all resolved with device removal — initial clinical trials have produced promising results in the treatment's ability to improve weight loss and glucose homeostasis outcomes.

Ileal Interposition is a Metabolic Surgery procedure, used to treat overweight diabetic patients through surgical means. First presented by the Brazilian surgeon Aureo De Paula in 1999, this technique is applied by placing ileum, which is the distal part of the small intestine, either between stomach and the proximal part of the small intestine (1) or by placing the ileum to the proximal part of the small intestine without touching the natural connections of the stomach (2). There are 2 different versions of the operation. Sleeve gastrectomy procedure is standard for both of the versions.

Stomach Intestinal Pylorus-Sparing (SIPS) surgery is a type of weight-loss surgery. It was developed in 2013 by two U.S. surgeons, Daniel Cottam from Utah and Mitchell S. Roslin from New York.

In medicine, endoscopic sleeve gastroplasty (ESG) is a minimally-invasive, non-surgical (incisionless), endoscopic weight loss procedure that is part of the field of endoscopic bariatric therapies. To perform ESG, a physician sutures a patient’s stomach into a narrower, smaller tube-like configuration. The result is a more restricted stomach that forces patients to feel fuller sooner, eating fewer calories, which facilitates weight loss.

Intestinal bypass is a bariatric surgery performed on patients with morbid obesity to create an irreversible weight loss, when implementing harsh restrictions on the diets have failed. Jejunocolic anastomosis was firstly employed. Nonetheless, it led to some unexpected complications such as severe electrolyte imbalance and liver failure. It was then modified to jejunoileal techniques. Viewed as a novel form of treatment for obesity, many intestinal bypass operations were carried out in the 1960s and 1980s. Significant weight loss was observed in patients, but this surgery also resulted in several complications, for instance, nutritional deficiencies and metabolic problems. Due to the presence of surgical alternatives and anti-obesity medications, intestinal bypass is now rarely used.

<span class="mw-page-title-main">Edward E. Mason</span> American surgeon and research scientist

Edward Eaton Mason was an American surgeon, professor, and medical researcher who specialized in obesity surgery. He is known for developing restrictive gastric surgery for morbidly obese patients. Mason introduced the first gastric bypass surgery in 1966 and was the inventor of the first vertical banded gastroplasty surgery in 1980.

<span class="mw-page-title-main">Antrectomy</span> Type of gastric resection surgery

Antrectomy, also called distal gastrectomy, is a type of gastric resection surgery that involves the removal of the stomach antrum to treat gastric diseases causing the damage, bleeding, or blockage of the stomach. This is performed using either the Billroth I (BI) or Billroth II (BII) reconstruction method. Quite often, antrectomy is used alongside vagotomy to maximise its safety and effectiveness. Modern antrectomies typically have a high success rate and low mortality rate, but the exact numbers depend on the specific conditions being treated.

References

  1. ↑ "Coding for Obesity". Archived from the original on 2007-11-11. Retrieved 2007-10-14.
  2. ↑ L. Biertho et al. BPL-DS indicated for patient with BMI<50. SOARD 6(2010)508-515.
  3. ↑ Bariatric Surgery, A systematic Review and Meta-Analysis JAMA, October 13, 2004-Vol (292) (14) 1724-1728
  4. ↑ Hess DS, Hess DW, Oakley RS (2005). "The Biliopancreatic Diversion with the Duodenal Switch: Results Beyond 10 Years". Obesity Surgery. 15 (3): 408–16. doi:10.1381/0960892053576695. PMID   15826478. S2CID   33367968.
  5. ↑ Rubino F, Moo T, Rosen DJ, Dakin GF, Pomp A (2009). "Diabetes Surgery: A New Approach to an Old Disease". Diabetes Care. 32(Suppl 2) (suppl_2): S368–S372. doi:10.2337/dc09-S341. PMC   2811475 . PMID   19875583.
  6. ↑ Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K (2004). "Bariatric surgery: a systematic review and meta-analysis". JAMA. 292 (14): 1724–37. doi:10.1001/jama.292.14.1724. PMID   15479938.
  7. ↑ Baltasar A, Bou R, Bengochea M, Arlandis F, Escriva C, Mir J, Martinez R, Perez N (2001). "Duodenal switch: an effective therapy for morbid obesity--intermediate results". Obesity Surgery. 11 (1): 54–8. doi:10.1381/096089201321454114. PMID   11361169. S2CID   29234731.
  8. ↑ Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, Olbers T, Bøhmer T (2009). "Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch". American Journal of Clinical Nutrition . 90 (1): 15–22. doi: 10.3945/ajcn.2009.27583 . PMID   19439456.
  9. ↑ "Duodenal Switch Surgery (SADI-S)" . Retrieved 2016-12-20.
  10. ↑ Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S (2007). "Duodenal Switch: Long-Term Results". Obesity Surgery. 17 (11): 1421–30. doi:10.1007/s11695-008-9435-9. PMID   18219767. S2CID   46536628.
  11. ↑ Weight-control Information Network, National Institutes of Health. Gastrointestinal Surgery for Severe Obesity Archived 2015-03-30 at the Wayback Machine
  12. ↑ Quinlan, J, Duodenal Switch Surgery (DS): Complete Patient Guide, Bariatric Surgery Source, retrieved 10 November 2014
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.