Duodenal switch
Encyclopedia
The duodenal switch procedure, also known as biliopancreatic diversion with duodenal switch (BPD-DS) or gastric reduction duodenal switch (GRDS), is a weight loss surgery
procedure that is composed of a restrictive and a malabsorptive aspect.
The restrictive portion of the surgery
involves removing approximately 70% of the stomach
along the greater curvature.
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 only absorb approximately 20% of the fat they intake.
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. The results are so favorable that some surgeons in Europe are performing the "switch" or intestinal surgery on non-obese patients for the benefits of curing the diabetes.
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%.
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.
Diet following the DS is more normal and better tolerated than with other surgeries.
The malabsorptive component of the DS is fully reversible as no small intestine is actually removed, only re-routed.
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.
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; avoiding simple carbohydrates and fatty foods.
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, some reversal by stretching always occurs.
.
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 hernia
and bowel obstruction
.
Malnutrition is an uncommon and preventable risk after duodenal switch.
state that if you meet the following guidelines, weight loss surgery may be an appropriate measure for permanent weight loss:
Bariatrics
Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity. The term bariatrics was created around 1965, from the Greek root bar- , suffix -iatr , and suffix -ic...
procedure that is composed of a restrictive and a malabsorptive aspect.
The restrictive portion of the surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
involves removing approximately 70% of the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
along the greater curvature.
The malabsorptive portion of the surgery reroutes a lengthy portion of the small intestine
Small intestine
The small intestine is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. In invertebrates such as worms, the terms "gastrointestinal tract" and "large intestine" are often used to...
, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive
Digestive
Digestive may refer to:*Digestion, biological process of metabolism*Digestive biscuit, a British semi-sweet biscuit*Digestif, small beverage at the end of a meal...
loop, takes food from the stomach to the common channel. The much longer pathway, the biliopancreatic loop, carries bile from the liver
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
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
Bile
Bile or gall is a bitter-tasting, dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the process of digestion of lipids in the small intestine. In many species, bile is stored in the gallbladder and upon eating is discharged into the duodenum...
from the biliopancreatic loop before emptying into the large intestine
Large intestine
The large intestine is the third-to-last part of the digestive system — — in vertebrate animals. Its function is to absorb water from the remaining indigestible food matter, and then to pass useless waste material from the body...
. 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
Fat
Fats consist of a wide group of compounds that are generally soluble in organic solvents and generally insoluble in water. Chemically, fats are triglycerides, triesters of glycerol and any of several fatty acids. Fats may be either solid or liquid at room temperature, depending on their structure...
. As a result, following surgery, these patients only absorb approximately 20% of the fat they intake.
Advantages
The primary advantage of duodenal switch (DS) surgery is that its combination of moderate intake restriction with substantial calorie malabsorption results in a very high percentage of excess weight loss for obese individuals, with a very low risk of significant weight regain.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. The results are so favorable that some surgeons in Europe are performing the "switch" or intestinal surgery on non-obese patients for the benefits of curing the diabetes.
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%.
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
Ghrelin
Ghrelin is a 28 amino acid peptide and hormone that is produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger. Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone...
, is removed with the greater curvature of the stomach.
Diet following the DS is more normal and better tolerated than with other surgeries.
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 vitaminVitamin
A vitamin is an organic compound required as a nutrient in tiny amounts by an organism. In other words, an organic chemical compound is called a vitamin when it cannot be synthesized in sufficient quantities by an organism, and must be obtained from the diet. Thus, the term is conditional both on...
and mineral
Mineral
A mineral is a naturally occurring solid chemical substance formed through biogeochemical processes, having characteristic chemical composition, highly ordered atomic structure, and specific physical properties. By comparison, a rock is an aggregate of minerals and/or mineraloids and does not...
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
Calcium citrate
Calcium citrate is the calcium salt of citric acid. It is commonly used as a food additive , usually as a preservative, but sometimes for flavor. In this sense, it is similar to sodium citrate. Calcium citrate is also used as a water softener because the citrate ions can chelate unwanted metal...
, and the fat-soluble vitamins A, D, E and K.
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; avoiding simple carbohydrates and fatty foods.
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, some reversal by stretching always occurs.
Risks
All surgical procedures involve a degree of risk however this must be balanced against the significant risks associated with severe obesityObesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
.
Some of the surgical risks or complications for this procedure are: perforation involving small bowel, duodenum
Duodenum
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
, or stomach causing a leak, infection, abscess, deep vein thrombosis
Deep vein thrombosis
Deep vein thrombosis is the formation of a blood clot in a deep vein. Deep vein thrombosis commonly affects the leg veins or the deep veins of the pelvis. Occasionally the veins of the arm are affected...
(blood clot), and pulmonary emboli (blood clot traveling to the lungs).
Longer term risks include hernia
Hernia
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm....
and bowel obstruction
Bowel obstruction
Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
.
Malnutrition is an uncommon and preventable risk after duodenal switch.
Qualifications
The National Institutes of HealthNational Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
state that if you meet the following guidelines, weight loss surgery may be an appropriate measure for permanent weight loss:
- BMIBody mass indexThe body mass index , or Quetelet index, is a heuristic proxy for human body fat based on an individual's weight and height. BMI does not actually measure the percentage of body fat. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing...
of 40 or over - BMI of 35 or over with obesity-related illnesses such as:
- Diabetes mellitus type 2Diabetes mellitus type 2Diabetes mellitus type 2formerly non-insulin-dependent diabetes mellitus or adult-onset diabetesis a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Diabetes is often initially managed by increasing exercise and...
- Coronary heart diseaseCoronary heart diseaseCoronary artery disease is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the myocardium with oxygen and nutrients. It is sometimes also called coronary heart disease...
- Sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
- OsteoarthritisOsteoarthritisOsteoarthritis also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion...
- Diabetes mellitus type 2
- An understanding of the operation and lifestyle changes necessary following the surgery.