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Monday, January 23, 2006

About the Duodenal Switch
Duodenal Switch procedure (also called vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS) is performed by approximately 50 surgeons worldwide. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) and by limiting the amount of food (specifically fat) that is absorbed into the body (intestinal bypass or duodenal switch). It is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to augment and help maintain long-term weight loss. Of the procedures currently performed for the treatment of obesity, it has some powerful and effective components, but also maybe associated with more complications associated with it. Because of this, some insurance companies will not authorize it and consider it investigational. Most surgeons do not perform this procedure because of concerns about the long-term effects of malabsorption and the technical difficulty involved with this procedure.

Restriction (Vertical Gastrectomy): The stomach is restricted by dividing it vertically and removing more than 85 percent of it. This part of the procedure is not reversible. The stomach that remains is shaped like a thin banana and measures from 4-7 ounces (120-250cc) depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary.

Malabsorption (Duodenal Switch): The intestines are divided and rearranged to separate food from the digestive juices, thereby creating malabsorption. The food limb is attached to the duodenum and receives food from the stomach. This limb is 150 cm long. The digestive juices are now separated from the food and travel for more than 500 cm in the bypassed small intestine. Food and digestive juices mix and travel together for 100 cm in the common limb. Thus, food and digestive juices are separated for most of the length of the intestines. This prevents patients who have undergone this surgery from absorbing all of the calories they eat. By comparison, the intestinal bypass in a Roux-en-Y gastric bypass is much less extensive, and the common limb for digestive juices and food to mix is approximately five times longer. The Roux-en-Y gastric bypass, therefore, has minimal malabsorption compared to the Duodenal Switch procedure.

Duodenal Switch Advantages
The more normal stomach allows for better eating quality
No dumping syndrome because the pylorus is preserved
Minimizes ulcer risk
Very effective for high BMI patients (BMI>55 kg/m2)
The intestinal bypass is partially reversible for those having malabsorptive complications
Laparoscopic approach is offered by some surgeons
Duodenal Switch Disadvantages
Greater chance of chronic diarrhea
Significant malabsorption leads to anemia, protein deficiency and metabolic bone disease in up to 5 percent of patients
More foul smelling stools and gas
Carbohydrates can be well absorbed and if eaten in significant quantities lead to inadequate weight loss
This procedure is the most complex surgical weight loss procedure and may yield an unacceptable level of complications in high risk patients (heart failure, sleep apnea)

As with any surgery, there can be complications. Complications can include:

DVT (blood clot in leg) --0.7%
Pulmonary Embolus (blood clot to lung) --0.5%
Pneumonia --0.5%
Splenectomy --0.9%
Gastric leak and fistula --2.0%
Duodenal leak --1.5%
Distal Roux-en-Y leak --0.25%
Postoperative bleeding --0.5%
Duodenal stomal obstruction --0.75%
Small bowel obstruction --2.0%
Death -- 1.0%

Some useful links:
Duodenal Switch Information Zone
Anne Collins
Obesity Law Institute
MedLine Plus
ABC News
Food & Diet
The American Society for Bariatric Surgery (ASBS)
California Pacific Medical Center


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