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Will Weight Loss Surgery Resolve All Common Co-Morbid Conditions?

August 28, 2020 1:07 pm

This is an article that I wrote for Obesity Help. You can find the article at the following link.

Blood Work and Lab Orders

June 21, 2020 12:19 pm

Routine blood work and lab orders are vital to maintaining good health following the Duodenal Switch weight loss surgery. Everyone’s body is different and by examining the blood work and adjusting vitamin, mineral supplements and protein intake a patient will not only be healthier, but will also be able to detect any potential problems that may occur. The surgeon will have his or her own list of recommended blood work and lab orders. Be sure to follow the surgeon’s guidelines and send the results to the surgeon for evaluation. For informational purposes only there are lists of blood work and lab orders from various sources to follow. From the American Association of Clinical Endocrinologists: AACE Guidelines  

Recommended Biochemical Surveillance of Nutritional Status After Malabsorptive Bariatric Surgical Procedures

Time Interval First Year – every 3-6 months. Some surgeons get an abbreviated limited blood work at 4-8 weeks time base on a patients specific clinical condition. Thereafter – Every 6-12 months depending on symptoms. Laboratory tests CBC, platelets Electrolytes Glucose Iron studies, ferritin Vitamin B12 Liver function Lipid profile Albumin and Pre-albumin RBC folate Fat-soluble vitamins (6-12 months) – Vitamin A – Vitamin D, 25-OH – Vitamin E – Vitamin K1 and INR Metabolic bone evaluation – Intact PTH – 24-Hour urine calcium – Urine N-telopeptide (annually) Metabolic stone evaluation (annually) – 24-Hour urine calcium, citrate, uric acid and oxalate Zinc – Trace elements (annually or as needed) – Selenium Miscellaneous (as needed) – Carnitine – Essential fatty acid chromatography

Causes of Morbid Obesity

June 21, 2020 12:17 pm

Articles focused on the causes of morbid obesity. Contribution of bariatric surgery to the comprehension of morbid obesity. Marceau Jan 2005 PubMed Abstract Convinced that morbid obesity was not due to food excess but rather to a metabolic disorder, we searched in the literature for data in favor of a metabolic disorder. We have found evidence in support of the thesis that the cause of morbid obesity is the inability to burn excessive caloric intake normally. It would involve the difficulty to increase heat with the amount of calories taken, which would be faulty and force fat deposition. This mechanism called dietinduced thermogenesis (DIT) allows the dispersion by heat of excessive calories to obtain energy balance. Results from bariatric surgery and particularly biliopancreatic diversion (BPD) give further support to this thesis. BPD would improve heat production to a meal (DIT) by one of these mechanisms: increased insulin sensitivity, change in intestinal hormone secretion, or chronic lipid malabsorption. Available results show that surgery, to be efficient, must change the physiology and not solely decrease food intake.

Comparison of DS and RNY

June 21, 2020 12:16 pm

In this section a comparison of DS and RNY bariatric procedures will be made explaining the biological differences in anatomy, how the changes affect the body and the impact they could have on a patient’s lifestyle. Both Roux-en-Y Gastric Bypass (RNY) and Duodenal Switch (DS) contain restrictive and varying degree of malabsorption components, an examination of those differences will then be compared to excess weight loss long term and resolution of comorbidities in both procedures.  

Restrictive Component

RNY A pouch is created at the top part of the stomach to restrict the amount of food a patient can eat. The lower part of the stomach that is no longer used is called the bypassed stomach. Food passes through the anastomosis (connection-stoma) created between the pouch and the small intestine, which is deliberately made quite narrow to keep food in the pouch longer, thus making the patient feel fuller longer. The pylorus is at the bottom of the bypassed stomach and is no longer able to regulate the flow of food into the small intestine. This is the reason why some patients who consume food with high sugar or fat content develop dumping syndrome manifested by high hearth rate, palpitation, nausea, vomiting, and/or explosive diarrhea. The stomach “pouch” is reduced to10 – 30 mL in volume following surgery [51] but will stretch over time. Weight maintenance is achieved through caloric restriction.   Dumping Dumping is the unpleasant and uncomfortable experience that some gastric bypass patients experience. This is caused by unregulated and an uncontrolled flow of food in the small bowel. The symptoms can be divided in to Early and Late Dumping. “Early” dumping begins during or right after a meal; symptoms include nausea, vomiting, bloating, cramping, diarrhea, dizziness and fatigue. “Late” dumping happens 1 to 3 hours after eating; symptoms include weakness, sweating, and dizziness. Some patients choose RNY surgery because they prefer the possibility of “dumping” to help them control eating junk food containing sugar or fat. Approximately 70%-76% of patients dump. [60-64] Patients dump with different foods, some never dump, some only on certain quantities, and some “outgrow” it. Also note, that there is no scientific evidence that shows any benefit to dumping in gastric bypass patients will help them maintain their weight loss. [71]   Ulcers Standard diagnostic techniques can be used on the “pouch” stomach. The “blind” stomach is inaccessible to standard non-evasive diagnostic tools like x-ray and endoscope. It makes it extremely difficult to identify ulcers or masses in the “bypassed” stomach. “Normally if a patient develops ulcer symptoms, a gastroenterologist can look into the stomach with an endoscope and make the diagnosis of an ulcer. If that ulcer is bleeding, the gastroenterologist can also treat the ulcer to stop it from bleeding by injecting a drug into it or putting some electric current on the ulcer to coagulate it. These options are taken away once you have a RNY bypass”. [59] The blind stomach can only be scoped, under general anesthesia, through a small incision on the abdomen wall, and advancing the scope through the incision into the blind stomach. The tissue at the anastomosis, between the stomach and small intestine, has lost some of its blood supply making it more fragile, and increases the risk of ulceration. Smoking will increase the risk of ulceration in the anastomosis area as well.   NSAIDs Taking Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) causes increased risk for ulcers. Since diagnosing and treating ulcers is so difficult in RNY patients due to the fragile state of the anastomosis, many surgeons do not recommend RNY patients take NSAIDs following surgery. NSAIDs include Ibuprofen (Advil, Motrin), Naproxen (Naprosyn, Aleve) etc.   DS About 70% of the outer curvature of the stomach is removed, which reduces the amount of food a patient can eat. The stomach retains normal function, the pylorus continues to control food moving from the stomach into the intestine, and as a result DS patients do not experience “dumping”. A benefit of removing a portion of the stomach is that it also greatly reduces the amount of ghrelin producing tissue and the amount of acid. Ghrelin is the “hunger hormone” and reducing the amount produced suppresses the appetite. The remaining stomach is about 3-5 ounces and holds approximately 90 to 150mL in volume. After DS, patients can consume a wide variety of foods and after about a year they can consume approximately half of their preoperative volume. [2] A DS patient’s stomach is probably the largest out of all other weight loss surgical procedures. The reason is DS weight loss is maintained through malabsorption rather than caloric restriction and the increased protein requirement means more room is needed to consume 100 grams of protein a day. DS patients don’t dump because their pylorus remains in use, so there are no food’s they “can’t” eat. With this freedom comes responsibility, patients need to eat protein based meals following the surgery to stay healthy. Some patients choose DS surgery because they prefer unrestricted food options or they need to continue taking NSAIDs.  

Malabsorption Component

The small intestine consists of 3 sections; duodenum, jejunum and ileum. Vitamins and minerals are absorbed in different sections of the small intestine; bypassing different sections will result in different supplement needs.   RNY The small bowel is divided about 45 cm below the lower stomach. The entire duodenum and a little bit of the jejunum are bypassed.

• Vitamin and mineral supplementation is vital, which require maintaining good health.
• Routine blood work is mandatory. Adjust supplements as necessary.
• Basic vitamin requirements are multivitamins, calcium citrate, B12, B1, and iron.

  DS The small bowel is divided approximately 2 inches into the duodenum. The common channel, where food and bile mix and nutrients are absorbed, is usually 75 – 100 cm.

• This allows a patient to only absorb 20% of the fat they consume. Eating too much fat can cause loose stools. The inability to absorb fats also interferes with absorption of the fat-soluble vitamins A, D, E & K.
• This allows a patient to only absorb approximately 60% of the protein they consume. Patients must intake between 80-120g of protein a day.
• This allows a patient to only absorb 60% of complex carbohydrates and 100% of simple carbohydrates.
• Gas and stool tend to be stronger smelling due to the intestine re-routing and can be enhanced if a patient eats too many simple carbs.

  It is important to bear in mind car service to lax airport during covid-19 and that the percentages given above are at best an estimation of extrapolated information of the relative length of the common channel, and alimentary length as a percentage of the total length. Vitamin and mineral supplementation is vital and a requirement to maintaining good health. Routine blood work is mandatory and adjustment of supplements as necessary. Unfortunately, patients get a false sense of security with the resolution of the comorbidities after weight loss surgery, and fail to follow up with their bariatric surgeon or a primary care physician who has an in-depth understanding of, not only the particular surgery, but also the details of the laboratory studies needed. A common example is when patients return to a surgeon’s office with a very low Vitamin D level, and having only had Calcium levels checked by their primary care for years. Note that Calcium levels will remain normal for some time even with low Vitamin D levels. Weight maintenance is achieved through malabsorption. The malabsorption component is attributed to the higher percentage excess weight loss (EWL) long term when compared to other bariatric procedures. Basic vitamin requirements are multivitamins, calcium citrate, vitamin A, vitamin D, and zinc.  

Excess Weight Loss (EWL)

Excess weight loss percentages can be calculated by determining pounds lost divided by total excess pounds. The RNY and DS statistics for excess weight loss percentages can be found in the AACE/TOS/ASMBS Guidelines. [51]   RNY EWL% at 1-2 years 48%-85% EWL% at 3-6 years 53%-77% EWL% at 7-10 years 25%-68%   DS EWL% at 1-2 years 65%-83% EWL% at 3-6 years 62%-81% EWL% at 7-10 years 60%-80%   Resolution of Comorbidities Following bariatric surgery, many obesity related comorbidities can be improved or cured. The RNY and DS statistics for the resolution of comorbidities can be found in Buchwald et al. Bariatric Surgery: A Systematic Review and Meta-Analysis. [58]   RNY Type 2 Diabetes 84% Hyperlipidemia 97% Hypertension 68% Sleep Apnea 80%   DS Type 2 Diabetes 99% Hyperlipidemia 99% Hypertension 83% Sleep Apnea 92%   The Duodenal Switch weight loss surgery procedure has seen the highest rate of type 2 diabetes cure (remission), often before leaving the hospital following surgery! For more information on how DS surgery can have such a quick result, see the metabolic effect in our section on the Duodenal Switch Procedure.  

Additional Comparisons

Central Valley Bariatrics Weight Loss Surgery Procedures and Outcome

Duodenal Switch As A Revision Surgery

June 21, 2020 12:15 pm

Studies addressing Duodenal Switch as a revision surgery for other failed weight loss surgery procedures. Is biliopancreatic diversion with duodenal switch a solution for patients after laparoscopic gastric banding failure? Poyck et al. Sept 2011 PubMed Abstract BACKGROUND: Weight loss failure after laparoscopic gastric banding (LAGB) can occur in =25% of patients. Conversion to a malabsorptive procedure might provide more durable weight loss. The present study evaluated biliopancreatic diversion with duodenal switch (BPD/DS) after LAGB failure with a 3-year follow-up period. METHODS: A total of 35 patients underwent BPD/DS after LAGB failure and were prospectively analyzed using a multidisciplinary approach. Weight indexes, co-morbidities, complications, morbidity/mortality, and nutritional status were analyzed. RESULTS: Excess weight decreased from 91% (134 kg, body mass index 48 kg/m(2)) to 75% (124 kg, body mass index 44 kg/m(2)) after LAGB failure and decreased further to 40% (100 kg, body mass index 35 kg/m(2)) after BPD/DS. The mean percentage of excess weight loss was 55% after LAGB and BPD/DS together and 48% after BPD/DS alone. The incidence of co-morbidities, such as diabetes, sleep apnea, hypertension, hyperlipidemia, joint problems, and chronic obstructive pulmonary disease was reduced after BPD/DS. Nutritional deficiencies were already present after LAGB failure (e.g., iron, ferritin, vitamins B(12), B(6), A, D, and E, albumin, and calcium) and either increased (folic acid, potassium, and vitamin B(12)), remained stable (iron, ferritin, vitamin A), or decreased after BPD/DS (albumin and vitamins B(6) and E). CONCLUSION: BPD/DS provided substantial weight loss after LAGB failure and reduced the incidence of obesity-related co-morbidities during a 3-year period. Long-term nutritional follow-up is advocated for all patients after malabsorptive BPD/DS. Laparoscopic repeat sleeve gastrectomy versus duodenal switch after isolated sleeve gastrectomy for obesity. Dapri et al. Aug 2010 PubMed Abstract BACKGROUND: Repeat sleeve gastrectomy (re-SG) and the addition of the duodenal switch (DS) are possible options to increase weight loss after isolated SG (ISG). We report the feasibility, safety, and outcomes of laparoscopic re-SG versus DS in patients presenting with insufficient weight loss or weight regain after ISG. METHODS: From November 2003 to December 2009, 7 and 19 patients underwent laparoscopic re-SG and DS, respectively, mainly because of the patients’ dietary habits: volume eating (hyperphagia) was treated by re-SG and eating meals too frequently (polyphagia) by DS. RESULTS: At ISG, the mean weight and BMI was 127.7 ± 31.4 kg, and 45.1 ± 11.8 kg/m(2) for the re-SG group and 119.8 ± 20.9 kg and 41.2 ± 5.5 kg/m(2) for the DS group, respectively. The mean interval between ISG and reoperation was 37.1 ± 20.3 months for the re-SG group and 29.8 ± 24.9 months for the DS group. At reoperation, the mean weight, BMI, and percentage of excess weight loss (%EWL) was 109.7 ± 21 kg, 38.9 ± 8.7 kg/m(2), 24.3 ± 16.6% for the re-SG group and 107.6 ± 19.6 kg, 36.9 ± 4.2 kg/m(2), and 19.5 ± 19.9% for the DS group, respectively. The mean operative time was 137.5 ± 75.5 minutes for the re-SG group and 152.6 ± 54.3 minutes for the DS group. No conversion to open surgery was required, and no mortality occurred. One patient in the re-SG group developed a leak at the angle of His. In the DS group, 1 patient presented with bleeding, 1 patient with a duodenoileostomy leak, and 1 patient with a duodenoileostomy stenosis. The mean hospital stay was 11.5 ± 20.5 days for the re-SG group and 4.7 ± 2.7 days for the DS group. The mean follow-up was 23.2 ± 11.1 months for the re-SG group and 24.9 ± 20.1 months for the DS group. The mean weight, BMI, and %EWL was 100 ± 21.1 kg, 35.3 ± 8.3 kg/m(2), 43.7 ± 24.9% for the re-SG group and 80.7 ± 22.5 kg, 27.3 ± 5.2 kg/m(2), 73.7 ± 27.7% for the DS group, respectively. During follow-up, 3 patients in the DS group required corrective surgery for late complications. CONCLUSION: The results of the present study have shown that laparoscopic re-SG is feasible but carries the risk of fistula development, which is difficult to treat. Laparoscopic DS was also shown to be feasible at a cost of not negligible complications, which are easier to manage than with re-SG. The efficacy seemed greater after DS than after re-SG. Conversion of failed vertical banded gastroplasty to biliopancreatic diversion, a wise option. Weiner et al. Dec 2009 PubMed Abstract BACKGROUND: Reoperations due to failures constitute an essential but challenging part of bariatric surgery practice today. The aim of this study was to evaluate the perioperative safety, efficacy, and postoperative quality of life in patients with biliopancreatic diversion (BPD), after failed vertical banded gastroplasty (VBG). METHODS: Twelve patients after failed or complicated VBG, eight females and four males, median age 45 years (range 39-52), median body mass index (BMI) 46.39 kg/m2 (range 25.89-69.37), who underwent conversion to BPD, were studied. RESULTS: Ten patients due to weight regain and two patients because of severe stenosis of the gastric pouch outlet were submitted in conversion to BPD. In eight (66.6%) patients the primary VBG had been followed by at least one revisional operation due to inadequate weight loss. The 10 patients after failed VBG, reached the lowest BMI recorded after VBG in just a year after BPD (p=0.721 for the comparison between the two time points). The two patients with stomal stenosis regained weight in the first six postoperative months and remain stable since then. Regarding safety, one major perioperative complication (gastrojejunostomy stenosis) occurred. At a median follow-up of 21 months (range 12-30) six complications have been documented, including a case of incisional hernia, four cases of pouch gastritis and a case of intractable iron-deficiency anemia. CONCLUSION: Our early results indicate that conversion of failed VBG to BPD is highly effective with acceptable morbidity. Our data show that the effect on weight is strongly dependent on the indication for the conversion. Conversion to BPD, in such a group of patients, is a wise alternative, since it may reduce operative risks. Laparoscopic conversion of adjustable gastric banding and vertical banded gastroplasty to duodenal switch. Dapri et al. Nov-Dec 2009 PubMed Abstract BACKGROUND: The aim of this retrospective consecutive study was to evaluate the feasibility, safety, and efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) into duodenal switch (DS) by laparoscopy. METHODS: From November 2003 to February 2007, laparoscopic conversion into DS was performed in 1-step in 43 patients, 31 after LAGB and 12 after VBG. The reason for conversion was weight loss issues, such as insufficient excess weight loss (EWL) or weight regain. The mean interval from LAGB and VBG to conversion to the DS was 42.7 +/- 28.7 months and 172.2 +/- 86.9 months, respectively. The mean %EWL at conversion was 8.3% +/- 19.3% after LAGB and 20.8% +/- 30% after VBG. RESULTS: The mean operative time was 205.8 +/- 44.8 minutes for LAGB and 210.9 +/- 53.7 minutes for VBG. No conversions to open surgery occurred. One patient in the LAGB group died on the third postoperative day of sudden death syndrome, as shown by the postmortem examination. Major complications occurred in 6.4% of patients with LAGB (1 hemoperitoneum and 1 ileoileostomy leak) and in 50% with VBG (1 sleeve gastrectomy leak with subsequent duodenoileostomy leak, 3 duodenoileostomy leaks, 1 pancreatitis, and 1 respiratory insufficiency). The mean hospital stay was 5.5 +/- 5 days for the LAGB group and 34.5 +/- 50.3 days for the VBG group. After a mean follow-up of 28 +/- 15.7 months for LAGB to DS and 43.5 +/- 6 months for VBG to DS, reoperations for late complications were required in 6 patients (20.6%) in the LAGB to DS group and in 5 patients (62.5%) in the VBG to DS group. Three patients (25%) died within 8 months after conversion of VBG. The 29 surviving patients (LAGB to DS) showed a mean %EWL and percentage of excess body mass index loss of (%EBMIL) 78.4% +/- 24.9% and 77.8% +/- 23.7%, respectively. The 8 surviving patients (VBG to DS) had a mean %EWL and %EBMIL of 85.1% +/- 20% and 85.8% +/- 18.7%, respectively. CONCLUSION: According to these results, laparoscopic conversion of LAGB to DS seems feasible and effective, despite the 1 death. However, in our hands, laparoscopic conversion of VBG to DS had an unacceptable rate of complications and deaths. Revision bariatric surgery: laparoscopic conversion of failed gastric bypass to biliopancreatic diversion with duodenal switch. Gagner et al. Jun 2009 PubMed Abstract With more than 40% failures of gastric bypass in Body Mass Index>50 kg/m2, a successful alternative has to be proposed. Laparoscopic conversion of failed Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch is technically feasible, safe and can be performed in 1 or 2 stages. This revision surgery is the most effective treatment to date, and should also be proposed for failed vertical-banded gastroplasty, adjustable gastric banding and Magenstrasse and Mill procedure, as it may provide the most durable weight loss of all revision surgeries with acceptable morbidity. This may result in lesser degrees of hypoproteinemia, commonly seen after distal gastric bypass. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Gagner et al. Nov-Dec 2007 PubMed Abstract BACKGROUND: Weight loss failure after Roux-en-Y gastric bypass (RYGB) is a challenging problem facing bariatric surgeons today. Conversion from RYGB to biliopancreatic diversion with duodenal switch (BPD-DS) might provide the most durable weight loss of all revision procedures currently available. Revision to BPD-DS can be done laparoscopically in 1 or 2 stages and involves 4 anastomoses: gastrogastrostomy, duodenoileostomy, ileoileostomy, and jejunojejunostomy (to reconnect the old Roux limb). This study reports on our early outcomes after laparoscopic conversion from RYGB to BPD-DS. METHODS: The data from all patients undergoing conversion from failed RYGB to BPD-DS were retrospectively reviewed. The data analyzed included age, body mass index, excess weight loss, method of gastrogastrostomy, and morbidity/mortality. RESULTS: Twelve patients were identified for analysis. The mean age and body mass index before conversion was 41 years and 41 kg/m(2), respectively. Of these 12 patients, 4 (33%) had undergone revision surgery (lengthening of the Roux limb, resizing the gastric pouch, adjustable band on pouch, or distal gastric bypass) before conversion; 8 (66%) had obesity-related co-morbidities; 7 (58%) underwent conversion to BPD-DS in 1 stage. Most gastrogastrostomies were performed using the 25-mm circular stapler. No patient died and no leaks developed. One patient required laparotomy, and 4 developed stricture at the gastrogastrostomy. The patients lost a dramatic amount of weight after conversion to BPD-DS, with a mean body mass index and excess weight loss of 31 kg/m(2) and 63%, respectively, at 11 months postoperatively. All co-morbidities resolved completely with the weight loss. CONCLUSION: Our preliminary results indicate that laparoscopic conversion to BPD-DS from failed RYGB is highly effective with an acceptable morbidity. Using a linear stapler to construct the gastrogastrostomy might reduce the stricture rate. Duodenal Switch is a Safe Operation for Patients who have Failed Other Bariatric Operations Keshishian et al. Oct 2004 PubMed Abstract Full Article BACKGROUND: The incidence of morbid obesity and its surgical treatment have been increasing over the last few years. With this increase, there has been a rise in the number of patients who have had less than desirable outcome after bariatric operations. We perform the duodenal switch (DS) in patients for whom other weight loss surgical procedures have failed, because of inadequate weight loss, weight regain or significant complications, such as solid intolerance or dumping syndrome. METHOD: From November 1999 to March 2004, 46 revisional surgeries were performed at our institution. The data was prospectively collected and reviewed, based on a number of parameters. Operative details, perioperative morbidity, and results are reported. RESULTS: 46 patients had their original bariatric surgical operation revised to DS. This resulted in complete resolution of their presenting complaints. The %EWL was 69% at the time of publication, with a mean lapsed time of 30 months. We had no mortality. Anastomotic leak occurred in 4 patients, 2 in our first 8 patients. We also noted that the majority of the patients were not aware of all the surgical procedures available to them at the time of their original operation. CONCLUSION: In patients in whom gastroplasty, gastric bypass or both have failed to provide adequate weight loss, or worse have resulted in complications, DS can be performed as a safe revisional operation. The revision of other failed bariatric operations to DS results in both weight loss and resolution of the complications.

Duodenal Switch Compared to Other Weight Loss Surgeries

June 21, 2020 12:14 pm

Clinical data discussing results of Duodenal Switch compared to other weight loss surgeries including Adjustable Gastric Band, Vertical Sleeve Gastrectomy or Gastric Bypass. Perioperative complications in a consecutive series of 1000 duodenal switches. Marceau et al. Nov 2011 PubMed Abstract BACKGROUND: In the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center. METHODS: A consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups. RESULTS: The mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m(2) (47 ± 7 laparoscopy versus 52 ± 8 kg/m(2) open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS. CONCLUSION: The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries. Effect of different bariatric operations on food tolerance and quality of eating. Schweiger et al. Oct 2010 PubMed Abstract ABSTRACT: Many bariatric operations are associated with reduced food tolerance and frequent vomiting, which may cause nutritional deficiencies and influence quality of life. However, the impact of different bariatric procedures on quality of eating and food tolerance has not yet been studied enough. Two hundred and eighteen participants filled a quality of eating questionnaire, at three different time periods after bariatric operation: short-term (3-6 months, n=63), medium-term (6-12 months, n=69) and long-term follow-up (over 12 months, n=86). The participants underwent the following procedures: 99 patients have had Roux-en-Y gastric bypass (RYGB), 49 laparoscopic gastric banding (LAGB), 56 sleeve gastrectomy (SG), and 14 biliopancreatic diversion with duodenal switch (BPD-DS) . At short-term period score achieved for all section of the questionnaire was similar for all operations. The total score of the questionnaire at the medium-term group was 20.27 +/- 3.57, 14.47 +/- 5.92, 22.27 +/- 4.66, and 20.91 +/- 3.26 (p<0.001) and the total score for the long-term group of was 21.56 +/- 5.16, 15.5 +/- 3.75, 20.45 +/- 4.9, and 24.2 +/- 2.16 (p<0.001) for RYGB, LAGB, SG, and BPD-DS, respectively. In a linear regression model we found that LAGB patients had a significantly lower total score compared to all other procedures (p<0.001). Every 1% of %EWL was associated with a total score decrease in 0.045 points (p=0.009). Impaired quality of eating and food intolerance is common following many types of bariatric procedures. However, the difficulties diminish as time passes after operation and can be affected by the type of procedure. Patients undergoing LAGB have significantly greater limitations and difficulties to ingest variety of foods. Comparison of weight loss and body composition changes with four surgical procedures. Gagner et al. April 2009 PubMed Abstract BACKGROUND: A paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group. METHODS: At the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences. RESULTS: A total of 101 gastric bypass (GB) patients were evaluated at 19.1 +/- 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 +/- 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 +/- 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 +/- 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m(2), 53.2, 46.7, and 44.3 kg/m(2) for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 +/- 8.3), 32.5 (difference 15.6 +/- 5.0), 37.2 (difference 18.2 +/- 8.2), and 39.5 kg/m(2) (difference 7.5 +/- 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% +/- 7.0%) 32.7% (16.1% +/- 10.5%) 37.7% (16.7% +/- 5.6%), and 42% (6.0% +/- 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal. CONCLUSION: Although the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.   Obesity surgery results depending on technique performed: long-term outcome. Gracia et al. April 2009 PubMed Abstract BACKGROUND: Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. METHODS: This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). RESULTS: One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. CONCLUSIONS: The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

Duodenal Switch Compared to Gastric Bypass

June 21, 2020 12:08 pm

Articles that discuss Duodenal Switch Compared to Gastric Bypass surgery. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Søvik et al. Feb 2010 PubMed Abstract BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results. METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups. RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001). CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year. Registration number: NCT00327912 (http://www.clinicaltrials.gov). Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI > or = 50 kg/m2) compared with gastric bypass. Prachand et al. Feb 2010 PubMed Abstract OBJECTIVE: Increased body mass index is associated with greater incidence and severity of obesity-related comorbidities and inadequate postbariatric surgery weight loss. Accordingly, comorbidity resolution is an important measure of surgical outcome in super-obese individuals. We previously reported superior weight loss in super-obese patients following duodenal switch (DS) compared to Roux-en-Y gastric bypass (RYGB) in a large single institution series. We now report follow-up comparison of comorbidity resolution and correlation with weight loss. METHODS: Data from patients undergoing DS and RYGB between August 2002 and October 2005 were prospectively collected and used to identify super-obese patients with diabetes, hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD). Ali-Wolfe scoring was used to describe comorbidity severity. Chi-square analysis was used to compare resolution and two-sample t tests used to compare weight loss between patients whose comorbidities resolved and persisted. RESULTS: Three hundred fifty super-obese patients [DS (n=198), RYGB (n=152)] were identified. Incidence and severity of hypertension, dyslipidemia, and GERD was comparable in both groups while diabetes was less common but more severe in the DS group (24.2% vs. 35.5%, Ali-Wolfe 3.27 vs. 2.94, p<0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p<0.05). There were no differences in weight loss between comorbidity “resolvers” and “persisters”. CONCLUSIONS: In comparison to RYGB, DS provides superior resolution of diabetes, hypertension, and dyslipidemia in the super-obese independent of weight loss. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Aasheim et al. July 2009 PubMed Abstract BACKGROUND: Bariatric surgery is widely performed to induce weight loss. OBJECTIVE: The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN: A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS: Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS: Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912. Bowel Habits after Gastric Bypass Versus the Duodenal Switch Operation. Wasserberg et al. Aug 2008 PubMed Abstract BACKGROUND: One of the perceived disadvantages of the biliopancreatic diversion with duodenal switch operation is diarrhea. The aim of this study was to compare the bowel habits of patients after duodenal switch operation or Roux-en-Y gastric bypass. METHODS: A prospective comparative case series design was used. Forty-six patients who underwent duodenal switch (n = 28) or gastric bypass (n = 18) were asked to complete a daily diary for 14 days after losing least 50% of their excess body weight. Data were collected on number of bowel episodes, incontinence, urgency, stool consistency, and awakening from sleep to defecate. Background variables were recorded from the medical files. RESULTS: The duodenal switch group was heavier (body mass index 53.5 vs 47.0 kg/m(2), p = 0.03) and older (47.5 vs 41.0 years, p = NS) than the gastric bypass group. Median time to 50% excess body weight loss was 22 months in the duodenal switch group compared to 10.0 months in the gastric bypass group (p = 0.001). Patients after duodenal switch surgery reported a median of 23.5 bowel episodes over the 14-day study period compared to 16.5 in the gastric bypass group (p = NS). There was no between-group differences in any of the other bowel parameters studied. CONCLUSIONS: Although duodenal switch is associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass. Duodenal Switch Provides Superior Weight Loss in the Super-Obese (BMI >50kg/m2) Compared With Gastric Bypass Prachand et al. Oct 2006 PubMed Abstract OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB). METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight. RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05). CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS. Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population: prospective comparison of the efficacy and the incidence of metabolic deficiencies. Skroubis et al. April 2006 PubMed Abstract BACKGROUND: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. METHODS: From a cohort of 130 patients with BMI 35 to 50 kg/m(2), 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. RESULTS: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. CONCLUSION: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.

Duodenal Switch for Morbid Obesity

June 21, 2020 12:05 pm

A series of articles about Duodenal Switch for Morbid Obesity (BMI > 40). Outcome of laparoscopic duodenal switch for morbid obesity. Magee et al. Oct 2010 PubMed Abstract BACKGROUND: The aim of this study was to determine the safety and efficacy of laparoscopic duodenal switch (LDS) as a treatment option in a selected group of patients with morbid obesity. METHODS: This retrospective analysis of a prospective database assessed the frequency of all complications and alterations in weight, body mass index (BMI), co-morbidity and quality of life. RESULTS: One hundred and twenty-one patients underwent LDS between April 2003 and March 2009. Median preoperative weight was 160 kg and median BMI 55 kg/m(2). All procedures were performed laparoscopically. The in-hospital mortality rate was zero. No ileoduodenal anastomotic stenosis was encountered. There were four clinical leaks (3·3 per cent) managed by laparoscopic drainage and placement of a feeding jejunostomy. Median percentage excess weight loss was 75 per cent at 12 months and 90 per cent at 24 months. Thirty-six of 40 diabetic patients had complete resolution of diabetes within 1 year. There were significant improvements in other obesity-related co-morbidity. Only a few patients developed postoperative protein deficiency, and fat-soluble vitamin deficiencies were easily managed with oral supplementation. CONCLUSION: The LDS procedure is a safe and effective treatment for morbid obesity and its associated co-morbidity in selected patients. Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m(2)? Marceau et al. Sept 2010 PubMed Abstract BACKGROUND: Biliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] >/=50 kg/m(2)). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m(2). METHODS: This was a retrospective study of all patients with a BMI <50 kg/m(2) who had undergone DS from June 1992 to May 2005. The data are reported as the mean +/- standard deviation. RESULTS: The data from 810 consecutive patients, with a mean initial BMI of 44.2 +/- 3.6 kg/m(2), were reviewed. The mean follow-up was 103 +/- 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% +/- 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%, and 37% would have preferred to lose more weight. CONCLUSION: These results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D. The Duodenal Switch Operation for Morbid Obesity Anthone Aug 2005 PubMed Abstract The duodenal switch provides excellent weight loss with preservation of good alimentation, even in the superobese. This is accomplished with acceptable operative mortality and minimal dietary limitations and metabolic sequelae. The results of the duodenal switch that are reported in the literature should remove any inhibitions that exist about the use of this procedure as treatment for patients who have morbid obesity. This article discusses the duodenal switch operation for morbid obesity. The Duodenal Switch as an Increasing and Highly Effective Operation for Morbid Obesity Rabkin et al. June 2004 PubMed Abstract Full Article INTRODUCTION: “Morbid Obesity” (ICD 278.01 / BMI >40) is an entity distinct from “obesity”, the latter term encompassing the broad range of over weight. Available treatment modalities as well as outcomes differ substantially over the spectrum of higher BMI. Representative data for behavior modification, diet and exercise show at best an average weight loss of 4-7 kg at 2 years, with decreasing benefit in the longer term. The reported maximum of 7 kg is hardly significant for a morbidly obese individual who might be carrying an excess weight 45-75 kg or more. Those morbidly obese patients who do respond to non-surgical weight loss programs, generally fail to maintain the weight loss, with recidivism rates exceeding 95%. Behavior modification, diet and exercise have been found to be ineffective on an intermediate and long-term basis for treatment of obesity, particularly morbid obesity. Regain of the lost weight is the rule, and more than the initial weight lost is commonly regained. Surgery is the only modality proven to be effective in the treatment of morbid obesity; however, surgical treatment entails known finite risks influenced by clinical factors. To achieve a beneficial net reduction in morbidity and mortality, the risks from the excess weight must exceed the risks of surgery and anesthesia. It is interesting to note that published series show significant increases in the relative risk associated with obesity at a BMI of 27 kg/m2, and exponential increases at a BMI of 32 kg/m2 (the highest bracket reported) – well below the 35 to 40 kg/m2 often considered minimum for surgical intervention. Duodenal Switch: An Effective Therapy for Morbid Obesity – Intermediate Results Baltasar et al. April 2002 PubMed Abstract BACKGROUND: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a verticalsubtotal gastrectomy and pylorus preservation. METHODS: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of thepatients super obese (SO). Patients have been followed for an intermediate period. RESULTS: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in allpatients. CONCLUSION: DS was very effective for the treatment of the morbid obesity in the SO patients. Biliopancreatic Diversion with a Duodenal Switch Hess et al. June 1998 PubMed Abstract BACKGROUND: This paper evaluates biliopancreatic diversion combined with the duodenal switch, forming a hybrid procedure which is a combination of restriction and malabsorption. METHODS: The evaluation is of the first 440 patients undergoing this procedure who had had no previous bariatric surgery. The mean starting weight was 183 kg, with 41% of our patients considered super morbidly obese (BMI > 50). RESULTS: There was an average maximum weight loss of 80% excess weight by 24 months postoperation; this continued at a 70% level for 8 years. Major complications were found in almost 9% of the cases. There were two perioperative deaths, one from pulmonary embolism and one from acute pulmonary obstruction. There were 36 type II diabetics, all of whom have discontinued medication following the surgery. Seventeen revisions were performed to correct excess weight loss and low protein levels. There have been no marginal ulcers, no cases of dumping syndrome, no foreign material used, and the procedure is a pyloric saving procedure which is functionally reversible. CONCLUSIONS: This operation has vastly improved the lives of seriously obese patients with many comorbidities. All type II diabetics have essentially been cured of their disease. The procedure was tolerated well and patients are quite satisfied. There was minimal regain of weight with this method.

Duodenal Switch for Super Morbid Obesity

June 21, 2020 12:04 pm

Clinical data addressing Duodenal Switch for super morbid obesity (BMI > 50).


Outcome of laparoscopic duodenal switch for morbid obesity.
Magee et al. Oct 2010
PubMed Abstract

BACKGROUND: The aim of this study was to determine the safety and efficacy of laparoscopic duodenal switch (LDS) as a treatment option in a selected group of patients with morbid obesity.

METHODS: This retrospective analysis of a prospective database assessed the frequency of all complications and alterations in weight, body mass index (BMI), co-morbidity and quality of life.

RESULTS: One hundred and twenty-one patients underwent LDS between April 2003 and March 2009. Median preoperative weight was 160 kg and median BMI 55 kg/m2. All procedures were performed laparoscopically. The in-hospital mortality rate was zero. No ileoduodenal anastomotic stenosis was encountered. There were four clinical leaks (3.3 per cent) managed by laparoscopic drainage and placement of a feeding jejunostomy. Median percentage excess weight loss was 75 per cent at 12 months and 90 per cent at 24 months. Thirty-six of 40 diabetic patients had complete resolution of diabetes within 1 year. There were significant improvements in other obesity-related co-morbidity. Only a few patients developed postoperative protein deficiency, and fat-soluble vitamin deficiencies were easily managed with oral supplementation.

CONCLUSION: The LDS procedure is a safe and effective treatment for morbid obesity and its associated co-morbidity in selected patients. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity.
Søvik et al. Feb 2010
PubMed Abstract

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Registration number: NCT00327912 (http://www.clinicaltrials.gov). Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI > or = 50 kg/m2) compared with gastric bypass.
Prachand et al. Feb 2010
PubMed Abstract

OBJECTIVE: Increased body mass index is associated with greater incidence and severity of obesity-related comorbidities and inadequate postbariatric surgery weight loss. Accordingly, comorbidity resolution is an important measure of surgical outcome in super-obese individuals. We previously reported superior weight loss in super-obese patients following duodenal switch (DS) compared to Roux-en-Y gastric bypass (RYGB) in a large single institution series. We now report follow-up comparison of comorbidity resolution and correlation with weight loss.

METHODS: Data from patients undergoing DS and RYGB between August 2002 and October 2005 were prospectively collected and used to identify super-obese patients with diabetes, hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD). Ali-Wolfe scoring was used to describe comorbidity severity. Chi-square analysis was used to compare resolution and two-sample t tests used to compare weight loss between patients whose comorbidities resolved and persisted.

RESULTS: Three hundred fifty super-obese patients [DS (n=198), RYGB (n=152)] were identified. Incidence and severity of hypertension, dyslipidemia, and GERD was comparable in both groups while diabetes was less common but more severe in the DS group (24.2% vs. 35.5%, Ali-Wolfe 3.27 vs. 2.94, p<0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p<0.05). There were no differences in weight loss between comorbidity "resolvers" and "persisters".

CONCLUSIONS: In comparison to RYGB, DS provides superior resolution of diabetes, hypertension, and dyslipidemia in the super-obese independent of weight loss.

Duodenal Switch Operative Mortality and Morbidity Are Not Impacted by Body Mass Index.
Buchwald et al. Oct 2008
PubMed Abstract

OBJECTIVE: This report examines the up to 30-day postoperative mortality and morbidity in our first 190 duodenal switch (DS) patients.

BACKGROUND DATA: DS is the most weight loss effective and the most difficult to perform bariatric procedure. Indeed, certain surgeons have advocated a 2-stage approach to minimize complications, especially in the super obese (body mass index [BMI] >/=50 kg/m).

METHODS: DS procedures were performed (n = 190) by either open (n = 168) or laparoscopic/robotic surgery in an academic setting: common channel 75 to 125 cm, sleeve gastrectomy (approximately 100 mL gastric pouch), closed duodenal stump, end-to-side duodenoileostomy hand-sewn in 2 layers, with most staple lines oversewn, and all mesentery defects closed.

RESULTS: For the 190 patients, 149 were female (78%) and the mean age was 43 years (range, 16-71). Mean preoperative weight 151.4 kg (range, 74.1-332.7); mean preoperative BMI 53.4 kg/m (range, 32-107), with 100 (52.6%) of the patients super obese (BMI >/=50 kg/m). Seventy-four patients had concurrent procedures, eg, cholecystectomy (n = 22), ventral or umbilical hernia repair (n = 19), and hiatus hernia repair (n = 10). Mean operating room time was 337 minutes (range, 127-771); mean hospitalization time was 6 days (range, 2-38). There were no deaths. Serious /=50 kg/m (NS). Surgical site infections occurred in 7 patients with a BMI <50 kg/m and in 12 with a BMI >/=50 kg/m (NS). Overall complication rate in patients with a BMI <50 kg/m was 14.4% (13 of 90) and 24% (24 of 100) with a BMI >/=50 kg/m (NS).

CONCLUSIONS: With attention to careful surgical technique, DS can be performed relatively safely in the morbidly and super morbidly obese, and does not require a 2-stage procedure.

Outcome of duodenal switch with a transitory vertical gastroplasty, in super-super-obese patients in an 8-year series.
Di Betta et al. Feb 2008
PubMed Abstract

BACKGROUND: In super-super obese (SSO) patients [body mass index (BMI) superior of 60 kg/m2] results of bariatric surgery are still controversial. This study evaluated safety and efficacy of open duodenal switch associated with transitory vertical gastroplasty (DS-TVG) after 8 years of follow-up.

METHODS: A prospective observational study of 32 SSO patients who underwent an open DS-TVG from January 1999 till March 2006 was performed. Study endpoints included preoperative comorbidities [diabetes, hypertension, and obstructive sleep apnea syndrome (OSAS)], postoperative morbidity and mortality, and long-term results of BMI and percent of excess weight loss (%EWL) (median 48 months).

RESULTS: Results in terms of BMI and %EWL were, respectively, after 12 months, 46.3 +/- 10.2 and 57.1 +/- 9.8; after 36 months (n = 21), 37.5 +/- 7.5 and 73.5 +/- 6.2; and after 84 months (n = 5), 31.7 +/- 2.8 and 76.0 +/- 4.1. With regard to comorbidities, we observed complete control of lipid alterations and type-2 diabetes (suspension therapy within 1 year). All patients with OSAS improved within 1 year without needing domiciliary oxygen therapy. Neither malnutrition nor mortality was observed during the follow-up. Major complications occurred in a total of 5 patients (15.6%): pulmonary embolism (2 cases-9.4%); gastrointestinal bleeding, requiring transfusions (1 case-3.1%); 1 case (3.1%) of abdominal rupture; and 1 case of acute pancreatitis (3.1%). Minor complications occurred in 4 patients (12.5%): 1 case of pneumonia, 1 urinary tract infection, and 2 wound infections.

CONCLUSION: Although this study evaluated the outcomes of a small series of patients after open DS-TVG, this procedure seems to be safe and effective in obese patients who have a BMI greater than 60 kg/m2. In our opinion, DS-TVG should be considered as a valid surgical option with two staged laparoscopic procedures.


Duodenal Switch Provides Superior Weight Loss in the Super-Obese (BMI >50kg/m2) Compared With Gastric Bypass
Prachand et al. Oct 2006
PubMed Abstract
Full Article

OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB).

METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight.

RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05).

CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS.