Bilio-pancreatic diversion with duodenal switch (also called Duodenal switch, or BPD-DS) is a complex procedure that induces weight loss by a sleeve gastrectomy and intestinal bypass. This approach results in decreased absorption of food. With this procedure, the surgeon removes approximately 60-70 percent of the stomach so that the stomach takes the shape of a tube (sleeve gastrectomy). The lower intestine is then divided much further downstream than with gastric bypass so that two thirds or more of the intestine is bypassed, leaving only a few feet of intestine where food and digestive enzymes meet. This is the intestinal bypass portion of the operation. The name duodenal switch comes from the fact that in this operation the intestinal bypass starts at the duodenum. The first part of the intestine, the duodenum, is divided and attached to the lower portion of the small intestine, the ileum. BPD/DS is generally performed as a single procedure; however, in select circumstances, the procedure may be performed as two separate operations — sleeve gastrectomy followed by intestinal bypass once weight loss has begun.
While a BPD/DS is very effective, it has more risks, including malnutrition and vitamin deficiencies. This procedure is generally recommended for people with a body mass index (BMI) greater than 50.
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 $27,00 in Iran, although this varies widely across states and clinics.
As with any major surgery, a BPD/DS poses potential health risks, both in the short term and long term.
Risks associated with BPD/DS are similar to any abdominal surgery and can include:
Malabsorption plays a key role in BD/DS surgery by reducing the amount of fats absorbed during digestion. It also prevents the body from absorbing full amounts of essential nutrients. The resulting lack of iron and calcium may lead to anemia or osteoporosis. Deficiencies in thiamine (though rare) and vitamins A, D, E, and K can invite beriberi, which causes damage to the nervous system if it goes untreated. A type of protein deficiency malnutrition occurs in 18% of patients. Doctors require patients to continue their follow-up visits throughout their lifetimes, and regular blood tests are administered for early detection of any dangerous conditions. Most patients avoid all maladies simply by taking supplements prescribed following surgery.
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 In a Systemic Meta Analysis of the weight loss surgical procedures Buckwald et al. Type 2 diabetics have had a 98% "cure" 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. 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.
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
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.
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.
The duodenal switch operation is malabsorptive. This means that the way your body digests nutrients will change following your DS procedure. While this change permits you to absorb fewer fats and enhance your weight loss efforts, it also means that you need to be careful of vitamin deficiencies.
Taking vitamins regularly is an important aspect of life after DS. Your doctor may suggest liquid or chewable supplements depending on your preferences.
The dietary limitations after duodenal switch surgery are small, especially compared with other types of bariatric procedures, but that is not an excuse for poor eating habits. Eating a healthy diet and exercising regularly has a big impact on your mind as well as your body, and can help you to maintain a healthy way of life for years to come.
The most important thing to remember after DS surgery is to follow your surgeon’s dietary instructions to avoid any complications. If you have any additional questions concerning dietary guidelines with the duodenal switch, don’t hesitate to speak with your weight loss surgeon.
Ultimately, recovery time will depend on the overall health of the patient, the complications that may occur as well as the directions given from the surgeon to the patient after their surgery. Most patients that undergo the lengthy surgery can expect anywhere from three to four weeks for recovery, but 4-6 weeks is the optimal healing time (for open surgery types). Those who had duodenal switch surgery laparoscopically, recovery time will be just 1 to 2 weeks (while the new diet will occur for 6 weeks). Even after this recovery time, there is ongoing recovery due to the need for serious lifestyle changes and changes in eating habits. Individuals that go through surgery can expect a fair amount of pain that can be treated with prescription pain medication from the physician.
Pain medications will be needed for at least the first week following surgery and the incision site(s) may be tender or sore. The healing process will occur throughout the new diet plan. For the first month following duodenal switch surgery, the patient’s stomach will only be able to have liquids or soft foods. Patients should remain hydrated throughout the day but never drink before a meal as it will trick the body into thinking your food when you’re just full of liquid. A dietician will work with DS patients in order to devise both a diet plan and a supplement plan.
As a part of full recovery, the patient needs to understand proper nutrition and portion control. With a smaller stomach, it is important that the food put into the stomach is of use and not wasted food. In addition, it is wise to find your full mark and stick to it. Knowing your body and understanding the signs that will stop you from overeating is very important. You can expect that a good exercise plan will be a part of your overall recovery.
Life changes are an important part of getting back on your feet. While you may be able to return to normal activity after a few weeks, it is important that you understand that lifestyle changes are a major part of your continued recovery after the surgery. Many patients do very well as long as they have a plan and stick to the proper eating habits. Full recovery will take a great deal longer than the few weeks after the surgery completion and will require a lifelong commitment to change.
The longitudinal gastrectomy with duodenal switch is a safe and effective primary procedure for the treatment of morbid obesity. It has the advantage of allowing acceptable alimentation with a minimum of side effects while producing and maintaining significant weight loss. These results are achieved without developing significant dietary restrictions or clinical metabolic or nutritional complications. It’s important to always weigh out the options available when deciding whether duodenal switch surgery is right for your particular health. Your primary care physician and weight loss surgeon can help decide whether or not you’re healthy enough for surgery and if you are prepared enough for the healthy lifestyle commitment following surgery. This commitment will help increase your weight loss success as a whole.