Introduction

You may have heard of the Biliopancreatic Diversion with Duodenal Switch procedure referred to as the BPD/DS, the "Duodenal Switch", the "DS", or simply the "Switch".  The Duodenal Switch is a modification of the original Biliopancreatic Diversion which is so popular in Europe.  The BPD/DS is a more advanced bariatric operation compared to the Bypass or Lap-Band, and it is performed laparoscopically and open.  We perform the Duodenal Switch Laparoscopically, and at present our Weight Loss Surgery Program is the only one in Kansas and several states in the area performing the Duodenal Switch. 

The Biliopancreatic Diversion with Duodenal Switch works by malabsorption and restriction.  The majority of the stomach is removed, and the small intestine is re-arranged to induce a large degree of malabsorption by delaying the point where the digestive enzymes meet with the food.  The last 50-100 cm of small intestine is where the food mixes with the digestive enzymes and digestion and absorption begins.  The length of the small bowel can be increased or decreased to change the degree of malabsorption. 

While these operations remove a large part of the original stomach, the stomach pouch created is larger than with the bypass or lap-band. Many patients find this attractive about the operation because they can eat relatively normally once the stomach has recovered, as opposed to the gastric bypass, in which the stomach pouch remains very small. Though restriction contributes to weight loss, the operation mostly relies on altering the normal digestive process by inducing malabsorption for weight loss.  The absorption of food and calories is reduced to a much greater degree than with the bypass.

The Laparoscopic Duodenal Switch is especially good if you have a great deal of weight to lose, and if you have insulin-dependent diabetes and high triglyceride levels in the blood.  In many cases the weight loss with the lap-band or bypass may not be enough to get many patients out of the Morbidly Obese BMI range.  The DS has a higher average weight loss of 80 to 85%, which some patients need to reach for a healthy BMI range.

Proceeding with weight loss surgery is a very personal and often difficult decision.  Educating yourself about weight loss surgery is a very important first step.  Although the information presented here may be very helpful, patients have repeatedly told us that attending the weight loss surgery informational seminar helped the most.

For those of you who are not from Kansas, we treat many patients from out-of-state, and from all across the United States.  When contacting the office please inform the staff that you are out-of-state and access our out-of-state link for more information on how we can help you with the preparatory process.

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Am I a Candidate for the Lap-Band?

To be a candidate for any type of weight loss surgery, the individual must be morbidly obese.  Below are tools you can use to determine if you are morbidly obese and potentially a candidate for the Duodenal Switch. If you determine you are morbidly obese you are a candidate for the Duodenal Switch.

Morbid obesity is usually defined as being 100 pounds over the ideal body weight. A better way of defining morbid obesity is by using the Body Mass Index (BMI). BMI is a calculated number that takes weight and height into consideration. A person weighing 300 pounds that is 5ft tall will have a higher BMI than a person weighing 300 pounds but is 6ft tall.  A BMI above 40 indicates that a person is severely obese and therefore a candidate for surgery. Surgery may also be an option for people with a BMI between 35 and 40 who already suffer from cardiopulmonary problems or diabetes.

You are likely morbidly obese if you:

• Are more than 100 lbs. over your ideal body weight, or have a Body Mass Index (BMI) of over 40
• Have a 35 BMI or greater and are experiencing severe negative health effects or co-morbidities, such as high blood pressure, diabetes, sleep apnea, reflux disease, etc. related to being severely overweight
• Are unable to achieve a healthy body weight for a sustained period of time, even through medically supervised dieting
• Have physical, psychological, social, or economic problems that could be significantly improved by weight loss

If you determine you are a candidate, your next step should be to attend an Informational Weight Loss Surgery Seminar to learn more about bariatric surgery from our surgeons or proceed with a consultation with the surgeon.

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The Duodenal Switch Procedure

The Biliopancreatic Diversion with Duodenal Switch works by malabsorption and restriction.  The majority of the stomach is removed.  The stomach that is left behind or the new pouch is tubular in shape, with preservation of the pyloric valve. The small intestine is then re-arranged to induce a large degree of malabsorption by delaying the point where the digestive enzymes meet with the food.  After rearranging the small intestine the "Alimentary Limb" is the intestine that carries the food from the stomach. The ‘Biliopancreatic Limb” leading from the gallbladder and pancreatic ducts carries the digestive enzymes to the alimentary limb at about 50-100 cm from the ileocecal valve. The last 50-100 cm of small intestine is where the food mixes with the digestive enzymes and is called the "Common Channel".  The length of the common channel can increase or decrease the degree of malabsorption.  The most important feature of the Duodenal Switch is that it diverts your food stream so that it is only in the last 50-100 cm, the "common channel", that your food can mix with your digestive juices, in order to start digestion and absorption of food.

The operation is done laparoscopically with 5 small incisions.  Your hospital stay can be as short as 24 hours, and it is possible to return to work in about 2 weeks from the time of surgery.  If you are able to do light duty at work, there is the possibility of going back to work sooner than two weeks for some patients.

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How Does the Duodenal Switch Work?

The reduction of the size of the stomach, to about 100 - 120 cc in volume results in restriction.  As a result, patients feel full after a very small amount of food, and lose weight because they eat less, and they are happy eating less.  The stomach goes from the size of a small melon to the size and shape of a hotdog. The pylorus, which is the valve at the outlet of the stomach, remains intact and controls pouch emptying.  While the food travels through the alimentary limb, which carries the food from the stomach, very little food absorption occurs at this time.  The real digestion of the food cannot start until the biliopancreatic limbs delivers the digestive juices from the liver and pancreas to the intestine carrying the food.  This only happens in the last 50 to 100 cm of the small intestine left - the point where the alimentary limb joins the biliopancreatic limb to form the common channel.  The common channel can measure 50 to 100cm.  The longer it is the more digestion of the food occurs and more of the food can be absorbed.  

The DS has a greater weight loss then the Lap-Band or Bypass.  The DS takes advantage of major malabsorption as well as restriction.  It relies on restriction for initial weight loss, and on malabsorption for continued weight loss and maintenance.  The BPD-DS is also a "bigger" operation than the gastric bypass with potentially more risks. The pylorus remains intact with the DS: this usually keeps the dumping syndrome from occurring after surgery.  Since the stomach pouch is larger than with other bariatric operations, you can eat larger portions than with the gastric bypass or lap-band.

Specific dietary changes, dietary requirements, and lifestyle changes that will be expected from you are further discussed in the Duodenal Switch Diet Guide.

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Advantages

1. These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
2. The malabsorptive operations also have a higher success rate of improving and curing many of the medical problems associated with morbid obesity.  Some literature can quote 90% cure rates of diabetes, high blood pressure, sleep apnea and hypercholesteremia.
3. These procedures on average produce one of the greatest excess weight loss because they provide the highest levels of malabsorption.
4. In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
5. An average excess weight loss of 80 to 85% can be expected
6. Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.  Average is about 70%.
7. Long term success rates of 80 to 90% can be expected

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Risks

• For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition lessens over time, but may be a permanent lifelong occurrence.  An average of 3-4 bowel movements per day can be expected.
• Abdominal bloating and malodorous stool or gas may occur.  This is now easily controlled with pro-biotics.
• Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
• Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
• Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.
• On occasion with larger BMI’s the operation may require staging.  Staging is performing the operation one part at a time.  The DS operation can be staged into two operations if necessary: the restrictive part – sleeve gastrectomy first, and the malabsorptive part – re-arranging of the small intestines after some weight has been lost with the sleeve gastrectomy.
• It is necessary to take a number of nutritional supplements after the operation. These include:
  • Multivitamins (usually twice per day)
  • Iron supplements (usually twice per day)
  • Calcium (usually twice per day)
  • ADEKs (fat-soluble vitamins) usually 3 times per day
• Additionally, there are some very significant side effects that accompany this procedure, including:
  • Frequent soft bowel movements (up to 4-6 per day)
  • Frequent passing of foul-smelling gas
  • Change in body odor
  • Gas pains and bloating
  • Hair loss
  • Intolerance of certain foods (varies from person to person)

The possible problems experienced with the operation are mostly malabsorptive in nature, but most can be managed, when they occur, by taking supplements. The major complication to worry about with this operation in the long-term is protein malabsorption.  If patients are being followed appropriately, this is usually caught early, and can be managed very well with adjustment of the type and quality of protein the patient is consuming, the addition of pancreatic enzymes, and then if necessary, surgical lengthening of the common channel to improve absorption. Malabsorption of the fat-soluble vitamins, Vitamins A, D, E and K, are also potentially at risk, and these must be followed as well. Prolonged, uncorrected deficiencies of these Vitamins can be very serious, leading to problems such as night blindness (Vitamin A deficiency) and immune system compromise (Vitamin E deficiency). These can also be managed well with supplements if the deficiency can be caught early.  A more complete list of the potential risk and benefits of weight loss surgery operations is provided for you by the Risks and Benefits link.

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Deciding on the Duodenal Switch

The decision about which operation is best for you is a complicated, and very personal decision. Although the information presented here may be helpful, you will be able to learn substantially more about the benefits and risks of the BPD-DS operation during your consultation with the bariatric surgeon or at our free weight loss surgery seminars.

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Weight Loss Surgery Program

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The Next Step

Proceeding with weight loss surgery is a very personal and often difficult decision.  Educating yourself about weight loss surgery is a very important first step.  Although the information presented here may be very helpful, patients have repeatedly told us, that attending the weight loss surgery informational seminars helped them the most.  At the seminar, you will be able to separate fact from fiction, meet the surgeons, ask questions, and hear testimonials from patients who have already undergone weight loss surgery. The patient testimonials are often the highlight of the seminar.  Individuals considering weight loss surgery enjoy talking to patients and getting first hand accounts of how the operations have worked for them and how it has changed their lives. 

The next step is to meet in consultation with the surgeon.  The visit has multiple purposes:  determine your health and operative risk, discuss which operation may be best for you, answer your specific questions and concerns, and start the preparatory process toward getting insurance pre-approval and scheduling your surgery.  You can save about 45 minutes of your time at the doctor’s office by filling out the New Patient Forms prior to coming for your doctor consultation.

While waiting for your insurance approval or obtaining your medical work-up, start reading the Preparatory Guide and the DS Diet Guide.  These will prepare you for your surgery as well as what to expect after your operation.  For further questions do not hesitate to contact the office at (913) 322-7401.

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