The duodenal switch (DS) procedure, also known as a gastric reduction duodenal switch (GRDS), is a weight loss surgery procedure that is composed of a restrictive and a malabsorptive aspect. The restrictive portion of the

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

involves removing approximately 70% of the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

(along the greater curvature) and most of the

duodenum The duodenum is the first section of the small intestine in most vertebrates, including mammals, reptiles, and birds. In mammals, it may be the principal site for iron absorption. The duodenum precedes the jejunum and ileum and is the shortest p ...

. The malabsorptive portion of the surgery reroutes a lengthy portion of the

small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...

, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive loop, takes food from the stomach to the common channel. The much longer pathway, the biliopancreatic loop, carries bile from the

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

to the common channel. The common channel is the portion of small intestine, usually 75-150 centimeters long, in which the contents of the digestive path mix with the

bile Bile (from Latin ''bilis''), also known as gall, is a yellow-green/misty green fluid produced by the liver of most vertebrates that aids the digestion of lipids in the small intestine. In humans, bile is primarily composed of water, is pro ...

from the biliopancreatic loop before emptying into the

large intestine The large intestine, also known as the large bowel, is the last part of the gastrointestinal tract and of the Digestion, digestive system in tetrapods. Water is absorbed here and the remaining waste material is stored in the rectum as feces befor ...

. The objective of this arrangement is to reduce the amount of time the body has to capture

calories The calorie is a unit of energy that originated from the caloric theory of heat. The large calorie, food calorie, dietary calorie, kilocalorie, or kilogram calorie is defined as the amount of heat needed to raise the temperature of one liter o ...

from food in the small intestine and to selectively limit the absorption of

fat In nutrition science, nutrition, biology, and chemistry, fat usually means any ester of fatty acids, or a mixture of such chemical compound, compounds, most commonly those that occur in living beings or in food. The term often refers specif ...

. As a result, following surgery, these patients absorb only approximately 20% of the fat they consume.

Comparison to other surgeries

Advantages

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 than a purely restrictive gastric bypass for all individuals. In a systemic metaanalysis of the weight loss surgical procedures (Buckwald et al.) Type 2 diabetics have had a 98% "cure" (i.e. became euglycemic) almost immediately following surgery, which is due to the metabolic effect from the intestine switch. The results are so favorable that some surgeons in Europe are performing the "switch" or intestinal surgery on non-obese patients to cure 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 83%. Because the pyloric valve between the stomach and small intestine is preserved, people who have undergone the DS do not experience the dumping syndrome common with people who have undergone the Roux-en-Y gastric bypass surgery (RNY). Much of the production of the hunger hormone,

ghrelin Ghrelin (; or lenomorelin, INN) is a hormone primarily produced by enteroendocrine cells of the gastrointestinal tract, especially the stomach, and is often called a "hunger hormone" because it increases the drive to eat. Blood levels of ghrel ...

, is removed with the greater curvature of the stomach. The summarized data can be found on a poster
comparative poster
Diet following the DS is more normal and better tolerated than with other surgeries. The malabsorptive component of the DS is fully reversible as no small intestine is actually removed, only re-routed.

Disadvantages

The malabsorptive element of the DS requires that those who undergo the procedure take

vitamin Vitamins are Organic compound, organic molecules (or a set of closely related molecules called vitamer, vitamers) that are essential to an organism in small quantities for proper metabolism, metabolic function. Nutrient#Essential nutrients, ...

and

mineral In geology and mineralogy, a mineral or mineral species is, broadly speaking, a solid substance with a fairly well-defined chemical composition and a specific crystal structure that occurs naturally in pure form.John P. Rafferty, ed. (2011): Mi ...

supplements in excess of those needed by 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 A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of ...

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 Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...

, 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.

Risks

All surgical procedures involve a degree of risk; however this must be balanced against the significant risks associated with severe

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

. Some of the surgical risks or complications for this procedure are: perforation involving small bowel,

, or stomach causing a leak, infection, abscess,

deep vein thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enl ...

(blood clot), and pulmonary emboli (blood clot traveling to the lungs). Longer term risks include the possibility of vitamin and mineral deficiency,

hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...

and

bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

. There is little information as to the longer-term risks (greater than 15 years), as this procedure was very rarely performed before 2000. The traditional biliopancreatic diversion with duodenal switch (BPD-DS) led to persistent

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...

in some patients. However, the loop duodenal switch reduces this risk because it bypasses a smaller portion of the small intestine, but there is no long term information for the loop duodenal switch to fully and accurately compare. Malnutrition is an uncommon and preventable risk after duodenal switch.

Qualifications

The

National Institutes of Health The National Institutes of Health (NIH) is the primary agency of the United States government responsible for biomedical and public health research. It was founded in 1887 and is part of the United States Department of Health and Human Service ...

state that for patients who meet the following guidelines, weight loss surgery may be an appropriate measure for permanent weight loss: * BMI of 40 or over * BMI of 35 or over with obesity-related illnesses such as: **

Diabetes mellitus type 2 Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent ...

Coronary heart disease Coronary artery disease (CAD), also called coronary heart disease (CHD), or ischemic heart disease (IHD), is a type of cardiovascular disease, heart disease involving Ischemia, the reduction of blood flow to the cardiac muscle due to a build-up ...

Sleep apnea Sleep apnea (sleep apnoea or sleep apnœa in British English) is a sleep-related breathing disorder in which repetitive Apnea, pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor vent ...

Osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

GERD Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

* An understanding of the operation and lifestyle changes necessary following the surgery.

Costs

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; this 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 $27,000 in the United States, although this varies widely across states and clinics. For example, surgical practices in the least expensive state (New Jersey) average about $24,000 while practices in the most expensive state (Nebraska) charge about $32,500. This surgery is also performed by some surgeons in Mexico at a much lower cost than in the United States.

References

External links

Duodenal Switch vs Normal Anatomy comparison tool
{{DEFAULTSORT:Duodenal Switch Bariatric surgery sv:Sleeve gastrectomy