Duodenal Switch- Video 12

Duodenal Switch- Video 12


(tranquil music) – I’ve been asked to talk to you about the biliopancreatic
diversion with switch. That is a big mouthful. So if you can remember duodenal switch, or depending on what part
of the country you’re from, duodenal, versus duodenal,
switch, or even DS, we’ll know what you’re talking about. The duodenal switch is our most powerful bariatric operation. It combines restriction,
meaning it restricts how much you can eat at any
one time, with malabsorption, in that it restricts
how much you can absorb of the food that you actually eat. And in fact, how this operation is done, is you actually amputate
the greater curvature of the stomach, removing
about 85% of the stomach. This is a sleeve gastrectomy. I know the sleeve gastrectomy will be talked about separately as a possible stand-alone operation. And that actually came
out of the duodenal switch as a staged operation for patients who are really large or really sick, they could do the sleeve
gastrectomy first, they could then lose weight, and then six months, a year later, do the second portion of the operation. And the second portion of the operation, we then go down below the
stomach, under the duodenum, which is the first portion
of the small intestine, about an inch, and divide
the duodenum at that point. Then we create our Roux limb, just very similar to the gastric bypass, but instead we actually
measure the length of it, starting at the large intestine backwards. So now, once everything
is hooked back together, the food comes down this side, the digestive enzymes
come down this other side, they mix here, and then
you, once they’ve mixed, the food is mixed with digestive enzymes, you absorb your nutrients
in this common channel, which in this picture looks short, it is short, it’s only
about three feet long. Comparing that to the gastric bypass, where we divide the stomach, we don’t actually remove any of it, making this small pouch that holds about one to
three ounces of food, and we divide the small intestine, measuring it from what we
call a ligament of Treitz, down the upper part, the
front part of the intestine, we divide it, bring one end
up to here and sew it there, this end gets sewn back to the bowel here. So that now the food comes down this limb, the digestive enzymes come down this limb. They mix here, and you
absorb most of your nutrients in this common limb. This picture, it looks short, it is not. It is 15 to 20 feet long still, so there’s very little malabsorption. Now the pros to this operation, is this is our very best
weight loss operation. Patients lose on average, of greater than 80% of their excess body weight. It is our most durable operation, in that less than 10% of patients are regaining any substantial
weight at 10 years. There is minimal dumping,
so the stomach is actually, empties fairly normally,
so if patients do slip up and eat a milkshake or
something like that, they’re probably not going
to get dumping syndrome. They may have some other problems, but they won’t have the dumping syndrome. And finally, it is because
of the fat malabsorption that occurs with this operation it’s the most effective operation in treating people with
severe hypertriglyceridemia. The downside, there’s nothing
for free in this world. This operation carries with
it also the highest risk. Both highest surgical risk, it is the most complicated
operation that we do, and while there’s controversy
over how risky it is, it appears to have a risk very similar to that of a gastric bypass, but it may be a little bit riskier, although we are often doing this in our largest, sickest, patients. It also has your highest nutritional risk. Particularly protein malnutrition and fat-soluble vitamin deficiencies. These are usually well managed with eating properly
and taking supplements. We’ve actually seen very little of this problem in our patient population. The other downside, when you’re
dealing with malabsorption, is diarrhea and possible
foul-smelling gas. Now, if you eat too much fat,
that will cause diarrhea. If you eat too many carbohydrates, it will often cause more gas. These are strong incentives
not to do those sort of things, and that’s what makes this
operation so powerful. Number one, it is restrictive, and it restricts how much you can eat. It is malabsorptive, although
not nearly as malabsorptive as more current studies are showing that patients probably malabsorb maybe 10% possibly 20% of
the food that they’re eating, but it helps patients because now, if they do eat improperly,
like eating high fatty foods, or eating carbohydrates,
there’s a price to be paid, and they know up front, so they can avoid that by eating properly. Put all of those together, it’s one of the most powerful
operations that we have. Now, who should undergo this operation? Again, it can be beneficial for anybody who is a candidate for bariatric surgery. If your BMI is only 35
you still are a candidate, but the patients who
tend to benefit the most, are the malignantly, morbidly, obese. The patient with a BMI of 60 or greater, I would recommend that they
consider this operation. As with these very large patients, with all of our operations, it’s very hard for them
to get their weight down and get down to a healthy weight, but with this operation, it’s the one that’s most
likely to get them down. As far as comorbidity resolution, again, the gastric bypass and duodenal switch are very similar, but the duodenal switch
has a better profile. When we look at type 2
diabetes for instance, the diabetes resolution
has been well documented. Multiple studies have been somewhere between 90%
to 95% of all patients. Most studies in the 95%
resolution of type 2 diabetes, and again this is a very
powerful metabolic operation, as this resolution of these problems go away within the first
few days, first few weeks. As far as sleep apnea,
hypercholesterolemia, very similar to that of gastric bypass. And if you have severe
hypertriglyceridemia, it’s the most effective operation at resolving those problems. All in all, a very effective operation. Very good operation for the patient who is willing to be careful and eat right and take their supplements and
follow up with their doctors, it can be a very effective operation. Thank you very much. (tranquil music)

5 thoughts on “Duodenal Switch- Video 12

  1. When you say the DS is not good for fats, do you mean ALL fats including coconut oil and other medium and long chain fats or just the unhealthy ones?

  2. I had gastric bypass and did not lose 30% of weight. I exercise, eat well and controlled. Now, I have noticed that all the weight is coming back. I do have several medical problems, which is why I had the surgery. I noticed that weight has been creeping up again and I have not changed any eating habits, plenty of vegetables and protein. I am not sure of what to do about this.

  3. Had the RNY and not DS and had a 180lb loss. Was told that with my regain I could get a revision to long limb now they are refusing. I wish I would have know I should've had the Sleeve…angry but thankful for this channel and it's abundance of information. At present I have multi nutrient deficiency and can barely walk!!!

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