Duodenal Switch Post-Op One-YearMay 19, 2020
Duodenal Switch Post-Op: One-Year
Before we get into this Duodenal Switch Post-Op article, let's take this opportunity to remind ourselves of the importance of physical distancing, wearing a face mask if personal spaces are limited or when required, and frequent hand washing. Isolation should be considered if there has been any clinical presentation suspicious for Covid-19 viral infection or exposure to a known person.
Obesity is a poor prognostic indicator for Covid-19 infected patients. Given that at the time of publication of this article, there are no vaccines available and the treatment options are limited to supportive measures with only marginal improvement with antiviral medications, all patients should minimize their risks of exposure to the Covid-19 infection.
There are many surgical procedures for the treatment of obesity. They have different outcomes short and long-term. There are some risks associated with weight-loss surgical procedures that are common amongst all of the procedure types. They have unique outcomes, safety profiles, and complications associated with different weight-loss surgical procedures.
Duodenal Switch (DS) operation is by far the most effective weight-loss surgical procedure.
There are multitudinous changes that occur during the first year following duodenal switch operation. For some patients, it can be quite easy to see the physical changes that occur, whereas others have difficulty seeing themselves even in the mirror as physically changed. Patients may also find the psychological changes challenging or uplifting. Most changes are positive, and there may be a few negative ones as well.
We should remember that bariatric surgery is similar to running a marathon. We have to keep our eyes on the long-term goal and work towards it.
Each individual will adapt in different ways depending on their own experiences and history; no two people will have the same recovery experience. The long-term goal is to be healthy and with improved or resolved co-morbidities.
Duodenal Switch Post-Op Changes
- Functional changes: An improvement of joint pains significantly improves patients’ physical ability. Most patients report tangible functional improvement within the first few weeks after the Duodenal Switch procedure. As the patient increases physical activity, there is an increased energy expenditure which can increase weight loss. This also has tangible benefits in the improvement of sleep. More physical activity can provide a more effective sleep pattern. Improved sleep patterns have physical, emotional, and psychological benefits that have been well documented. Improved functional ability also acts as a catalyst for the improvement of metabolic conditions such as diabetes.
Although we think of functional improvements as a physical change, these changes can have a significant positive improvement in a patient's psychological view of themselves. Increasing their self-esteem and confidence due to their improved abilities or goals that have been met.
- Resolution of co-morbidities: Different co-morbidities improve or completely resolve at a different rate.
- Sleep apnea may improve or completely resolve within the first month or so for most patients. This appears to be related to an improvement in the size of the upper airway. The observation is that with early weight loss there is much less swelling of the tissues in the upper airway, the nares, soft palate, and the tongue. This helps with snoring and major report resolution of the snoring in addition to the sleep apnea.
- Diabetes (Type II) also dramatically improves for most patients within the first few weeks. This improvement is most likely an effect of decreased insulin resistance, weight loss, changes in gut hormones, and their effectiveness as well as other physiological changes. Almost all patients will have a reduction in the doses of diabetic medications to some degree. There are a number of patients that are able to completely discontinue their diabetic medications and have remission of their diabetes.
- Hypertension is more effectively controlled following Duodenal Switch. This may be due to the decrease of the inflammatory response following improvement in diabetes or other gastrointestinal hormone and kidney regulations. Some patients are able to eliminate a number of medications. Other patients may experience a resolution in their hypertension and get off all blood pressure medications.
- Hyperlipidemia also significantly improves over time with Duodenal Switch operation. The improvement of dyslipidemia is a hallmark of the Duodenal Switch procedure. The separation of the alimentary channel and the biliopancreatic channel decreases the absorption of fat from foods that are eaten thereby lowering lipid levels.
In our experience the most often talked about side effects have to do with adjustments to the healthier eating habits. Duodenal switch operation involves anatomical changes to the small bowel. During the first year, there are changes involving the bowel that the patients need to get used to. This includes frequent bowel movements and possibly increased flatus. There's a direct correlation between excess fat, carbohydrates, fiber intake, and increase bowel frequency, diarrhea, and flatus.
What we have seen over the 20+ years of performing the Duodenal Switch is in nearly all cases, patients who have a significant problem with excessive gas and diarrhea have not incorporated the healthy dietary recommendations.
In nearly all patients the gas and diarrhea issue gets resolved over time as the bowel hypertrophy’s and becomes more efficient in absorption. Long-term this may be one of the contributing factors of some of the minimal weight gain years later.
Other issues that frequently come up during the first year are weight loss, body image changes, supplements, food tolerances, substance abuse, transfers addictions and issues with interpersonal relationships.
Psychological changes cannot be underestimated. With any weight loss, patients experience increased attention, mostly positive from their friends families and coworkers. Some patients are unable effetely deal with the increase attention and may become a source of significant anxiety for some. There may also be negative attention in a multitude of forms and it can take a significant toll on relationships of all types.
It is critical to maintain a healthy network of friends, family, health care providers, and even mental health professionals for the long-term success of any weight loss surgical procedure.
I would like to take the opportunity to talk about the higher incidence of alcohol use that's been reported in the literature after the gastric bypass operation. There's some literature that also delineates patients with different weight loss surgical procedures having an increase in alcohol abuse. It is very important for patients to be aware of this possibility and avoid replacing certain poor dietary behavior with alcohol usage.
Transfer addiction has also been documented in other weight loss procedures and we should acknowledge that the possibility of this occurrence in all bariatric procedures.
Transfer Addictions typically occur in patients that have risk factors or past addictive tendencies. Transfer addition can move to shopping, sexual, gambling, or substance abuse. Approximately 30% of bariatric patients may experience some degree of this as food is not a reward or comfort that it once was.
The average weight loss with primary duodenal switch is approximately 1 pound per day for the first 30 to 60 days. The weight loss then averages to approximately 0.75/day for 60-120 days.
Between 6-9 months, the average weight loss is approximately 0.5 lbs/day. Please note that this is only a gross approximation for an average patient. There are a number of variables that affect the weight loss rate.
Younger, taller male patients may lose weight at a faster pace than shorter, older female patients. It appears that co-morbidities of diabetes, hypothyroidism, and polycystic ovarian syndrome may result in somewhat of a slower weight loss.
Patients who are getting revised to the Duodenal Switch operation from a previous weight loss surgery tend to have a slower weight loss rate. However; most patients will get to their projected weight after Duodenal Switch, what may differ is the rate at which they get there.
The first year of a Duodenal Switch patient’s dietary record should consist of high-quality protein products, hydration, low-carb, and supplements added as tolerated. I also recommend that my patients eat “close to the dirt.” This means whole unprocessed foods, organic whenever possible.
This is the time to relearn the body’s signals of fullness, taste, likes, and dislikes. During this timeframe, it is important to develop healthy habits and preferences to improve patients’ long term success and outcomes. We recommend that a patient work their way up to 30 grams of protein by the first 30 days following surgery and eventually work up to 90 grams of protein by 90 days post-op.
The proteins are a value that we look at closely with our follow-up appointments and laboratory studies. Due to the decreased absorption of food following Duodenal Switch there needs to be a heightened awareness regarding protein needs both by the patient and their care team. It’s important to take full advantage of the rapid weight loss phase during this first year.
Dehydration can easily become an issue, especially in the immediacy post-operative period. It is critical to maintain a good hydration regime and to become more mindful of symptoms and to continuously be on top of hydration needs.
Immediately after weight loss surgery, the focus is on hydration and protein intake. I recommend that our patients attempt to start on the vitamin and mineral supplements only after they been able to maintain hydration and adequate protein intake.
Unless pre-operative deficiencies have been identified, I recommend patients start on multivitamins and calcium first, and then throughout the first year, we evaluate how and when to add additional supplements. Additional supplements are recommended based on an individual's needs, history, and ongoing laboratory studies. We utilize vitamin A and vitamin D injections as well for patients who may need them.
We also recommend patients start walking in the hospital and build on that as time goes by. Developing a daily exercise routine is important to capitalize on the weight loss phase and to prevent complications due to inactivity such as deep vein thrombosis or pulmonary embolism.
There are also physical and psychological benefits of having a routine exercise program. Improving muscle mass, self-esteem, confidence, metabolism and function status are all benefits.
Early on, days and weeks after surgery, the complications may be related to dehydration, food and liquid intolerance, and malnutrition. These may present as fatigue, dizziness, and weakness.
For most patients, by the one year mark as hydration and protein intake have improved and normalized, functional status improves. The complications encounters may be internal hernia due to scar tissue, Pulmonary embolism due to dehydration and inactivity, infection, and wound-related issues.
Nearly all early complications of Duodenal Switch after patient discharge from the hospital are managed with no long term consequence. It is important to remember that the nutritional concerns should always be in the mind of Duodenal Switch patients to avoid malnutrition, or protein, minerals, and vitamin deficiencies.
It is important that Duodenal Switch patients maintain a working and long term relationship with their surgeon to prevent, head off, and minimize nutritional issues as well as improving long term success.
ABOUT THE AUTHORDr. Ara Keshishian is Director and Surgeon at Central Valley Bariatrics. He has performed more than 2,000 Duodenal Switch procedures and 500+ revisions from other procedures such as RNY, Lap-Band & VSG to the DS since 1999. He has published several research articles on weight loss surgery topics.
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