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 Obesity Surgery, 17, 1421-1430 (2007)

Duodenal Switch: long-Term Results

Picard Marceau, MD, PhD1;Simon Biron, MD, MSc1; Frederic-Simon Hould, MD1; Stefane. Lebel, MD1; Simon Marceau, MD1; Odette Lescelleur, MD1; Laurent Biertho, MD1; Serge Simard, MSc2

'Department ofSurgery, Laval University, Laval Hospital, Quebec, Canada; 2Biostatistician Laval Hospital Research Center



Results: Survival rate was 92% after DS. The risk of death (Excess Hazard Ratio (EHR) was 1.2, almost that of the general population. After a mean of 7.3 years (range 2-15), 92% of patients with an initial BMI > 50 kg/m2 obtained a BMI <35 and 83% of those with an initial BMI >50 obtained a BMI <40Diabetes was cured (i.e. medication was discontinued) in 92% and medication decreased in the others. The use of the CPAP apparatus was discontinued in 90%, medication for asthma was decreased in 88%, and the prevalence of a cardiac risk index >5 was decreased by 86%.  Patients' satisfaction in regard to weight loss was graded 3.6 on a basis of 5, and 95% of patients were satisfied with the overall results. Operative mortality was 1% which is comparable with gastric bypass surgery. The need for  revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%).  Failure to lose >25% of initial excess weight was 1.3%.  Revision for failure to lose sufficient weight was needed in only 1.5%.  Severe anemia, deficiency in vitamins or bone damage were exceptional, easily treatable, preventable and no permanent damage was documented.

Conclusion: In the long term, DS was very efficient in terms of cure rate for morbid obesity and its comorbidities.  In terms of risk/benefit, DS was very sucessful with an appropriate system of follow-up.



In our view, morbid obesity is a metabolic disease that extends beyond uncontrolled appetite and abnormal food intake.  For the past 25 years, our goal has been to change the basic physiology of these patients, allowing for excess weight loss, maintenance of weight loss and continuation of a normal life. We consider that it is important for quality of life to be able to eat normally. We felt that it was preferable not to concentrate our effort on food restriction, giving a false impression that the only problem is a lack of control of food intake, but rather to target correction of the metabolic dysfunction.  In these patients, the difficulty has never been to attain weight loss, but to maintain that weight loss. Morbid obesity should be considered a chronic disease, which requires treatment for life.

The first 8 years (1982-1990), BPD as described by Scopinaro was the procedure of choice within this center. While the results were positive, a decrease in side effects with improvement of absorption were further targets. The procedure was modified successfully. For the last 15 years (1992-2007), DS has been our primary procedure for all patients. This choice has been reinforced with additional knowledge on important involvement of intestinal hormones in the etiology of obesity.  It was also reinforced by the high long-term failure rates reported for numerous other procedures.

The present study could be considered exceptional.  The Canadian medical system has facilitated an efficient follow-up of a large unselected cohort.  We are not aware of any comparable study, using a consistent procedure with such an extended and thorough complete follow-up.

Our review shows excellent long-term results after 15 years. Both the weight loss and its maintenance compared favorably with any other procedure.  It has the best "cure rate" where cure rate is defined as the absence of morbid obesity: 83% of those with an initial BMI >50 maintained a BMI <40 and 92% of those with an initial BMI <50  maintained a postoperative BMI <35.

DS also targeted co-morbidities. It "cured" most diabetic and dyslipidemic patients. For other associated morbidities, results were related to the extent of weight loss, where DS was as efficient as any other procedure.

The reluctance for using DS has been the concern over long-term risks. The present review should be reassuring. The procedure saves lives. A 15-year survival rate of 92% is much better than that of nonoperated morbidly obese subjects and perhaps even better than after RYGBP.8  The operative mortality was found to be comparable to that of RYGBP.13

The long-term risk for malnutrition is real but preventable. Deficiency in albumin, iron, calcium and fat-soluble vitamins requires compliance and medical attention. These deficiencies were rare, they appeared slowly, and were always  reversible without permanent damage.

The procedure was relatively secure for bone maintenance.  It is possible that with the medical attention provided after surgery, including increased physical activity, better alimentation and appropriate nutritional supplements, the procedure may even be beneficial for bone metabolism, rather than representing a risk.

The negative side-effects with DS were not benign.  The unpleasant odor of stool and gas and the frequent abdominal bloating were the price to pay for these patients and it was a major preoccupation for many of them. However, 95% of patients declared themselves satisfied despite this handicap and no one has required reversal of the procedure for this reason.

The present evaluation has an important characteristic, in that it is comprised of a non-selected group of patients. No pre-selection was done on the basis of age, BMI, eating behavior, financial or psychological conditions, merits or expected difficulties for follow-up. With appropriate support, the procedure was found to be useful for all groups.

Thus, the global applications should be appreciated. We conclude that with a structured and devoted treatment team, DS is a very efficient bariatric operation, to the great satisfaction of both the patients and the care-providers.

Finally, one of the striking conclusions of this study is that, in spite of the inherent mortality risk of the bariatric surgery, the long-term outcomes are more positive than the mortality risk without surgery.  Furthermore, in spite of the side-effects which are not minimal, the overall patient satisfaction dominates.  These two points highlight the profound effect that morbid obesity has, not only on mortality, but also on quality of life.




Duodenal Switch






The Duodenal Switch procedure (also called vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, gastric reduction duodenal switch, DS, BPD-DS, or GR-DS) is an operation that is performed by only a minority of bariatric surgeons. It generates weight loss by restricting the amount of food that can be eaten through a reduction in stomach size, by limiting the amount of food that is absorbed into the body through a re-routing of the intestines, and by a metabolic effect induced by manipulating intestinal hormones as a result of intestinal re-routing. It is a more involved procedure because it has a significant component of malabsorption and metabolic effect - achieved by the intestinal bypass effect of the duodenal switch component of the operation - which acts to augment and maintain long-term weight loss. The overall effect is that patients are able to engage in fairly normal, free eating, while having the benefit of taking on the metabolism of a lean individual.


A The stomach is trimmed to a 3-4 ounce volume, preserving its natural inlet and outlet ( the pylorus). Trimming the stomach results in a temporary restrictive effect on eating for several months, which then reverts to normal, and decreases the incidence of ulcer formation as well.
B The small intestine that the stomach normally empties into (the duodenum) is "switched" to the downstream portion of the small intestine (the digestive limb-D). The outflow from the duodenum, carrying the digestive juices and enzymes (but no food) becomes the bilio-pancreatic limb (C) utilizing approximately 60% of the small intestines length.
D The digestive limb takes up approximately 40% of the small bowel length, and most of this length is upstream from where the biliopancreatic limb deposits its juices to allow for the absorption of fats, starches, and complex carbohydrates.
E The common limb, being the portion of intestine where both food and biliopancreatic outflow meet, is made up of the most downstream 100 cm of small intestine and is the only portion where absorption of dietary starches, fats, and complex carbohydrates occurs. The capacity for absorption reaches a maximum within several months after surgery and cannot be over eaten, resulting in long term sustained weight loss..
F The gallbladder and appendix are removed.

To view an animation of this procedure click here.
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Duodenal Switch: How it works:

Restriction (Vertical/Sleeve Gastrectomy): The stomach is restricted in size removing the vast majority of its volume. This is done by cutting away the left-hand side of the stomach in an up-and-down fashion. This reduces the stomach down from a 1-2 quart bag to a long skinny tube. This part of the procedure is not reversible; once this part of the stomach is removed from the body, it is gone forever. The stomach that remains measures from 3 to 4 oz. (90-120cc) in size. There are other aspects of how this portion of the Duodenal Switch procedure works to create restriction, which can be found in the description of the Vertical/Sleeve Gastrectomy procedure. The amount of restriction that patients experience changes with time. This is a process known as pouch maturation, and it is a process that is, for the most part, complete at 9-12 months after surgery. The stomach seems very small immediately after surgery - which helps to jump start weight loss - and stretches out to the point that patients report being able to eat only one-half to two-thirds the amount of food that they were able to eat prior to surgery. Since the stomach basically functions like a normal stomach, but only significantly smaller, patients are able to eat a wide variety of normal foods. With this configuration, it has been my observation that patients are able to follow the diet that has the best of all possible circumstances: they are able to control their intake while, at the same time, limit their intake to the healthiest of foods. Unlike Gastric Bypass, patients with this procedure are generally able to eat beef, steak, pork, stew meat, and other dense proteins without difficulty. These sources of protein are among the healthiest of protein sources, and this anatomic configuration allows patients the freedom to engage in the healthiest of eating habits. I say "allows", for with freedom comes responsibility, and the freedom to engage in free-eating needs to be accompanied by a devotion to eat in the healthiest way that our bodies allow. In essence, one has the ability to have dietary restriction in a way that allows for healthy eating in a way that they can realistically live with long-term.

Malabsorption (Duodenal Switch, Common Limb Effect): The intestines are divided and rearranged to separate food from the digestive juices, therefore creating malabsorption. The part of intestine that carries food - the food or alimentary limb - is attached to the duodenum and receives food from the stomach. The food limb is less than half the length of the total amount of intestine in the body, and consists of the downstream part of the intestine. This part of the intestine reacts differently to food than the upstream part of the intestine, which is bypassed. The bypassed part of the intestine carries digestive juices from the liver and the pancreas, but no food. This bypassed part of the intestine - which consists of over half of the length of the total intestines - joins up with the food limb for only the last 75-100cm (about 3 feet) of intestine known as the common limb. This common limb is the only part of the body that is capable of absorbing complex carbohydrates, starches, and fats. Since the patient's body is absorbing nutrients over only 40% or so of the total intestinal length, the patient's body works to be as efficient as possible in absorbing nutrients. As efficient as the human body can be, however, there is only so many calories that can be absorbed through a 75-100cm length of intestine. The excess of ingested fats and starches - which cannot be absorbed - are excreted from the body and passed in the stool. With appropriate eating, most patients have anywhere from 2-4 bowel movements per day. With increased intake of indigestible starches and fats, patients can have may more bowel movements per day.

Metabolic Effect: In addition to the effect of dietary restriction and malabsorption, Duodenal Switch has a metabolic effect to affect weight loss and improvement in health as well. The portion that food passes through - the alimentary limb - has the ability to absorb protein and sugars. This portion of intestine also has the ability to secrete a hormone - GLP-1, or Enteroglucagon - in the presence of undigested food. Since this portion of intestine is presented to undigested food earlier on as a result of the anatomic re-arrangement induced by Duodenal Switch, secretion of GLP-1 is enhanced. Enteroglucogan (GLP-1) has the effect of suppressing the secretion of insulin in response to a carbohydrate meal, resulting in a lesser amount of ingested carbohydrates being converted to body fat.

The portion of intestine that is bypassed holds an important role as well. Enterogastrone is a hormone that is secreted by the upstream small intestine when food passes through it. This hormone has the effect of converting food to fat. When the upstream portion of the intestine is bypassed - as is the case with Duodenal Switch - enterogastrone secretion is suppressed. The effect of this bypass is that the patient's body after Duodenal Switch has less of a tendency to convert food to fat.


Duodenal Switch: Balancing Freedom and Responsibility

A simplified way to explain the sum of these metabolic effects is that the patient after Duodenal Switch takes on the metabolism of a lean individual. We all know people who are able to eat large amounts of food, and yet are able to maintain a lean physique. These people have a metabolism that tolerates a sizeable caloric intake without resulting in obesity, yet their bodies are able to maintain normal protein levels and keep from becoming malnourished. Patients undergoing Duodenal Switch are able, for the most part, to eat normal amounts of food, but they must eat healthy foods if they are to keep from becoming malnourished. Duodenal Switch patients can't eat junk food all day and expect to remain healthy; with the freedom they have in eating freely, they must exercise responsibility in order to keep from becoming malnourished. Most patients after Duodenal Switch take in anywhere from 80 to 100grams of protein in their diet each day in order to remain healthy. You can't get this level of high quality of protein eating junk all day, but if one chooses to after Duodenal Switch, they can, due to the relatively ability to eat freely.

How Do We Decide How Long To Make Each Intestinal Limb?

Deciding how much intestine to bypass, how much to carry food, and how much to allow for mixing of food and digestive juices, is a process that has evolved with our understanding of how the Duodenal Switch procedure works. Most surgeons typically make the food limb 150cm, and the remainder of the intestine - however long it may be - to carry the digestive juices. While this "one size fits all" approach works well for most patients, it is possible to customize the limb lengths to fit the characteristics of the individual patient. We have had good results using "proportional limb lengths" in Duodenal Switch procedures. The entire intestinal length is measured at the time of surgery, and the lengths of the individual intestinal limbs determines based on this total length. Within certain parameters, the total food and common limb length - added together - is roughly 40% of the total intestinal length. The remaining 60% of intestine carries the digestive juices. The common limb by itself is roughly 10% of the total intestinal length. The rationale for using proportional limb lengths is to maximize weight loss while at the same time minimizing protein-calorie malnutrition and other malabsorptive complications. Minor variations to these limb lengths can be made based on other individual characteristics of the patient.

Duodenal Switch: Risks and Complications

As a general rule, the greater the magnitude of the surgery, and the less healthy the patient, the higher the risk of surgery. In the spectrum of weight-loss operations, Duodenal Switch is the most aggressive, and, therefore, has the highest potential for complications. These potential complications include leaks, blood clots forming in the legs, blood clots traveling to the lungs (otherwise known as pulmonary embolus), infections, abscesses, bowel obstruction, pneumonia, and problems with healing of the incision. Other possible complications include kidney failure, injury to the spleen (requiring its removal at the time of surgery), and bleeding. Some patients may need to spend extra time in the ICU as a result of these complications, or if their underlying health is marginal to begin with.

Some complications are more long term, and are not manifest until some time after surgery. These are nutritional and vitamin deficiencies, which may be for the most part preventable with proper supplementation. Deficiencies in protein, vitamin-D, vitamin-A, iron, and calcium can occur, resulting in osteoporosis, anemia, and generalized poor health. Patients undergoing Duodenal Switch should be vigilant in taking their vitamin and mineral supplements, eating a high-protein diet, and having their blood tested on an annual basis.


Hair Loss Prevention

From Carolyn M's Profile

Ready for one more set of tips? This is my hair loss prevention program: It is a 3-step program:

1. Make sure you get at least 60 grams of protein every day beginning as soon as you get out of the hospital. Use shakes until you can get enough food. Build up to 80 grams when you can. Protein is essential for hair growth and hair that doesn't grow falls out.

2. Force the fluids. At least 64 oz a day the first week or two then bump it up to 80-100 oz per day. Fluids flush out the ketones your body makes when burning fats. Ketones are toxic to rapidly dividing cells like the hair follicles.

3. Beginning the first week after surgery, add 100mg of Zinc and 200 mcg of Selenium to your supplements. Crush these tablets for the first 3 months to guarantee absorption. These mineral support the telogenic (resting)phase of hair growth.

Biotin supplements may also help, some swear by them. Nothing you put ON your hair from the outside will do anything to prevent loss, although it may plump up the individual strands and make your hair seem thicker. Topical emulsions don't usually penetrate the scalp to the level of the hair follicles--Minoxidil is an exception to this general rule.


Possible Co-Morbidities List for OHIP:
Elevated Cholestrol
Elevated Triglycerides
Heart Attack & Congestive Heart Failure
Cardiac Arrhythmias, Sudden Death
Renal Failure
Pulmonary Artery Hypertension
Cor Pulmonale (right heart failure)
Lung restriction
Shortness of breathe on exertion
Decreased Exercise Tolerance
Heavy Snoring
Obstructive Sleep Apnea
Uterine Lining cancer
Heartburn (GERD)
Joint and back pain
Accelerated Degenerative Joint Disease
Gallstone formation
Hormone Abnormalities
Excess Estrogen
Abnornal Menstrual Cycle
Excess Testosterone
Facial Hair
Stress incontinance
Varicose Veins
Leg, Ankle Swellings
Rashes, infections, excess sweating
Panniculitis (infected abdominal skin fold)
Nephrotic Syndrome
Increased risk of certain cancers
Steatohepatitis (fat induced hepatitis)
Hypercoagulable States
Pulmonary embolism
Lack of self esteem
Social rejection
Loss of job potential
Inappriopriate coping strategies

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Ottawa, ON
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Oct 18, 2007
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