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Duodenal Switch

First reported by Dr. Doug Hess in 1986, the duodenal switch (DS) is a modification of the biliopancreatic diversion BPD.  DS has some of the highest reported weight loss but also has the highest rate of nutritional complications compared to Gastric Bypass and the purely restrictive procedures.

While DS is a valid option for many patients considering bariatric procedure, Dr. Spivak typically considers it for patients with BMI>60, patients with special needs, and as a revision surgery for failed Gastric Sleeve procedure.

The DS works through gastric restriction as well as intestinal malabsorption. The stomach is transected  into a small sleeve, preserving the pylorus, transecting the duodenum and connecting the intestine to the duodenum above where digestive juices enter the intestine.

The duodenum is tolerant of stomach acid and therefore is much more resistant to ulceration compared to the small intestine (like the situation in Gastric Bypass). Removing part of the stomach also decreases the amount of acid present. Whereas the Gastric Bypass involves an anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the duodenum and the intestine. The duodenum is cut about 2-4 cm from the stomach (measured from the pyloric valve). The intestine is sewn to the end of the duodenum which remains in continuity with the stomach. The other side of the duodenum will carry all the bile and pancreatic secretions. Technically, the disadvantage of transecting the duodenum is the large number of vital structures immediately adjacent to the duodenum. Several large blood vessels and the major bile duct are located here. Injury to these structures can be life-threatening.

Advantages of Duodenal Switch:

• Increased amount of food intake compared to the bypass and band
• Less food intolerance
• Possibly greater long-term weight loss
• More rapid weight loss compared with gastric banding procedures
  
  

Complications of Duodenal Switch:

• Diarrhea and foul smelling gas especially after a meal that is high in fat
• An average of 3-4 loose bowel movements a day
• Malabsorption of fat soluble vitamins (Vitamins A, D, E, and K)
• Vitamin A deficiency, which causes night blindness  
• Vitamin D deficiency, which causes osteoporosis
• Iron deficiency –a similar incidence with the Gastric Bypass
• Protein-calorie malnutrition, which might require a second operation to lengthen the common channel
• Ulcers (less frequent with DS)
• Dumping syndrome (less frequent with DS)