The Laparoscopic Sleeve Gastrectomy with Duodenal Switch (DS)

The Sleeve Gastrectomy with Duodenal Switch Procedure, sometimes referred to as the Biliopancreatic Diversion with Duodenal Switch, is a mixed malabsorptive and restrictive operation. It involves making a tubular pouch of the stomach, with preservation of the pyloric valve. The duodenum is then divided just beyond the pylorus. The small bowel is then divided, and the end going to the cecum of the colon is connected to the short stump of the duodenum. This becomes the "alimentary limb". The other end, leading from the gallbladder and pancreatic ducts, is connected onto the alimentary limb at about 75-100 cm from the iliocecal valve. This limb is the "biliopancreatic limb". The last 75-100 cm then becomes the "common channel".

The Duodenal Switch can be done open or laparoscopically although Dr. Smith does all of his Duodenal Switch operations laparoscopically. It is especially good for people who have a great deal of weight to lose. The Duodenal Switch is also very good for insulin-dependent diabetics and those with high triglyceride levels in their blood. People can eat relatively normally once the stomach has recovered afterward, as opposed to the gastric bypass, in which the stomach pouch remains very small.

Weight Loss Mechanism

The Duodenal Switch operation usually obtains the best weight loss (an average of around 80-85% of excess body weight) of the three operations. The most important feature of the operation is that it diverts the food stream so that it is only in the last 75-100 cm, the “common channel”, that the food can mix with the digestive stream, in order to be digested and absorbed. The result is a "malabsorptive" weight loss. The reduction of the size of the stomach, to about 100 - 150 cc in volume, also results in a restrictive component on weight loss. As a result, this operation provides a mixed malabsorptive and restrictive weight loss.

Preservation of Pyloric Valve

Also very important is the fact that the Duodenal Switch procedure preserves the pylorus, the valve that regulates emptying of the stomach, with preservation of several centimeters of the duodenum. This means dumping and marginal ulcers are much less a problem than with the Roux-en-Y Gastric Bypass. The normal satiety mechanism is preserved as well.

Malabsorption

Problems with the Duodenal Switch operation are malabsorptive in nature, largely, but most can be managed, when they occur, by taking supplements. The major complication to worry about with this surgery in the long-term is protein malabsorption, which should occur about 1% of the time if done in this configuration. If patients are being followed appropriately, this is usually caught early, and can be managed very well with adjustment of the type and quality of protein the patient is consuming, the addition of pancreatic enzymes, and then if necessary, surgical lengthening of the common channel to improve absorption. This can usually be done so that the patient’s protein absorption is improved without the patient gaining substantial weight.

Malabsorption of the fat-soluble vitamins, Vitamins A, D, E and K, are also potentially at risk, and these must be followed as well. Prolonged, uncorrected deficiencies of these Vitamins can be very serious, leading to problems such as night blindness (Vitamin A deficiency) and immune system compromise (Vitamin E deficiency). These can also be managed well with supplements if the deficiency can be caught early.

Lifelong Follow-Up

Patients who have the Duodenal Switch procedure must absolutely have lifelong medical follow-up, since the side effects can be subtle, and can appear months to years after the surgery. Sometimes diarrhea and foul smelling gas are problems, but they are usually just a minor nuisance. Leaks and obstructions are possible. Iron and Calcium absorption are also a concern with this operation, as with the Gastric Bypass. As mentioned above, nutritional and vitamin deficiencies are possible, but most can be managed with supplements. Protein malnutrition is potentially a major problem, but it is rare with proper follow-up, and can be managed by lengthening of the common channel. There is also the possibility of liver failure, although this is an extremely unusual complication, and would require extreme non-compliance on the part of the patient.

Laparoscopic Duodenal Switch Streaming Video!

Click here to watch a Streaming Video (9+ minutes) of Dr. Smith doing the Totally Laparoscopic Sleeve Gastrectomy with Duodenal Switch. Note: You'll need Windows Media Player to view this video.

Click here to watch a Video Clip of Dr. Smith doing the Duodeno-Ileal Anastomosis of the Laparoscopic Duodenal Switch, in which he does a hand-sewn, two layer sutured anastomosis laparoscopically. Note: You'll need Windows Media Player to view this video.

Click here to watch a Video Clip of Dr. Smith doing the Sleeve Gastrectomy of the Laparoscopic Duodenal Switch, in which the lateral 3/4 of the stomach is resected, leaving a narrow tubular stomach. Note: You'll need Windows Media Player to view this video.

Our Poster From The 2005 ASBS Meeting:

Click to View .pdf of Poster Presented at the 2005 ASBS Meeting: Laparoscopic Biliopancreatic Diversion with Duodenal Switch in Patients with BMI > 60
--Laparoscopic Biliopancreatic Diversion with Duodenal Switch in Patients with BMI > 60. Dennis C. Smith, Jr., MD, et al; The Advanced Obesity Surgery Center, WellStar Health System Bariatric Surgery Program, Marietta, Georgia, USA.
Conclusions: The completely Laparoscopic Biliopancreatic Diversion with Duodenal Switch is a safe, feasible and very effective operation for patients with BMI’s in the 60’s and above.
A single-stage Laparoscopic Duodenal Switch can be performed in patients with BMI’s > 60 with a very low morbidity and mortality.

Please call or email our office for more information about the Duodenal Switch and whether it might be right for you.

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The Advanced Obesity Surgery Center
A Certified Bariatric Surgery Center of Excellence
Marietta, Georgia, USA