History of Duodenal Switch

The History of Duodenal Switch explains why this hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch (BPD-DS). Duodenal Switch is sometimes confused with old or outdated weight loss surgeries so we will start the history of Duodenal Switch lesson in the 1950s and will clarify the differences between Duodenal Switch and these other procedures.

Jejunoileal Bypass (JIB)
The Jejunoileal Bypass, a strictly malabsorptive procedure, was performed in the 1950s and was the first surgery developed to achieve weight loss. The stomach remains intact and all but 35 cm (18 in) of the small intestine is detached and set to the side, not reattached anywhere. With no liquid flowing through the bypassed intestine to cleanse it, some potentially serious complications could develop, like toxic bacterial overgrowth leading to sepsis. Patients were also at risk of developing severe malnutrition and liver failure from not effectively absorbing vitamin B complex and vitamin C. The JIB is no longer recommended as a bariatric surgical procedure and many patients have had this procedure reversed or revised.

Roux-en-Y Gastric Bypass (RNY, RYGBP or Proximal Gastric Bypass)
While the story of Gastric Bypass or Roux-en-Y is not required in this lesson on the history of Duodenal Switch, the information below will help explain why Distal Gastric Bypass patients have similar malabsorption to DS patients.

In the 1970s, the Roux-en-Y Gastric Bypass was developed as a revision to the Loop Gastric Bypass and combined restrictive and malabsorptive procedures. A small (15-30 cc) pouch is created at the top of the stomach to restrict food intake. The small bowel is divided about 45 cm (18 in) below the lower stomach and is re-arranged into a Y-formation. The pyloric valve at the bottom of the "blind" stomach and is not in use because food travels out of the top "pouch" stomach straight into the small intestine via the roux limb. For this reason sugar moves quickly into the bowel and can cause "dumping". Proximal patients have their roux limb measured approx 80 - 150 cm (30 to 60 inches) from the top of the small intestine therefore most of the small bowel absorbs nutrients and their malabsorption is mild.

A less common modification of the RYGBP is the Distal Gastric Bypass. Distal patients have the same "pouch" stomach as proximal patients but have their roux limb measured approx 100 to 150 cm from the bottom of the small bowel. As a result, Distal Gastric Bypass patients have increased malabsorption similar to Duodenal Switch patients.

Biliopancreatic Diversion (BPD)
The history of Duodenal Switch lesson continues with Dr. Nicola Scopinaro introducing the Biliopancreatic Diversion in Italy in 1979. It combines malabsorption with temporary gastric restriction. The stomach is divided horizontally. A large pouch between 250 and 400 ccs is created with the upper portion and the lower stomach is surgically removed (distal gastrectomy). The pyloric valve is not in use so "dumping" often occurs. The duodenum (top part of the small intestine) is bypassed and the stomach pouch is connected to the lower 2.75 metres of the small intestine. 4-metres of the small bowel (60%) are bypassed. The common channel is approximately 50 cm.

Stand-alone Duodenal Switch
The stand-alone Duodenal Switch procedure (without the accompanying gastric bypass as used in weight-loss surgery) was developed by Dr. Tom R. DeMeester in the 1980's to treat bile gastritis, a condition in which the stomach and esophagus are burned by bile.

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
The history of Duodenal Switch concludes in 1986 when Dr. Douglas Hess modified Scopinaro's BPD and combined it with DeMetter's Duodenal Switch. This hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch, but keep in mind the BPD portion has been modified from the original procedure so the name can be misleading.

Duodenal Switch (DS)
DS surgeons and patients commonly refer to this procedure as the Duodenal Switch. Hess's Duodenal Switch has the advantages of the BPD but without some of the associated problems, such as marginal ulcers, stoma closures and blockages, dumping syndrome, and serious protein-calorie malnutrition; all of which can occur after other gastric bypass procedures.

Dr. David Greenbaum explains,

He (Hess) started this as a revisional operation for those who failed other weight loss operations and it showed great success. Later he started performing it as a primary operation. Its popularity was initially marginal because it was a difficult operation; it was not well understood and was constantly grouped with Dr Scopinaro's BPD which had a too many unwanted complications. Slowly, however, many weight loss surgical groups throughout the world started performing it and the results were extremely good.

In 2006, a group of surgeons brought their results of well over 100,000 patients to Washington and presented them to the Center For Medicare and Medicaid Services and it finally gained approval after almost 30 years.

For more information on the history of Duodenal Switch:
Story of surgery for obesity from the American Society for Metabolic and Bariatric Surgery (ASMBA).