Duodenal Switch As A Revision Surgery

Studies addressing Duodenal Switch as a revision surgery
for other failed weight loss surgery procedures.

Is biliopancreatic diversion with duodenal switch a
solution for patients after laparoscopic gastric banding

Poyck et al. Sept 2011

PubMed Abstract

BACKGROUND: Weight loss failure after laparoscopic gastric
banding (LAGB) can occur in =25% of patients. Conversion
to a malabsorptive procedure might provide more durable
weight loss. The present study evaluated biliopancreatic
diversion with duodenal switch (BPD/DS) after LAGB failure
with a 3-year follow-up period.

METHODS: A total of 35 patients underwent BPD/DS after LAGB
failure and were prospectively analyzed using a multidisciplinary
approach. Weight indexes, co-morbidities, complications,
morbidity/mortality, and nutritional status were analyzed.

RESULTS: Excess weight decreased from 91% (134 kg, body mass
index 48 kg/m(2)) to 75% (124 kg, body mass index 44 kg/m(2))
after LAGB failure and decreased further to 40% (100 kg,
body mass index 35 kg/m(2)) after BPD/DS. The mean percentage
of excess weight loss was 55% after LAGB and BPD/DS together
and 48% after BPD/DS alone. The incidence of co-morbidities,
such as diabetes, sleep apnea, hypertension, hyperlipidemia,
joint problems, and chronic obstructive pulmonary disease
was reduced after BPD/DS. Nutritional deficiencies were
already present after LAGB failure (e.g., iron, ferritin,
vitamins B(12), B(6), A, D, and E, albumin, and calcium)
and either increased (folic acid, potassium, and vitamin
B(12)), remained stable (iron, ferritin, vitamin A), or
decreased after BPD/DS (albumin and vitamins B(6) and E).

CONCLUSION: BPD/DS provided substantial weight loss after
LAGB failure and reduced the incidence of obesity-related
co-morbidities during a 3-year period. Long-term nutritional
follow-up is advocated for all patients after malabsorptive

Laparoscopic repeat sleeve gastrectomy versus duodenal
switch after isolated sleeve gastrectomy for obesity.

Dapri et al. Aug 2010

PubMed Abstract

BACKGROUND: Repeat sleeve gastrectomy (re-SG) and the addition
of the duodenal switch (DS) are possible options to increase
weight loss after isolated SG (ISG). We report the feasibility,
safety, and outcomes of laparoscopic re-SG versus DS in patients
presenting with insufficient weight loss or weight regain after ISG.

METHODS: From November 2003 to December 2009, 7 and 19 patients
underwent laparoscopic re-SG and DS, respectively, mainly
because of the patients’ dietary habits: volume eating (hyperphagia)
was treated by re-SG and eating meals too frequently (polyphagia) by DS.

RESULTS: At ISG, the mean weight and BMI was 127.7 ± 31.4 kg,
and 45.1 ± 11.8 kg/m(2) for the re-SG group and 119.8 ± 20.9
kg and 41.2 ± 5.5 kg/m(2) for the DS group, respectively.
The mean interval between ISG and reoperation was 37.1 ±
20.3 months for the re-SG group and 29.8 ± 24.9 months for
the DS group. At reoperation, the mean weight, BMI, and percentage
of excess weight loss (%EWL) was 109.7 ± 21 kg, 38.9 ± 8.7
kg/m(2), 24.3 ± 16.6% for the re-SG group and 107.6 ± 19.6
kg, 36.9 ± 4.2 kg/m(2), and 19.5 ± 19.9% for the DS group,
respectively. The mean operative time was 137.5 ± 75.5 minutes
for the re-SG group and 152.6 ± 54.3 minutes for the DS group.
No conversion to open surgery was required, and no mortality
occurred. One patient in the re-SG group developed a leak at
the angle of His. In the DS group, 1 patient presented with
bleeding, 1 patient with a duodenoileostomy leak, and 1 patient
with a duodenoileostomy stenosis. The mean hospital stay was
11.5 ± 20.5 days for the re-SG group and 4.7 ± 2.7 days for
the DS group. The mean follow-up was 23.2 ± 11.1 months for
the re-SG group and 24.9 ± 20.1 months for the DS group. The
mean weight, BMI, and %EWL was 100 ± 21.1 kg, 35.3 ± 8.3
kg/m(2), 43.7 ± 24.9% for the re-SG group and 80.7 ± 22.5
kg, 27.3 ± 5.2 kg/m(2), 73.7 ± 27.7% for the DS group, respectively.
During follow-up, 3 patients in the DS group required corrective
surgery for late complications.

CONCLUSION: The results of the present study have shown that
laparoscopic re-SG is feasible but carries the risk of fistula
development, which is difficult to treat. Laparoscopic DS was
also shown to be feasible at a cost of not negligible complications,
which are easier to manage than with re-SG. The efficacy seemed
greater after DS than after re-SG.

Conversion of failed vertical banded gastroplasty to
biliopancreatic diversion, a wise option.

Weiner et al. Dec 2009

PubMed Abstract

BACKGROUND: Reoperations due to failures constitute an essential
but challenging part of bariatric surgery practice today. The
aim of this study was to evaluate the perioperative safety,
efficacy, and postoperative quality of life in patients with
biliopancreatic diversion (BPD), after failed vertical banded
gastroplasty (VBG).

METHODS: Twelve patients after failed or complicated VBG,
eight females and four males, median age 45 years (range 39-52),
median body mass index (BMI) 46.39 kg/m2 (range 25.89-69.37),
who underwent conversion to BPD, were studied.

RESULTS: Ten patients due to weight regain and two patients
because of severe stenosis of the gastric pouch outlet were
submitted in conversion to BPD. In eight (66.6%) patients the
primary VBG had been followed by at least one revisional
operation due to inadequate weight loss. The 10 patients
after failed VBG, reached the lowest BMI recorded after VBG
in just a year after BPD (p=0.721 for the comparison between
the two time points). The two patients with stomal stenosis
regained weight in the first six postoperative months and
remain stable since then. Regarding safety, one major perioperative
complication (gastrojejunostomy stenosis) occurred. At a median
follow-up of 21 months (range 12-30) six complications have been
documented, including a case of incisional hernia, four cases
of pouch gastritis and a case of intractable iron-deficiency

CONCLUSION: Our early results indicate that conversion of
failed VBG to BPD is highly effective with acceptable morbidity.
Our data show that the effect on weight is strongly dependent
on the indication for the conversion. Conversion to BPD, in
such a group of patients, is a wise alternative, since it
may reduce operative risks.

Laparoscopic conversion of adjustable gastric banding
and vertical banded gastroplasty to duodenal switch.

Dapri et al. Nov-Dec 2009

PubMed Abstract

BACKGROUND: The aim of this retrospective consecutive study
was to evaluate the feasibility, safety, and efficacy of
the conversion of laparoscopic adjustable gastric banding
(LAGB) and open vertical banded gastroplasty (VBG) into
duodenal switch (DS) by laparoscopy.

METHODS: From November 2003 to February 2007, laparoscopic
conversion into DS was performed in 1-step in 43 patients,
31 after LAGB and 12 after VBG. The reason for conversion
was weight loss issues, such as insufficient excess weight
loss (EWL) or weight regain. The mean interval from LAGB
and VBG to conversion to the DS was 42.7 +/- 28.7 months
and 172.2 +/- 86.9 months, respectively. The mean %EWL at
conversion was 8.3% +/- 19.3% after LAGB and 20.8% +/-
30% after VBG.

RESULTS: The mean operative time was 205.8 +/- 44.8 minutes
for LAGB and 210.9 +/- 53.7 minutes for VBG. No conversions
to open surgery occurred. One patient in the LAGB group died
on the third postoperative day of sudden death syndrome, as
shown by the postmortem examination. Major complications
occurred in 6.4% of patients with LAGB (1 hemoperitoneum and
1 ileoileostomy leak) and in 50% with VBG (1 sleeve gastrectomy
leak with subsequent duodenoileostomy leak, 3 duodenoileostomy
leaks, 1 pancreatitis, and 1 respiratory insufficiency). The
mean hospital stay was 5.5 +/- 5 days for the LAGB group and
34.5 +/- 50.3 days for the VBG group. After a mean follow-up
of 28 +/- 15.7 months for LAGB to DS and 43.5 +/- 6 months
for VBG to DS, reoperations for late complications were required
in 6 patients (20.6%) in the LAGB to DS group and in 5 patients
(62.5%) in the VBG to DS group. Three patients (25%) died
within 8 months after conversion of VBG. The 29 surviving
patients (LAGB to DS) showed a mean %EWL and percentage of
excess body mass index loss of (%EBMIL) 78.4% +/- 24.9% and
77.8% +/- 23.7%, respectively. The 8 surviving patients (VBG
to DS) had a mean %EWL and %EBMIL of 85.1% +/- 20% and 85.8%
+/- 18.7%, respectively.

CONCLUSION: According to these results, laparoscopic conversion
of LAGB to DS seems feasible and effective, despite the 1 death.
However, in our hands, laparoscopic conversion of VBG to DS had
an unacceptable rate of complications and deaths.

Revision bariatric surgery: laparoscopic conversion of
failed gastric bypass to biliopancreatic diversion with
duodenal switch.

Gagner et al. Jun 2009

PubMed Abstract

With more than 40% failures of gastric bypass in Body Mass
Index>50 kg/m2, a successful alternative has to be proposed.
Laparoscopic conversion of failed Roux-en-Y gastric bypass
to biliopancreatic diversion with duodenal switch is technically
feasible, safe and can be performed in 1 or 2 stages. This
revision surgery is the most effective treatment to date,
and should also be proposed for failed vertical-banded gastroplasty,
adjustable gastric banding and Magenstrasse and Mill procedure,
as it may provide the most durable weight loss of all revision
surgeries with acceptable morbidity. This may result in lesser
degrees of hypoproteinemia, commonly seen after distal gastric

Laparoscopic conversion of failed gastric bypass to duodenal
switch: technical considerations and preliminary outcomes.

Gagner et al. Nov-Dec 2007

PubMed Abstract

BACKGROUND: Weight loss failure after Roux-en-Y gastric bypass
(RYGB) is a challenging problem facing bariatric surgeons
today. Conversion from RYGB to biliopancreatic diversion with
duodenal switch (BPD-DS) might provide the most durable weight
loss of all revision procedures currently available. Revision
to BPD-DS can be done laparoscopically in 1 or 2 stages and
involves 4 anastomoses: gastrogastrostomy, duodenoileostomy,
ileoileostomy, and jejunojejunostomy (to reconnect the old
Roux limb). This study reports on our early outcomes after
laparoscopic conversion from RYGB to BPD-DS.

METHODS: The data from all patients undergoing conversion
from failed RYGB to BPD-DS were retrospectively reviewed.
The data analyzed included age, body mass index, excess weight
loss, method of gastrogastrostomy, and morbidity/mortality.

RESULTS: Twelve patients were identified for analysis. The
mean age and body mass index before conversion was 41 years
and 41 kg/m(2), respectively. Of these 12 patients, 4 (33%)
had undergone revision surgery (lengthening of the Roux limb,
resizing the gastric pouch, adjustable band on pouch, or
distal gastric bypass) before conversion; 8 (66%) had
obesity-related co-morbidities; 7 (58%) underwent conversion
to BPD-DS in 1 stage. Most gastrogastrostomies were performed
using the 25-mm circular stapler. No patient died and no
leaks developed. One patient required laparotomy, and 4 developed
stricture at the gastrogastrostomy. The patients lost a dramatic
amount of weight after conversion to BPD-DS, with a mean body
mass index and excess weight loss of 31 kg/m(2) and 63%,
respectively, at 11 months postoperatively. All co-morbidities
resolved completely with the weight loss.

CONCLUSION: Our preliminary results indicate that laparoscopic
conversion to BPD-DS from failed RYGB is highly effective with
an acceptable morbidity. Using a linear stapler to construct
the gastrogastrostomy might reduce the stricture rate.

Duodenal Switch is a Safe Operation for Patients who
have Failed Other Bariatric Operations

Keshishian et al. Oct 2004

PubMed Abstract

Full Article

BACKGROUND: The incidence of morbid obesity and its surgical
treatment have been increasing over the last few years. With
this increase, there has been a rise in the number of patients
who have had less than desirable outcome after bariatric
operations. We perform the duodenal switch (DS) in patients
for whom other weight loss surgical procedures have failed,
because of inadequate weight loss, weight regain or significant
complications, such as solid intolerance or dumping syndrome.

METHOD: From November 1999 to March 2004, 46 revisional
surgeries were performed at our institution. The data was
prospectively collected and reviewed, based on a number of
parameters. Operative details, perioperative morbidity, and
results are reported.

RESULTS: 46 patients had their original bariatric surgical
operation revised to DS. This resulted in complete resolution
of their presenting complaints. The %EWL was 69% at the time
of publication, with a mean lapsed time of 30 months. We had
no mortality. Anastomotic leak occurred in 4 patients, 2 in
our first 8 patients. We also noted that the majority of the
patients were not aware of all the surgical procedures available
to them at the time of their original operation.

CONCLUSION: In patients in whom gastroplasty, gastric bypass
or both have failed to provide adequate weight loss, or worse
have resulted in complications, DS can be performed as a
safe revisional operation. The revision of other failed
bariatric operations to DS results in both weight loss and
resolution of the complications.