Duodenal Switch for Super Morbid Obesity

Clinical data addressing Duodenal Switch for super morbid
obesity (BMI > 50).

Outcome of laparoscopic duodenal switch for morbid obesity.

Magee et al. Oct 2010

PubMed Abstract

BACKGROUND: The aim of this study was to determine the safety
and efficacy of laparoscopic duodenal switch (LDS) as a treatment
option in a selected group of patients with morbid obesity.

METHODS: This retrospective analysis of a prospective database
assessed the frequency of all complications and alterations
in weight, body mass index (BMI), co-morbidity and quality of life.

RESULTS: One hundred and twenty-one patients underwent LDS
between April 2003 and March 2009. Median preoperative weight
was 160 kg and median BMI 55 kg/m2. All procedures were performed
laparoscopically. The in-hospital mortality rate was zero. No
ileoduodenal anastomotic stenosis was encountered. There were
four clinical leaks (3.3 per cent) managed by laparoscopic
drainage and placement of a feeding jejunostomy. Median percentage
excess weight loss was 75 per cent at 12 months and 90 per cent
at 24 months. Thirty-six of 40 diabetic patients had complete
resolution of diabetes within 1 year. There were significant
improvements in other obesity-related co-morbidity. Only a few
patients developed postoperative protein deficiency, and fat-soluble
vitamin deficiencies were easily managed with oral supplementation.

CONCLUSION: The LDS procedure is a safe and effective treatment
for morbid obesity and its associated co-morbidity in selected
patients. Copyright © 2010 British Journal of Surgery
Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of laparoscopic gastric bypass
versus laparoscopic duodenal switch for superobesity.

Søvik et al. Feb 2010

PubMed Abstract

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and
laparoscopic biliopancreatic diversion with duodenal switch
(LDS) are surgical options for superobesity. A randomized trial
was conducted to evaluate perioperative (30-day) safety and
1-year results.

METHODS: Sixty patients with a body mass index (BMI) of 50-60
kg/m(2) were randomized to LRYGB or LDS. BMI, percentage
of excess BMI lost, complications and readmissions were
compared between groups.

RESULTS: Patient characteristics were similar in the two
groups. Mean operating time was 91 min for LRYGB and 206
min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION: LRYGB and LDS can be performed with comparable
perioperative safety in superobese patients. LDS provides
greater weight loss in the first year.

Registration number: NCT00327912 (http://www.clinicaltrials.gov).
Copyright (c) 2009 British Journal of Surgery Society Ltd.
Published by John Wiley & Sons, Ltd.

Duodenal switch provides superior resolution of metabolic
comorbidities independent of weight loss in the super-obese
(BMI > or = 50 kg/m2) compared with gastric bypass.

Prachand et al. Feb 2010

PubMed Abstract

OBJECTIVE: Increased body mass index is associated with greater
incidence and severity of obesity-related comorbidities and
inadequate postbariatric surgery weight loss. Accordingly, comorbidity
resolution is an important measure of surgical outcome in super-obese
individuals. We previously reported superior weight loss in super-obese
patients following duodenal switch (DS) compared to Roux-en-Y gastric
bypass (RYGB) in a large single institution series. We now report
follow-up comparison of comorbidity resolution and correlation with
weight loss.

METHODS: Data from patients undergoing DS and RYGB between
August 2002 and October 2005 were prospectively collected
and used to identify super-obese patients with diabetes,
hypertension, dyslipidemia, and gastroesophageal reflux disease
(GERD). Ali-Wolfe scoring was used to describe comorbidity
severity. Chi-square analysis was used to compare resolution
and two-sample t tests used to compare weight loss between patients
whose comorbidities resolved and persisted.

RESULTS: Three hundred fifty super-obese patients [DS (n=198),
RYGB (n=152)] were identified. Incidence and severity of hypertension,
dyslipidemia, and GERD was comparable in both groups while diabetes
was less common but more severe in the DS group (24.2% vs. 35.5%,
Ali-Wolfe 3.27 vs. 2.94, p<0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p<0.05). There were no differences in weight loss between comorbidity "resolvers" and "persisters".

CONCLUSIONS: In comparison to RYGB, DS provides superior resolution
of diabetes, hypertension, and dyslipidemia in the super-obese
independent of weight loss.

Duodenal Switch Operative Mortality and Morbidity Are Not
Impacted by Body Mass Index.

Buchwald et al. Oct 2008

PubMed Abstract

OBJECTIVE: This report examines the up to 30-day postoperative
mortality and morbidity in our first 190 duodenal switch (DS)

BACKGROUND DATA: DS is the most weight loss effective and
the most difficult to perform bariatric procedure. Indeed,
certain surgeons have advocated a 2-stage approach to minimize
complications, especially in the super obese (body mass index
[BMI] >/=50 kg/m).

METHODS: DS procedures were performed (n = 190) by either
open (n = 168) or laparoscopic/robotic surgery in an academic
setting: common channel 75 to 125 cm, sleeve gastrectomy
(approximately 100 mL gastric pouch), closed duodenal stump,
end-to-side duodenoileostomy hand-sewn in 2 layers, with most
staple lines oversewn, and all mesentery defects closed.

RESULTS: For the 190 patients, 149 were female (78%) and the
mean age was 43 years (range, 16-71). Mean preoperative weight
151.4 kg (range, 74.1-332.7); mean preoperative BMI 53.4 kg/m
(range, 32-107), with 100 (52.6%) of the patients super obese
(BMI >/=50 kg/m). Seventy-four patients had concurrent procedures,
eg, cholecystectomy (n = 22), ventral or umbilical hernia
repair (n = 19), and hiatus hernia repair (n = 10). Mean
operating room time was 337 minutes (range, 127-771); mean
hospitalization time was 6 days (range, 2-38). There were no
deaths. Serious /=50 kg/m (NS).
Surgical site infections occurred in 7 patients with a BMI
<50 kg/m and in 12 with a BMI >/=50 kg/m (NS). Overall complication
rate in patients with a BMI <50 kg/m was 14.4% (13 of 90) and 24% (24 of 100) with a BMI >/=50 kg/m (NS).

CONCLUSIONS: With attention to careful surgical technique,
DS can be performed relatively safely in the morbidly and
super morbidly obese, and does not require a 2-stage procedure.

Outcome of duodenal switch with a transitory vertical gastroplasty,
in super-super-obese patients in an 8-year series.

Di Betta et al. Feb 2008

PubMed Abstract

BACKGROUND: In super-super obese (SSO) patients [body mass index
(BMI) superior of 60 kg/m2] results of bariatric surgery are still
controversial. This study evaluated safety and efficacy of open
duodenal switch associated with transitory vertical gastroplasty
(DS-TVG) after 8 years of follow-up.

METHODS: A prospective observational study of 32 SSO patients
who underwent an open DS-TVG from January 1999 till March 2006
was performed. Study endpoints included preoperative comorbidities
[diabetes, hypertension, and obstructive sleep apnea syndrome (OSAS)],
postoperative morbidity and mortality, and long-term results of BMI
and percent of excess weight loss (%EWL) (median 48 months).

RESULTS: Results in terms of BMI and %EWL were, respectively,
after 12 months, 46.3 +/- 10.2 and 57.1 +/- 9.8; after 36 months
(n = 21), 37.5 +/- 7.5 and 73.5 +/- 6.2; and after 84 months
(n = 5), 31.7 +/- 2.8 and 76.0 +/- 4.1. With regard to comorbidities,
we observed complete control of lipid alterations and type-2
diabetes (suspension therapy within 1 year). All patients with
OSAS improved within 1 year without needing domiciliary oxygen
therapy. Neither malnutrition nor mortality was observed during
the follow-up. Major complications occurred in a total of 5
patients (15.6%): pulmonary embolism (2 cases-9.4%); gastrointestinal
bleeding, requiring transfusions (1 case-3.1%); 1 case (3.1%) of
abdominal rupture; and 1 case of acute pancreatitis (3.1%). Minor
complications occurred in 4 patients (12.5%): 1 case of pneumonia,
1 urinary tract infection, and 2 wound infections.

CONCLUSION: Although this study evaluated the outcomes of a small
series of patients after open DS-TVG, this procedure seems to be
safe and effective in obese patients who have a BMI greater than 60
kg/m2. In our opinion, DS-TVG should be considered as a valid surgical
option with two staged laparoscopic procedures.

Duodenal Switch Provides Superior Weight Loss in the Super-Obese
(BMI >50kg/m2) Compared With Gastric Bypass

Prachand et al. Oct 2006

PubMed Abstract

Full Article

OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass
is acceptable in patients with preoperative body mass index (BMI)
between 35 and 50 kg/m, results from several series demonstrate
that failure rates approach 40% when BMI is > or =50 kg/m. Here
we report the first large single institution series directly
comparing weight-loss outcomes in super-obese patients following
biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y
Gastric Bypass (RYGB).

METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing
standardized laparoscopic and open DS and RYGB between August
2002 and October 2005 were identified from a prospective database.
Two-sample t tests were used to compare weight loss, decrease
in BMI, and percentage of excess body weight loss (% EBWL)
after surgery. chi analysis was used to determine the rate
of successful weight loss, defined as achieving at least 50%
loss of excess body weight.

RESULTS: A total of 350 super-obese patients underwent DS
(n = 198) or RYGB (n = 152) with equal 30-day mortality
(DS,1 of 198; RYGB, 0 of 152; P = not significant). The %
EBWL at follow-up was greater for DS than RY (12 months,
64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months,
71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater
in patients following DS (12 months, 83.9% vs. 70.4%; 18 months,
90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05).

CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior
weight loss outcomes for DS.