Duodenal Switch for Morbid Obesity

A series of articles about Duodenal Switch for Morbid Obesity (BMI > 40).

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/m(2). 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.

Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m(2)? 
Marceau et al. Sept 2010
PubMed Abstract 

BACKGROUND: Biliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] >/=50 kg/m(2)). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m(2).

METHODS: This was a retrospective study of all patients with a BMI <50 kg/m(2) who had undergone DS from June 1992 to May 2005. The data are reported as the mean +/- standard deviation.

RESULTS: The data from 810 consecutive patients, with a mean initial BMI of 44.2 +/- 3.6 kg/m(2), were reviewed. The mean follow-up was 103 +/- 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% +/- 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%, and 37% would have preferred to lose more weight.

CONCLUSION: These results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D.

The Duodenal Switch Operation for Morbid Obesity 
Anthone Aug 2005
PubMed Abstract 

The duodenal switch provides excellent weight loss with preservation of good alimentation, even in the superobese. This is accomplished with acceptable operative mortality and minimal dietary limitations and metabolic sequelae. The results of the duodenal switch that are reported in the literature should remove any inhibitions that exist about the use of this procedure as treatment for patients who have morbid obesity. This article discusses the duodenal switch operation for morbid obesity.

The Duodenal Switch as an Increasing and Highly Effective Operation for Morbid Obesity 
Rabkin et al. June 2004
PubMed Abstract 
Full Article 

INTRODUCTION: “Morbid Obesity” (ICD 278.01 / BMI >40) is an entity distinct from “obesity”, the latter term encompassing the broad range of over weight. Available treatment modalities as well as outcomes differ substantially over the spectrum of higher BMI. Representative data for behavior modification, diet and exercise show at best an average weight loss of 4-7 kg at 2 years, with decreasing benefit in the longer term.

The reported maximum of 7 kg is hardly significant for a morbidly obese individual who might be carrying an excess weight 45-75 kg or more. Those morbidly obese patients who do respond to non-surgical weight loss programs, generally fail to maintain the weight loss, with recidivism rates exceeding 95%. Behavior modification, diet and exercise have been found to be ineffective on an intermediate and long-term basis for treatment of obesity, particularly morbid obesity. Regain of the lost weight is the rule, and more than the initial weight lost is commonly regained.

Surgery is the only modality proven to be effective in the treatment of morbid obesity; however, surgical treatment entails known finite risks influenced by clinical factors. To achieve a beneficial net reduction in morbidity and mortality, the risks from the excess weight must exceed the risks of surgery and anesthesia. It is interesting to note that published series show significant increases in the relative risk associated with obesity at a BMI of 27 kg/m2, and exponential increases at a BMI of 32 kg/m2 (the highest bracket reported) – well below the 35 to 40 kg/m2 often considered minimum for surgical intervention.

Duodenal Switch: An Effective Therapy for Morbid Obesity – Intermediate Results 
Baltasar et al. April 2002
PubMed Abstract 

BACKGROUND: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a verticalsubtotal gastrectomy and pylorus preservation.

METHODS: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of thepatients super obese (SO). Patients have been followed for an intermediate period.

RESULTS: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in allpatients.

CONCLUSION: DS was very effective for the treatment of the morbid obesity in the SO patients.

Biliopancreatic Diversion with a Duodenal Switch
Hess et al. June 1998
PubMed Abstract 

BACKGROUND: This paper evaluates biliopancreatic diversion combined with the duodenal switch, forming a hybrid procedure which is a combination of restriction and malabsorption.

METHODS: The evaluation is of the first 440 patients undergoing this procedure who had had no previous bariatric surgery. The mean starting weight was 183 kg, with 41% of our patients considered super morbidly obese (BMI > 50).

RESULTS: There was an average maximum weight loss of 80% excess weight by 24 months postoperation; this continued at a 70% level for 8 years. Major complications were found in almost 9% of the cases. There were two perioperative deaths, one from pulmonary embolism and one from acute pulmonary obstruction. There were 36 type II diabetics, all of whom have discontinued medication following the surgery. Seventeen revisions were performed to correct excess weight loss and low protein levels. There have been no marginal ulcers, no cases of dumping syndrome, no foreign material used, and the procedure is a pyloric saving procedure which is functionally reversible.

CONCLUSIONS: This operation has vastly improved the lives of seriously obese patients with many comorbidities. All type II diabetics have essentially been cured of their disease. The procedure was tolerated well and patients are quite satisfied. There was minimal regain of weight with this method.