Laparoscopic Duodenal Switch

Studies on the laparoscopic Duodenal Switch procedure.

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.
Clinical application of laparoscopic bariatric surgery: an evidence-based review. 
Farrell et al. May 2009
PubMed Abstract 

BACKGROUND: Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS: This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS: Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS: Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Laparoscopic Technique for Performing Duodenal Switch with Gastric Reduction 
Rabkin et al. April 2003
PubMed Abstract 
Full Article 

BACKGROUND: The duodenal switch procedure with gastric reduction (DS) is a hybrid procedure for morbidobesity that combines moderate intake restriction with moderate malabsorption. This report describes the laparoscopic hand-assisted technique for the duodenal switch procedure (LapDS).

METHODS: Restriction is achieved via a greater curvature gastrectomy, reducing gastric capacity to 120ml. The malabsorptive component is constructed by dividing the duodenum 4 cm distal to the pylorus and anastomosing the proximal duodenum to the distal 250 cm of ileum. The biliopancreatic limb is anastomosed to create a 100 cm common channel. Laparoscopic cholecystectomy, cholangiogram, liver biopsy and appendectomy are performed in conjunction with DS.

RESULTS: 345 LapDS procedures (27 lap-assisted; 318 hand-assisted) were performed betweenSeptember 1999 and February 2002. There were 299 women and 46 men with a mean age of 43 years(range 19-67 years). Mean BMI was 50 (range 36-118 kg/m2). Mean operating time was 201 minutes (range 105-480). The median length of hospital stay was 3.0 days (range 2-22 days, excluding one outlier). There were 7 conversions to open laparotomy, 14 reoperations, and 21 readmissions. There were 3 pulmonary emboli, 2 deep venous thromboses, and 4 perioperative proximal anastomotic strictures. There were no deaths. Mean percent excess weight loss at 6, 18, and 24 months was 51%, 89%, and 91%, respectively.

CONCLUSION: Laparoscopic assisted duodenal switch procedure can be performed safely with acceptable operative times and without excess morbidity or mortality.
Early Results of Laparoscopic Biliopancreatic Diversion with Duodenal Switch: A Case Series of 40 Consecutive Patients. 
Gagner et al. Dec 2000
PubMed Abstract 
Full Article 

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure. We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity.

METHODS: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months.

RESULTS: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 +/- 1 years (+/- SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 +/- 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3-210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% +/- 2% excess weight loss (EWL) and at 9 months 58% +/- 3% EWL.

CONCLUSION: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.