What is second stage duodenal switch?

What is second stage duodenal switch?

As far as I have ever seen, it is the second half of the DS, if the procedure was done as a two step process. Occasionally, in cases where they don't want to have the patient under anesthesia too long, either because of extreme obesity or other health issues, they will first do the sleeve gastrectomy part of the DS, and then after a few months and the patient has lost some of their excess weight, is stronger and healthier, they will go in and do the switch part - the intestinal rerouting - to complete the job. It isn't done as much as it used to be as the surgeons have gotten better at handling very high BMI patients, but we do still see it occasionally.

Some surgeons do the second stage when a VSG patient does not lose enough with their sleeve alone. A "virgin" DS is normally more successful than when it is done in stages.

It is a little more subtle than that, as what you describe is more of a revision from an unsuccessful VSG rather than a preplanned staged DS. When discussing this with my surgeon - the prospect of a "plan B" revision if I didn't do well enough with the VSG alone - he explained that the two stage DS works best if you do the second stage before any substantial regain occurs (just like if it was planned that way.) But this is tough to do, as the patient is unlikely to throw in the towel and go for the completion surgery simply because their weight loss has stopped, or they are "afraid" of regaining, Further, insurance usually doesn't cooperate as they typically want to see the usual 35/40 BMI level before approving a revision (if they do so at all.)

Another factor of the "success" level is that the two stage DS is usually only done on the very high BMI patients, who are unlikely to see as high of an excess weight loss (with any procedure, including a single stage DS) as more "moderately" obese patients. A further wrinkle is that with a fully planned DS, the sleeved stomach is usually larger (typically a 56-60 Fr bougie rather than a 32-40 for a VSG) so that works better as a "team" with the malabsorption and has less chances of side effects such as severe GERD.)

So, as we typically see in the WLS world, revisions overall don't work as well as virgin WLS procedures, but I haven't seen much to support the notion that a planned two stage DS is any more or less effective than a single stage DS, given the same patient cir****tances.

The DS is technically a two-stage surgery. First step is the sleeve (VSG) and then the switch is shortening the intestines to provide malabsoption.

This is a great general description from Columbia University's website:

Bilio-pancreatic diversion with duodenal switch (also called Duodenal switch, or BPD-DS) is a complex procedure that induces weight loss by a sleeve gastrectomy and intestinal bypass. This approach results in decreased absorption of food. With this procedure, the surgeon removes approximately 60-70 percent of the stomach so that the stomach takes the shape of a tube (sleeve gastrectomy). The lower intestine is then divided much further downstream than with gastric bypass so that two thirds or more of the intestine is bypassed, leaving only a few feet of intestine where food and digestive enzymes meet. This is the intestinal bypass portion of the operation. The name duodenal switch comes from the fact that in this operation the intestinal bypass starts at the duodenum. The first part of the intestine, the duodenum, is divided and attached to the lower portion of the small intestine, the ileum.

A two step process was a real possibility for me when I had the DS. I was over 500 when the process started ( eval, etc) and the Doctor said if I didn't lose 50 lbs before I was ready to schedule he would do the first step VSG and then the switch as the 2nd part after I had lost some of the weight from the VSG.

I made it down to 464 and they did both steps in the same operation for which I was really grateful since I was pretty freaked out about going under the knife the first time without contemplating a 2nd trip.

Having gone through the whole thing I do think I would have done both stages if that was necessary.

Pete