Bariatric Times article - The Duodenal Switch Revisited - June 2009
I found this article while doing my research and I thought I would share it with you all.
If this has already been posted before I apologize for reposting.
The Duodenal Switch Revisited
June 2009
by Daniel J. Rosen, MD, and Alfons Pomp, MD, FACS
Both from Weill Medical College of Cornell University, New York Presbyterian
Hospital, New York, New York.
Introduction
It has been over a decade since Hess described a significant modification of the
Scopinaro bilio-pancreatic diversion (BPD).[1,2] In the duodenal switch (DS), a
vertical sleeve gastrectomy provides intake restriction, replacing the
horizontal gastric pouch of the Scopinaro operation with its distensible fundus.
A pylorus-sparing duodenoileostomy accomplishes a very distal intestinal bypass,
contributing a malabsorptive component to the weight loss. This can be construed
as a bariatric application of the duodeno-jejunostomy DeMeester pioneered to
treat bile reflux, and decreases the incidence of marginal ulcerations seen with
antrectomy and Roux-en-Y biliary diversion.[3] The DS provides excellent weight
loss and achieves significant improvement of obesity-related comorbidities.[4,5]
The laparoscopic era of bariatric surgery was pioneered by Alan Wittgrove in
1994 with an initial report of five patients undergoing laparoscopic Roux-en-Y
gastric bypass (RYGB).[6] The DS was first performed laparoscopically by Michel
Gagner's team in 1999.[7] With the wider adoption of laparoscopic techniques
over the last 10 years there has been an explosion in the number of bariatric
procedures performed.[8] This increase has mostly been represented in the
numbers of laparoscopic RYGB and more recently by adjustable gastric bandings
(AGB).
Despite being extraordinarily effective in terms of weight loss and comorbidity
resolution, the DS still accounts for only a small minority of the primary
bariatric operations performed in America.[5] There are numerous and complex
reasons for this. The extensive malabsorptive component certainly deters many
surgeons. Past experiences with the jejunoileal bypass (JIB) resulted in
patients with severe malnutrition who were rendered more medically compromised
by the operation than by their morbidly obese state. In the standard DS, only
the distal 15 percent of the small bowel is exposed to both nutrients and the
biliopancreatic secretions required for digestion and absorption of fats and
proteins.[9] The DS, whether attempted open or laparoscopic, is certainly a more
technically challenging procedure, and accordingly carries greater morbidity and
mortality than the gastric bypass or adjustable band. The greater risk of
complications evidently serves as a dissuading factor. Should the DS command
wider application? Ten years of surgical experience with this operation has
yielded certain insights.
Indications
When evaluating bariatric patients for surgery, the decision of which operation
to perform, if any, can influence the weight loss outcome and resolution of
comorbidities. The DS is effective, with durable excess weight loss (EWL) of 64
to 70 percent and diabetes resolution of 90 to 98 percent.[5,10] We also know
the DS carries a higher morbidity and mortality than other operative options and
therefore should be offered selectively. The irony for the super-obese patient
is that their best option is the most challenging, and they are the most
dangerous patients upon which to perform it. In most cases, we reserve the
laparoscopic DS for super-obese patients (BMI>50kg/m2). In a study by Prachard
et al, the percent EWL at three years was greater for DS than RYGB (68.9% vs.
54.9%; p<0.05). They also found a significant difference in the likelihood of
weight loss failure (EWL<50%) at three years, with a 41.7 percent failure rate
in the RYGB group and only 15.8 percent in the DS group.[11]
Early laparoscopic DS series showing higher complications in the super-obese has
led to a treatment algorithm based on a staged procedure.[7] Specifically, a
laparoscopic sleeve gastrectomy (LSG) achieves initial weight loss, and then the
duodenoileostomy is performed 8 to 12 months later for ongoing weight loss
maintenance.[12] While it was certainly expected that the initial procedure
would lessen the cumbersome visceral fat and abdominal wall torque that the
laparoscopic surgeon must combat in a single-stage operation, we were also
pleasantly surprised to find that the two-stage laparoscopic operation resulted
in a lower complication rate than a single-stage open procedure in this high
risk group.[12]
Buchwald et al, in a recent review of his first 190 DS cases (most performed
open), did not show a statistically greater rate of complications in the
super-obese patients, though a trend seemed to be present (p<0.1).[13] He
reported in his 2007 meta-analysis that 30-day mortality was 0.7 percent for
open DS and 1.1 percent for laparoscopic DS.[14] He suggests that advocacy for
the two-stage procedure in patients with BMI >50kg/m2 may have been premature,
based on early/poor outcomes from low-powered series.[13] This supposition has
been supported with a number of more recent DS series with excellent
outcomes.[11,15-17]
A DS patient can become malnourished even while consuming a "normal" diet. It is
therefore critical that he or she understand the implications of a malabsorptive
operation and know the steps required to achieve optimal results with minimal
nutritional complications. From the initial visit, patients must be made aware
that the DS carries an ongoing, lifetime cost for vitamins and supplements that
can approach $1,000 to $1,500 per year. If a patient is from a socioeconomic
strata that will make purchasing these necessary supplements a burden, the
patient may be best served by performing a different weight loss procedure. Even
when money is not a prohibitive factor, compliance regarding medication can be
an issue. It is often difficult to ensure that some patients adhere to a simple
daily medication to treat hypertension. A duodenal switch requires that patients
take 10 to 15 supplements a day for the rest of their lives. The psychological
assessment provides a good opportunity to assess compulsiveness of each patient,
as he or she will need to be diligent with the vitamins, supplements checkups,
and regular blood work.
In our experience, the patient who comes to a bariatric surgeon requesting a DS
has often already done substantial amounts of research on the internet. The
internet is a tremendous resource offering pictures, video, the description of
the procedure, and outcome data, as well as online support groups. The latter
can be especially helpful for patients to get answers about postoperative
lifestyle adjustments directly from those who have already undergone the
operation. It is the patient who comes to meet the surgeon already
educated—weight loss chronicle in hand—who often does the best with the surgery.
Contraindications
Though less often encountered in the morbidly obese patient, we consider a
strict vegan lifestyle to be a contraindication to the performance of a DS.
Patients must be willing to eat a significantly high proportion of their
calories in the form of protein of high biological value to avoid
hypoproteinemia. The number and quality (odor) of bowel movements per day
increases significantly after the DS procedure, and patients must be in a
work/social situation that allows easy access to facilities on a regular basis.
Significant gastroesophageal reflux disease (GERD) is a relative medical
contraindication that should lead the surgeon to council the patient toward a
RYGB rather than a DS, as gastric bypass achieves the greatest resolution of
GERD-like symptoms. Furthermore, if a DS is performed on a patient with GERD and
the symptoms persist despite maximal medical therapy, options for operative
intervention are limited as the fundus of the stomach has been resected.
Both inflammatory bowel disease (IBD) and severe irritable bowel syndrome (IBS)
serve as contraindications to DS. The increased frequency of bowel movements in
these patients and the recurring nature of the disease, as well as chronic
symptoms of abdominal pain, make restrictive weight loss operations the
procedures of choice. Multiple or complicated previous abdominal or pelvic
operations may contraindicate DS. Elevating the ileum out of the lower abdomen
to the level of the duodenum is difficult and exacerbated by the excess
friability and shortening of the mesentery seen with these conditions. Scarred
could leave the duodenoileal anastomosis with excess tension and increase the
incidence of anastomotic problems.
Technique
An experienced team, including anesthesiologists, scrub technicians, and
circulating nurses that work together on a regular basis, leads to optimal
outcomes in any complex (laparoscopic) operation. From a technical prospective,
the lap DS is significantly more difficult than a lap RYGB. To locate the
ileocecal valve and run the bowel for limb length measurements, the patient must
be placed in Trendelenburg position. Patients in higher BMI ranges often cannot
tolerate this "head down" position for prolonged periods. Handling the bowel
gently with graspers and during suturing is critical, as ileum and duodenum are
more fragile than stomach and jejunum, and missed perforations or anastomotic
breakdown due to excessive trauma can be fatal. Fashioning the duodenoileal
anastomosis requires advanced laparoscopic skills, for both EEA-stapled and
hand-sewn techniques. Operative times should not exceed 3.5 to 4 hours, as
respiratory complications, deep vein thrombosis, and rhabdomyolysis may develop.
In prolonged cases, aborting and opting for a staged procedure may prove
judicious.
Following the sleeve gastrectomy, the duodenum is divided 2 to 3cm distal to the
pylorus. The duodenal dissection may be difficult, especially in patients with
severe android adipose distributions and especially in patients with a prior
(open) cholecystectomy. A 21 EEA anvil is introduced into the abdomen and then
into the duodenum with a purse-string suture. In most of our patients, the ileum
is marked at 100cm from the ileocecal valve and the bowel is divided at 250cm in
order to set up a 150cm Roux (food) limb and a 100cm common channel. The right
side of omentum is mobilized off the hepatic flexure. We then intubate the bowel
destined to become Roux limb with the EEA stapler and rotate it up into the
right upper abdomen in an antecolic fashion, avoiding torsion of the mesentery
to perform the anastomosis. Methylene blue or endoscopy are used to rule out
leak. The ileoileostomy is formed using a linear stapler. Care in closing the
residual enterotomy should focus on avoiding reducing the lumen, as the ileum is
narrower caliber than jejunum. All mesenteric defects are closed. We perform a
cholecystectomy only in the presence of symptomatic cholelithiasis, as the
incidence of cholecystitis is low after LDS.[18]
Techniques that might simplify the duodenoileal anastomosis in order to make the
procedure less complex have been utilized. The robot has been employed to
improve dexterity and control in performing this difficult anastomosis. Average
case lengths of over 8.5 hours have been reported with an eight-percent leak
rate. Patients that are ASA III at baseline and carry a risk of rhabdomyolysis
and deep venous thrombosis because of their increased size need to be taken off
the operating room table expeditiously.[19] At this point use of the robot does
not seem warranted.
The duodenoileal anastomosis is particularly difficult because of the fixed
retroperitoneal position of the duodenum. Effort is often made to minimize
dissection around the pylorus for fear of disturbing blood supply and
compromising the anastomosis. This prevents full mobilization of the distal
stomach and proximal duodenum, a maneuver that may decrease anastomotic tension
and improve exposure. Studies by Marchesini clearly demonstrate a robust
submucosal network of vessels that prevent ischemia of the pyloric region or
proximal duodenum, even in the face of only left gastric perfusion. Marchesini
has reported on his personal series of 500 cases of DS over nine years. He
suggests division of the right gastric so that the duodenal bulb can be more
fully mobilized to limit tension. He reported no duodenoileal anastomotic leaks
over nine years.[20]
Patients are not routinely admitted to an intensive care unit or step-down
setting. Any hemodynamic instability, tachycardia, low urine output, or
unexpected excess of abdominal pain prompts a thorough evaluation by the
attending surgeon. There should be a low threshold for returning to the
operating room for diagnostic laparoscopy to rule out staple line leak or
hemorrhage. On the first postoperative day, the patients undergo an upper
gastrointestinal water-soluble contrast study to assess the anatomy and rule out
any staple line leaks. If this study is normal, the patients are advanced to
clears. In our experience, postoperative ileus is more common in DS patients
than RYGB patients, possibly due to the manipulation of the ileum. We therefore
usually hold patients' discharges until a return of bowel function (flatus). The
patients are instructed to return to the office at four weeks and to call the
office should signs of any complications begin to develop. Appointments are
scheduled at three-month intervals during the first postoperative year, and
yearly after that.
Routine blood work and ongoing nutrition follow-up is critical. We routinely
schedule DS patients to see the nutritionist at the same interval as the
surgical visits. Patients are seen at one month, three months, six months, one
year, and then semi-annually (6 months). Abnormal labs or symptoms will prompt
an earlier visit. Nutritional counseling in the postoperative period reinforces
the importance of regular lab work and supplements. Patients are screened for
signs and symptoms of vitamin and mineral deficiency (e.g. changes of skin,
hair, nails, energy level). Conservative measures to combat diarrhea and gas are
discussed, and the importance of getting adequate protein is stressed. Our lab
regimen follows the "Suggested Biochemical Monitoring Tools for Nutrition
Status."[21] It involves monitoring of serum albumin, serum total protein,
plasma retinol (vitamin A), serum vitamin B12, RBC folate, PT (vitamin K
screen), plasma zinc, vitamin D, and PTH levels. We include copper/ceruloplasmin
levels as well.
Results and outcomes
All bariatric surgery requires some compromise; the DS involves a more dramatic
anatomical rearrangement and difficulty in reversal for greater weight loss and
independence from implantable devices that require adjustment and may have
mechanical failure. DS—open or laparoscopic—will achieve a durable weight loss
on most patients with obesity. In the Buchwald meta-analysis, a review of
studies published between 1990 and 2003, it was concluded that BPD/DS resulted
in more weight loss, and greater improvement in diabetes, hyperlipidemia,
hypercholesterolemia, hypertriglyceridemia, and obstructive sleep apnea syndrome
(OSAS) than any other type of bariatric procedure.[5] The benchmark for a
successful bariatric operation is the durable loss of greater than 50 percent of
excess body weight. The DS is an effective weight loss operation in 95 percent
of patients with a BMI <50kg/m2, and for the super-obese it achieves a success
rate of 70 percent.[22,23,11]
DS is also the most effective procedure currently available for comorbidity
resolution. Cure rates for type 2 diabetes approach 90 to 98 percent following
DS.[9,24] DS achieves cure rates for hypertension that exceed 50 percent, and in
some studies approach 80 percent.[25]
Resolution of OSAS occurs in up to 98 percent of patients after DS.[26]
All of these results are superior to outcomes seen after AGB and RYGB.[5,27,28]
Complications of the DS
All bariatric operations carry the risk of long-term or late complications that
are unique to the procedure. For the RYGB, the most common complications are
marginal ulcer and late weight regain. For the AGB, they are slippage, erosion,
pouch/esophageal dilation, or port complications. For the LSG, as a stand-alone
procedure, they are new-onset gastroesophageal reflux disease (GERD) or
stenosis. Inherent to the DS are the complication risks of the LSG, as it is
constitutes the restrictive part of the procedure. The malabsorptive component,
with bypass of up to two-thirds of the small bowel, brings other complications
classically associated with the DS. These relate to bowel habits, namely
diarrhea, frequent foul-smelling stools, and flatulence, and complications of
malnutrition such as hypoproteinemia and vitamin/mineral deficiencies. These
complications, especially in those who develop debilitating malnutrition, can be
devastating. Before performing a DS, a clear incidence of these complications
must be known and the ability to treat them with non-surgical interventions must
be evaluated when making the ultimate decision about performing this operation.
A review of the complications following DS should first begin with the
complications it avoids. Comparing it to the other procedures that rely on a
gastrojejunal anastomosis to achieve some degree of bypass and nutrient delivery
to the distal small bowel (BPD and RYGB), the DS lessens the complications of
dumping syndrome, marginal ulceration, and vagus nerve transaction during pouch
formation.[29] Reviewing their series of over 700 open DS cases during a 10-year
period, Hamoui et al found that five percent of their patients (33/701) needed
reversal of their DS. Malnutrition, noted in 20/33 patients, followed by chronic
diarrhea, was the most commonly given reason for reversal. The development of
these complications is variable and not necessarily correlated to the degree of
small intestinal bypass. Patients *****quired reversal and cited diarrhea as a
motivating factor had up to five bowel movements per day, but in a cohort study
comparing DS to RYGB, the average number of bowel movements for the DS group was
1.68 per day. This did not reach a statistically significant difference from the
1.18 bowel movements per day seen in the RYGB group.[30] For those with
intractable diarrhea necessitating revision, Hamoui was able to decrease the
number of daily bowel movements from 5 to 1. His revision involved performing a
proximal "kissing `X'" enteroenterostomy in most patients, without repositioning
of the original ileoileostomy. Reversal of the DS does not tend to bring full
weight regain, as patients still maintain some restriction due to the sleeve
gastrectomy. A return of glucose intolerance or complete re-emergence of
diabetes following DS reversal is not guaranteed. In the aforementioned series,
7 out of 10 patients (70%) maintained their diabetes remission after proximal
enteroenterostomy for reversal.[31]
Following DS, vitamin and mineral deficiencies and severe protein/calorie
malnutrition can happen in the face of normal meal consumption.[32] Fat-soluble
vitamin deficiencies make strict adherence to daily supplementation a necessity.
Vitamin A deficiencies can present as difficulty with night vision. Serum
calcium levels are low, secondary to binding with intraluminal fats. This sets
the stage for oxalate absorption and may increase the incidence of
nephrolithiasis. Hypocalcemia paired with vitamin D deficiencies can cause
osteopenia and osteoporosis. Preventing iron deficiency anemia at times requires
the prescription of oral iron preparations, or in some cases where this is
poorly tolerated or ineffective, intravenous iron infusions.[33]
A rare complication that develops outside the first month postoperatively can be
stricture of the sleeve gastrectomy. It usually occurs at the angularis incisura
and is most often managed by endoscopic balloon dilation. Long-segment stenosis
of the sleeve develops in less than one percent of patients, and is less
amenable to balloon dilation. Dupri, Cadiere, and Himpens employ a laparoscopic
seromyotomy of the stenotic segment akin to a Heller myotomy of the esophagus.
This serves to restore passage of enteral contents and avoids a complicated
gastric resection with additional Roux limb drainage.[34] Wound complications,
hernias, abdominal pain, and length of stay are all decreased when the
laparoscopic approach to the DS is employed.[35]
Revisional surgery and DS
Revisional surgery after DS can be for inadequate weight loss or development of
late complications. In the event of inadequate weight loss following LDS, a
re-sleeve gastrectomy can be attempted.[36] Another option is to place a band
over the sleeve gastrectomy to augment restriction.[37] In revisions
necessitated by excessive weight loss or intractable diarrhea, vitamin
deficiency, or protein malnutrition, one option is to transect and relocate the
alimentary limb proximally on the BP limb.[36] An alternate technique for
reversal is an enteroenterostomy proximal to the junction of the alimentary limb
and the BP limb. This will facilitate earlier upstream mixing of the limb
contents.[31]
Conclusion
The duodenal switch evolved, in part, from a procedure to prevent reflux of bile
into the stomach and esophagus, into an operation to achieve massive weight
loss. The application of laparoscopic techniques to the DS improved
wound-related morbidity and recovery. Duodenal switch remains a powerful tool to
lose weight, but the operation requires an intelligent patient who will be
compliant with post-operative care and has the financial resources that will
allow him or her to purchase the appropriate supplements to prevent the serious
metabolic consequences of deficiencies. The duodenojejunal bypass (DJB) with
sleeve gastrectomy, basically a short-limb DS, is now being performed
laparoscopically in nonobese patient with diabetes with early, encouraging
results.[39] Larger series of metabolic surgery on low-BMI patients with
diabetes are eagerly anticipated.
If this has already been posted before I apologize for reposting.
The Duodenal Switch Revisited
June 2009
by Daniel J. Rosen, MD, and Alfons Pomp, MD, FACS
Both from Weill Medical College of Cornell University, New York Presbyterian
Hospital, New York, New York.
Introduction
It has been over a decade since Hess described a significant modification of the
Scopinaro bilio-pancreatic diversion (BPD).[1,2] In the duodenal switch (DS), a
vertical sleeve gastrectomy provides intake restriction, replacing the
horizontal gastric pouch of the Scopinaro operation with its distensible fundus.
A pylorus-sparing duodenoileostomy accomplishes a very distal intestinal bypass,
contributing a malabsorptive component to the weight loss. This can be construed
as a bariatric application of the duodeno-jejunostomy DeMeester pioneered to
treat bile reflux, and decreases the incidence of marginal ulcerations seen with
antrectomy and Roux-en-Y biliary diversion.[3] The DS provides excellent weight
loss and achieves significant improvement of obesity-related comorbidities.[4,5]
The laparoscopic era of bariatric surgery was pioneered by Alan Wittgrove in
1994 with an initial report of five patients undergoing laparoscopic Roux-en-Y
gastric bypass (RYGB).[6] The DS was first performed laparoscopically by Michel
Gagner's team in 1999.[7] With the wider adoption of laparoscopic techniques
over the last 10 years there has been an explosion in the number of bariatric
procedures performed.[8] This increase has mostly been represented in the
numbers of laparoscopic RYGB and more recently by adjustable gastric bandings
(AGB).
Despite being extraordinarily effective in terms of weight loss and comorbidity
resolution, the DS still accounts for only a small minority of the primary
bariatric operations performed in America.[5] There are numerous and complex
reasons for this. The extensive malabsorptive component certainly deters many
surgeons. Past experiences with the jejunoileal bypass (JIB) resulted in
patients with severe malnutrition who were rendered more medically compromised
by the operation than by their morbidly obese state. In the standard DS, only
the distal 15 percent of the small bowel is exposed to both nutrients and the
biliopancreatic secretions required for digestion and absorption of fats and
proteins.[9] The DS, whether attempted open or laparoscopic, is certainly a more
technically challenging procedure, and accordingly carries greater morbidity and
mortality than the gastric bypass or adjustable band. The greater risk of
complications evidently serves as a dissuading factor. Should the DS command
wider application? Ten years of surgical experience with this operation has
yielded certain insights.
Indications
When evaluating bariatric patients for surgery, the decision of which operation
to perform, if any, can influence the weight loss outcome and resolution of
comorbidities. The DS is effective, with durable excess weight loss (EWL) of 64
to 70 percent and diabetes resolution of 90 to 98 percent.[5,10] We also know
the DS carries a higher morbidity and mortality than other operative options and
therefore should be offered selectively. The irony for the super-obese patient
is that their best option is the most challenging, and they are the most
dangerous patients upon which to perform it. In most cases, we reserve the
laparoscopic DS for super-obese patients (BMI>50kg/m2). In a study by Prachard
et al, the percent EWL at three years was greater for DS than RYGB (68.9% vs.
54.9%; p<0.05). They also found a significant difference in the likelihood of
weight loss failure (EWL<50%) at three years, with a 41.7 percent failure rate
in the RYGB group and only 15.8 percent in the DS group.[11]
Early laparoscopic DS series showing higher complications in the super-obese has
led to a treatment algorithm based on a staged procedure.[7] Specifically, a
laparoscopic sleeve gastrectomy (LSG) achieves initial weight loss, and then the
duodenoileostomy is performed 8 to 12 months later for ongoing weight loss
maintenance.[12] While it was certainly expected that the initial procedure
would lessen the cumbersome visceral fat and abdominal wall torque that the
laparoscopic surgeon must combat in a single-stage operation, we were also
pleasantly surprised to find that the two-stage laparoscopic operation resulted
in a lower complication rate than a single-stage open procedure in this high
risk group.[12]
Buchwald et al, in a recent review of his first 190 DS cases (most performed
open), did not show a statistically greater rate of complications in the
super-obese patients, though a trend seemed to be present (p<0.1).[13] He
reported in his 2007 meta-analysis that 30-day mortality was 0.7 percent for
open DS and 1.1 percent for laparoscopic DS.[14] He suggests that advocacy for
the two-stage procedure in patients with BMI >50kg/m2 may have been premature,
based on early/poor outcomes from low-powered series.[13] This supposition has
been supported with a number of more recent DS series with excellent
outcomes.[11,15-17]
A DS patient can become malnourished even while consuming a "normal" diet. It is
therefore critical that he or she understand the implications of a malabsorptive
operation and know the steps required to achieve optimal results with minimal
nutritional complications. From the initial visit, patients must be made aware
that the DS carries an ongoing, lifetime cost for vitamins and supplements that
can approach $1,000 to $1,500 per year. If a patient is from a socioeconomic
strata that will make purchasing these necessary supplements a burden, the
patient may be best served by performing a different weight loss procedure. Even
when money is not a prohibitive factor, compliance regarding medication can be
an issue. It is often difficult to ensure that some patients adhere to a simple
daily medication to treat hypertension. A duodenal switch requires that patients
take 10 to 15 supplements a day for the rest of their lives. The psychological
assessment provides a good opportunity to assess compulsiveness of each patient,
as he or she will need to be diligent with the vitamins, supplements checkups,
and regular blood work.
In our experience, the patient who comes to a bariatric surgeon requesting a DS
has often already done substantial amounts of research on the internet. The
internet is a tremendous resource offering pictures, video, the description of
the procedure, and outcome data, as well as online support groups. The latter
can be especially helpful for patients to get answers about postoperative
lifestyle adjustments directly from those who have already undergone the
operation. It is the patient who comes to meet the surgeon already
educated—weight loss chronicle in hand—who often does the best with the surgery.
Contraindications
Though less often encountered in the morbidly obese patient, we consider a
strict vegan lifestyle to be a contraindication to the performance of a DS.
Patients must be willing to eat a significantly high proportion of their
calories in the form of protein of high biological value to avoid
hypoproteinemia. The number and quality (odor) of bowel movements per day
increases significantly after the DS procedure, and patients must be in a
work/social situation that allows easy access to facilities on a regular basis.
Significant gastroesophageal reflux disease (GERD) is a relative medical
contraindication that should lead the surgeon to council the patient toward a
RYGB rather than a DS, as gastric bypass achieves the greatest resolution of
GERD-like symptoms. Furthermore, if a DS is performed on a patient with GERD and
the symptoms persist despite maximal medical therapy, options for operative
intervention are limited as the fundus of the stomach has been resected.
Both inflammatory bowel disease (IBD) and severe irritable bowel syndrome (IBS)
serve as contraindications to DS. The increased frequency of bowel movements in
these patients and the recurring nature of the disease, as well as chronic
symptoms of abdominal pain, make restrictive weight loss operations the
procedures of choice. Multiple or complicated previous abdominal or pelvic
operations may contraindicate DS. Elevating the ileum out of the lower abdomen
to the level of the duodenum is difficult and exacerbated by the excess
friability and shortening of the mesentery seen with these conditions. Scarred
could leave the duodenoileal anastomosis with excess tension and increase the
incidence of anastomotic problems.
Technique
An experienced team, including anesthesiologists, scrub technicians, and
circulating nurses that work together on a regular basis, leads to optimal
outcomes in any complex (laparoscopic) operation. From a technical prospective,
the lap DS is significantly more difficult than a lap RYGB. To locate the
ileocecal valve and run the bowel for limb length measurements, the patient must
be placed in Trendelenburg position. Patients in higher BMI ranges often cannot
tolerate this "head down" position for prolonged periods. Handling the bowel
gently with graspers and during suturing is critical, as ileum and duodenum are
more fragile than stomach and jejunum, and missed perforations or anastomotic
breakdown due to excessive trauma can be fatal. Fashioning the duodenoileal
anastomosis requires advanced laparoscopic skills, for both EEA-stapled and
hand-sewn techniques. Operative times should not exceed 3.5 to 4 hours, as
respiratory complications, deep vein thrombosis, and rhabdomyolysis may develop.
In prolonged cases, aborting and opting for a staged procedure may prove
judicious.
Following the sleeve gastrectomy, the duodenum is divided 2 to 3cm distal to the
pylorus. The duodenal dissection may be difficult, especially in patients with
severe android adipose distributions and especially in patients with a prior
(open) cholecystectomy. A 21 EEA anvil is introduced into the abdomen and then
into the duodenum with a purse-string suture. In most of our patients, the ileum
is marked at 100cm from the ileocecal valve and the bowel is divided at 250cm in
order to set up a 150cm Roux (food) limb and a 100cm common channel. The right
side of omentum is mobilized off the hepatic flexure. We then intubate the bowel
destined to become Roux limb with the EEA stapler and rotate it up into the
right upper abdomen in an antecolic fashion, avoiding torsion of the mesentery
to perform the anastomosis. Methylene blue or endoscopy are used to rule out
leak. The ileoileostomy is formed using a linear stapler. Care in closing the
residual enterotomy should focus on avoiding reducing the lumen, as the ileum is
narrower caliber than jejunum. All mesenteric defects are closed. We perform a
cholecystectomy only in the presence of symptomatic cholelithiasis, as the
incidence of cholecystitis is low after LDS.[18]
Techniques that might simplify the duodenoileal anastomosis in order to make the
procedure less complex have been utilized. The robot has been employed to
improve dexterity and control in performing this difficult anastomosis. Average
case lengths of over 8.5 hours have been reported with an eight-percent leak
rate. Patients that are ASA III at baseline and carry a risk of rhabdomyolysis
and deep venous thrombosis because of their increased size need to be taken off
the operating room table expeditiously.[19] At this point use of the robot does
not seem warranted.
The duodenoileal anastomosis is particularly difficult because of the fixed
retroperitoneal position of the duodenum. Effort is often made to minimize
dissection around the pylorus for fear of disturbing blood supply and
compromising the anastomosis. This prevents full mobilization of the distal
stomach and proximal duodenum, a maneuver that may decrease anastomotic tension
and improve exposure. Studies by Marchesini clearly demonstrate a robust
submucosal network of vessels that prevent ischemia of the pyloric region or
proximal duodenum, even in the face of only left gastric perfusion. Marchesini
has reported on his personal series of 500 cases of DS over nine years. He
suggests division of the right gastric so that the duodenal bulb can be more
fully mobilized to limit tension. He reported no duodenoileal anastomotic leaks
over nine years.[20]
Patients are not routinely admitted to an intensive care unit or step-down
setting. Any hemodynamic instability, tachycardia, low urine output, or
unexpected excess of abdominal pain prompts a thorough evaluation by the
attending surgeon. There should be a low threshold for returning to the
operating room for diagnostic laparoscopy to rule out staple line leak or
hemorrhage. On the first postoperative day, the patients undergo an upper
gastrointestinal water-soluble contrast study to assess the anatomy and rule out
any staple line leaks. If this study is normal, the patients are advanced to
clears. In our experience, postoperative ileus is more common in DS patients
than RYGB patients, possibly due to the manipulation of the ileum. We therefore
usually hold patients' discharges until a return of bowel function (flatus). The
patients are instructed to return to the office at four weeks and to call the
office should signs of any complications begin to develop. Appointments are
scheduled at three-month intervals during the first postoperative year, and
yearly after that.
Routine blood work and ongoing nutrition follow-up is critical. We routinely
schedule DS patients to see the nutritionist at the same interval as the
surgical visits. Patients are seen at one month, three months, six months, one
year, and then semi-annually (6 months). Abnormal labs or symptoms will prompt
an earlier visit. Nutritional counseling in the postoperative period reinforces
the importance of regular lab work and supplements. Patients are screened for
signs and symptoms of vitamin and mineral deficiency (e.g. changes of skin,
hair, nails, energy level). Conservative measures to combat diarrhea and gas are
discussed, and the importance of getting adequate protein is stressed. Our lab
regimen follows the "Suggested Biochemical Monitoring Tools for Nutrition
Status."[21] It involves monitoring of serum albumin, serum total protein,
plasma retinol (vitamin A), serum vitamin B12, RBC folate, PT (vitamin K
screen), plasma zinc, vitamin D, and PTH levels. We include copper/ceruloplasmin
levels as well.
Results and outcomes
All bariatric surgery requires some compromise; the DS involves a more dramatic
anatomical rearrangement and difficulty in reversal for greater weight loss and
independence from implantable devices that require adjustment and may have
mechanical failure. DS—open or laparoscopic—will achieve a durable weight loss
on most patients with obesity. In the Buchwald meta-analysis, a review of
studies published between 1990 and 2003, it was concluded that BPD/DS resulted
in more weight loss, and greater improvement in diabetes, hyperlipidemia,
hypercholesterolemia, hypertriglyceridemia, and obstructive sleep apnea syndrome
(OSAS) than any other type of bariatric procedure.[5] The benchmark for a
successful bariatric operation is the durable loss of greater than 50 percent of
excess body weight. The DS is an effective weight loss operation in 95 percent
of patients with a BMI <50kg/m2, and for the super-obese it achieves a success
rate of 70 percent.[22,23,11]
DS is also the most effective procedure currently available for comorbidity
resolution. Cure rates for type 2 diabetes approach 90 to 98 percent following
DS.[9,24] DS achieves cure rates for hypertension that exceed 50 percent, and in
some studies approach 80 percent.[25]
Resolution of OSAS occurs in up to 98 percent of patients after DS.[26]
All of these results are superior to outcomes seen after AGB and RYGB.[5,27,28]
Complications of the DS
All bariatric operations carry the risk of long-term or late complications that
are unique to the procedure. For the RYGB, the most common complications are
marginal ulcer and late weight regain. For the AGB, they are slippage, erosion,
pouch/esophageal dilation, or port complications. For the LSG, as a stand-alone
procedure, they are new-onset gastroesophageal reflux disease (GERD) or
stenosis. Inherent to the DS are the complication risks of the LSG, as it is
constitutes the restrictive part of the procedure. The malabsorptive component,
with bypass of up to two-thirds of the small bowel, brings other complications
classically associated with the DS. These relate to bowel habits, namely
diarrhea, frequent foul-smelling stools, and flatulence, and complications of
malnutrition such as hypoproteinemia and vitamin/mineral deficiencies. These
complications, especially in those who develop debilitating malnutrition, can be
devastating. Before performing a DS, a clear incidence of these complications
must be known and the ability to treat them with non-surgical interventions must
be evaluated when making the ultimate decision about performing this operation.
A review of the complications following DS should first begin with the
complications it avoids. Comparing it to the other procedures that rely on a
gastrojejunal anastomosis to achieve some degree of bypass and nutrient delivery
to the distal small bowel (BPD and RYGB), the DS lessens the complications of
dumping syndrome, marginal ulceration, and vagus nerve transaction during pouch
formation.[29] Reviewing their series of over 700 open DS cases during a 10-year
period, Hamoui et al found that five percent of their patients (33/701) needed
reversal of their DS. Malnutrition, noted in 20/33 patients, followed by chronic
diarrhea, was the most commonly given reason for reversal. The development of
these complications is variable and not necessarily correlated to the degree of
small intestinal bypass. Patients *****quired reversal and cited diarrhea as a
motivating factor had up to five bowel movements per day, but in a cohort study
comparing DS to RYGB, the average number of bowel movements for the DS group was
1.68 per day. This did not reach a statistically significant difference from the
1.18 bowel movements per day seen in the RYGB group.[30] For those with
intractable diarrhea necessitating revision, Hamoui was able to decrease the
number of daily bowel movements from 5 to 1. His revision involved performing a
proximal "kissing `X'" enteroenterostomy in most patients, without repositioning
of the original ileoileostomy. Reversal of the DS does not tend to bring full
weight regain, as patients still maintain some restriction due to the sleeve
gastrectomy. A return of glucose intolerance or complete re-emergence of
diabetes following DS reversal is not guaranteed. In the aforementioned series,
7 out of 10 patients (70%) maintained their diabetes remission after proximal
enteroenterostomy for reversal.[31]
Following DS, vitamin and mineral deficiencies and severe protein/calorie
malnutrition can happen in the face of normal meal consumption.[32] Fat-soluble
vitamin deficiencies make strict adherence to daily supplementation a necessity.
Vitamin A deficiencies can present as difficulty with night vision. Serum
calcium levels are low, secondary to binding with intraluminal fats. This sets
the stage for oxalate absorption and may increase the incidence of
nephrolithiasis. Hypocalcemia paired with vitamin D deficiencies can cause
osteopenia and osteoporosis. Preventing iron deficiency anemia at times requires
the prescription of oral iron preparations, or in some cases where this is
poorly tolerated or ineffective, intravenous iron infusions.[33]
A rare complication that develops outside the first month postoperatively can be
stricture of the sleeve gastrectomy. It usually occurs at the angularis incisura
and is most often managed by endoscopic balloon dilation. Long-segment stenosis
of the sleeve develops in less than one percent of patients, and is less
amenable to balloon dilation. Dupri, Cadiere, and Himpens employ a laparoscopic
seromyotomy of the stenotic segment akin to a Heller myotomy of the esophagus.
This serves to restore passage of enteral contents and avoids a complicated
gastric resection with additional Roux limb drainage.[34] Wound complications,
hernias, abdominal pain, and length of stay are all decreased when the
laparoscopic approach to the DS is employed.[35]
Revisional surgery and DS
Revisional surgery after DS can be for inadequate weight loss or development of
late complications. In the event of inadequate weight loss following LDS, a
re-sleeve gastrectomy can be attempted.[36] Another option is to place a band
over the sleeve gastrectomy to augment restriction.[37] In revisions
necessitated by excessive weight loss or intractable diarrhea, vitamin
deficiency, or protein malnutrition, one option is to transect and relocate the
alimentary limb proximally on the BP limb.[36] An alternate technique for
reversal is an enteroenterostomy proximal to the junction of the alimentary limb
and the BP limb. This will facilitate earlier upstream mixing of the limb
contents.[31]
Conclusion
The duodenal switch evolved, in part, from a procedure to prevent reflux of bile
into the stomach and esophagus, into an operation to achieve massive weight
loss. The application of laparoscopic techniques to the DS improved
wound-related morbidity and recovery. Duodenal switch remains a powerful tool to
lose weight, but the operation requires an intelligent patient who will be
compliant with post-operative care and has the financial resources that will
allow him or her to purchase the appropriate supplements to prevent the serious
metabolic consequences of deficiencies. The duodenojejunal bypass (DJB) with
sleeve gastrectomy, basically a short-limb DS, is now being performed
laparoscopically in nonobese patient with diabetes with early, encouraging
results.[39] Larger series of metabolic surgery on low-BMI patients with
diabetes are eagerly anticipated.
Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
Awsome journal article!!!! Thanks for posting this!!!
Here is an illustrated chart.... comparing ALL of the WLS surgeries. Check it out!!!
http://www.lapsf.com/weight-loss-surgeries.html
-Jamie
Here is an illustrated chart.... comparing ALL of the WLS surgeries. Check it out!!!
http://www.lapsf.com/weight-loss-surgeries.html
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Thx girl that is a great chart.
Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
What a great article, Teena! Thanks for posting it!
I could have had a revision to an RNY performed locally by a surgeon I respect and admire (Dr. Shrikanth), but I knew this would be my last WLS, regardless of the outcome, and so I wanted to give myself the very best chance at success.
This is why I chose to travel for a DS:
...a significant difference in the likelihood of weight loss failure (EWL<50%) at three years, with a 41.7 percent failure rate in the RYGB group and only 15.8 percent in the DS group
I could have had a revision to an RNY performed locally by a surgeon I respect and admire (Dr. Shrikanth), but I knew this would be my last WLS, regardless of the outcome, and so I wanted to give myself the very best chance at success.
This is why I chose to travel for a DS:
...a significant difference in the likelihood of weight loss failure (EWL<50%) at three years, with a 41.7 percent failure rate in the RYGB group and only 15.8 percent in the DS group
-----------------------------------------------------------------------------------------------
Have you considered the Duodenal Switch? Information is power.
Have you considered the Duodenal Switch? Information is power.
Kathy,
I always post information when I find something I think others could benefit from it.
I feel the same way as you as this is going to be my last WLS no matter what the outcome is (I'm getting old) and I want to give myself the best success as well.
I read that information regarding weight loss failure at three years with the failure rate percentages and that is what helped me make my mind up about wanting DS.
I just now have to figure out how to get my insurance to see the light as I have.
I always post information when I find something I think others could benefit from it.
I feel the same way as you as this is going to be my last WLS no matter what the outcome is (I'm getting old) and I want to give myself the best success as well.
I read that information regarding weight loss failure at three years with the failure rate percentages and that is what helped me make my mind up about wanting DS.
I just now have to figure out how to get my insurance to see the light as I have.
Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
Facebook Contact Info/Email address:Skyedan[email protected]
10/09/09 - Distal Gastric Bypass (ERNY) Revision - Common Channel 90
"Never Let People,Places,Or Things Stand In Your Way Of Fulfilling Your Goals And Living Out Your Dreams." Teena Adler
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