Duodenal Switch Procedure

A duodenal switch procedure is also known as biliopancreatic diversion with a duodenal switch, or BPD-DS. This procedure is more complex than other types of weight loss surgery, and it is less common.

A duodenal switch involves two surgical procedures.

• The first procedure is similar to gastric sleeve surgery, in which a large portion of your stomach is removed.
• The second procedure redirects food so that it bypasses most of your small intestine. The bypassed section is reattached to the last part of your small intestine to allow digestive juices to mix with food.

This type of surgery may allow more weight loss, but it is also the most likely to cause surgery-related problems and vitamin or mineral deficiencies. For that reason, this procedure is generally recommended for people with a body mass index (BMI) greater than 50.

Single-Anastomosis Duodenal Switch (also known as SIPS- DS or Loop- DS)

The single-anastomosis duodenal switch, also called stomach intestinal pylorus sparing surgery (SIPS), or the single loop DS, is very similar to the standard duodenal switch operation, except that the small intestine is only transected at one point instead of two.

The gastric sleeve is created as a primary operation to achieve some weight loss and health improvement. Then typically a year after laparoscopic sleeve gastrectomy, patients who still have a BMI > 40, significant medical comorbidities and those who need an additional metabolic push, will proceed to the second laparoscopic operation to complete the SIPS-DS procedure.

The SIPS procedure is performed after the lap sleeve gastrectomy by bypassing roughly half of the upper small intestine, resulting in a moderate decrease in calorie absorption and powerful gut chemistry changes to effect metabolism. Weight loss is achieved through restriction of food consumption, metabolic change and some malabsorption, which results in very good long-term weight loss maintenance.

The SIPS-DS procedure will re-route the intestines so that calorie absorption is moderately reduced.

The duodenum (the first section of the small intestine) is transected after the pylorus. Rather than transecting the lower intestines (as is done with the standard duodenal switch), the surgeon simply attaches the small intestine at a point approximately 8-10 feet or 250-300 cm from the colon to the duodenal stump just beyond the pyloric valve. This creates a loop that diverts the food stream from the top half of the small intestines.

The top half of the intestine now carries just digestive juices (bile and pancreatic juices), and is called the bilio-pancreatic limb (BPL). The last segment of the intestine where the food and digestive juices mix is referred to as the common channel (CC).

Absorption of nutrients and calories is determined by the length of the common channel, so a shorter channel helps decrease the chance of weight regain by decreasing calorie absorption.

One reason that good long-term weight loss has been reported with the duodenal switch with single anastomosis is likely due to a dramatic decrease in the appetite-producing hormone known as ghrelin. The tissue that produces the hormone is almost completely removed with the outer portion of the stomach during the sleeve gastrectomy operation. 

Patients typically report a significant decrease in hunger and food consumption after this first stage operation. In addition, re-routing the intestines helps bring food to the lowest portion of the small intestines earlier than usual which releases important appetite-suppressing hormones such as polypeptideYY (PYY) and glucagon-like peptide 1 (GLP1). This may explain the superior weight loss, weight maintenance and diabetes resolution associated with this surgery.

Outcomes:

• Approximately 70% excess weight loss (EWL) has been reported. (Excess weight is the amount of weight over what is considered the “ideal body weight” for a person’s height [Current Weight – Ideal Weight = Excess Weight]. The percentage of excess weight loss (%EWL) is the percentage of weight loss from this excess weight.)
• Improvement/resolution in all major co-morbidities, including type 2 diabetes, sleep apnea, hypertension, high cholesterol and depression.
• There is very little risk of “dumping” syndrome—which occurs when a patient consumes sugar or carbohydrates, or eats too quickly, causing nausea, cramping, diarrhea, sweating, vomiting and heart palpitations.  Preservation of the pyloric valve provides for a more physiologic emptying of solid foods from the stomach enabling people to tolerate normal foods and reducing dumping syndrome.
• This is a pill-friendly operation. NSAIDS and Aspirin are well tolerated.
• Because weight loss is achieved through stomach restriction, metabolic changes, as well as malabsorption, this surgery typically provides very predictable weight loss with great long-term weight loss maintenance.
• Although patients report experiencing less malabsorptive symptoms compared to a standard duodenal switch because the common channel length is almost twice that of a standard DS, it is important to take vitamin supplements life-long to avoid nutritional deficiency and more frequent bowel movements should be expected.

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