Laparoscopic duodenal switch refers to a less invasive surgical technique for biliopancreatic diversion with duodenal switch. Risks are lower than open surgery, with shorter recovery time and similar preparation for surgery. Surgery is still performed under general anesthesia.
A biliopancreatic diversion with duodenal switch (BD/DS) is a restrictive/malabsorptive weight loss procedure. It is less popular than other procedures such as gastric bypass or lap band. During the procedure, a part of the stomach is removed, but the pylorus is left intact. The pylorus is the valve that controls food drainage from the stomach. In the process, a smaller stomach pouch, similar to the one created in a gastric sleeve procedure, is created. This is connected to the distal (most distant) portion of the small intestine, bypassing a significant amount of the small intestine. This diversion causes a reduction in nutrient absorption, as the majority of nutrients are absorbed in the small intestine.
Unlike other weight loss procedures, which can be performed laparoscopically, BD/DS is an open surgery. It can be conducted in two stages, first as a gastric sleeve surgery, with the addition of a duodenal switch afterwards. Similar to other weight loss surgeries, BD/DS requires permanent lifestyle and diet changes, and is irreversible. However, unlike gastric bypass, there is a lower risk of “dumping syndrome,” a collection of gastrointestinal symptoms that occur when the patient ingests too much food (or food that is too fatty or sugary). Weight loss is never fully guaranteed, but a significant degree of weight loss and subsequent reduction of other obesity-related disease symptoms is seen in over 75% of patients.
Who is a candidate?
Candidates tend to have a BMI over 40, or a BMI between 35 and 40 also with accompanying diseases such as diabetes, sleep apnea, cardiomyopathy (heart damage) or severe joint degeneration and pain. They should have a long record of failed previous non-surgical weight loss interventions (diet, exercise) before considering biliopancreatic diversion with duodenal switch. BD/DS is usually considered more for patients that have an extremely high BMI or multiple comorbidities (accompanying diseases). They should be willing to implement permanent lifestyle changes in order to lose weight and sustain the weight loss permanently.
For BD/DS, patients must be willing and able to supplement their diet with fat-soluble vitamins (A, D, K,E), vitamin B12, calcium and iron for the rest of their lives as part of their permanent lifestyle changes.
Who is not a candidate?
Patients who abuse drug and alcohol, have a history of binge eating, untreated major depression or psychosis, severe cardiac disease, or disorders that interfere with healing such as blood clot disorders are not good candidates for the BD/DS. BD/DS surgery should not be considered a first-line option for weight loss and should be considered only after first exhausting non-surgical weight loss options.
You may be asked to modify your diet, lose or maintain a stable weight, or alter your dietary habits (i.e. eating smaller meals throughout the day) before surgery. This increases the chance of successful, sustained weight loss after the surgery. Like other surgeries, BD/DS may require you to undergo certain general surgery procedures such as preoperative blood testing, medications, and cessation of smoking or use of pain relievers and anti-inflammatory drugs.
Recovery is a slow and gradual healing and readjustment process as you learn how to eat smaller portions of food. Pain in the first 2-3 days after surgery in the upper left part of the abdomen is common, but can be managed with pain relievers. Pain should be minimal to nonexistent by 2-3 weeks after the surgery. Although light walking is suggested soon after surgery, strenuous exercise should be avoided for the first few weeks. The initial period of healing and recovery for BD/DS takes 6-8 weeks, as it is an open surgery procedure rather than a laparoscopic procedure.
Patients should stick to an all-liquid diet for the first week, before gradually easing onto soft foods and eventually back to a normal diet. However, portion sizes should be heavily restricted and patients should eat slowly so they can properly gauge their satiety and fullness. Lifestyle changes implemented before the surgery should be maintained in the long run as patients adjust to eating smaller portions.
BD/DS carries the same risk of other open surgeries performed under general anesthesia, such as adverse reactions to anesthesia, infection at the wound site, allergic reactions to medication, and blood loss requiring transfusion. Risks of BD/DS in particular include deep vein thrombosis (DVT), leakage of digestive contents, stricture (narrowing of opening between stomach and small intestine), stomach ulcers, and kidney stones. BD/DS has a higher risk profile than other weight loss procedures, due to level of invasiveness and demonstrated higher risk of complications.
Long-term side effects include dumping syndrome, malnutrition from reduced nutrient absorption, diarrhea and nausea, and vitamin B12, iron, calcium or magnesium deficiency. Rare but fatal complications include small bowel blockage from pancreatitis, and pulmonary embolism.
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