This article is an inside look at the complications associated with the Duodenal Switch Procedure. The duodenal switch is known to be one of the most effective forms of bariatric surgery for long-term weight loss in morbidly obese people. Although that sounds very appealing and you may be ready to have the surgery after reading that sentence alone, there are some things you need to know before deciding on the duodenal switch.
Let’s start at the beginning… What is the duodenal switch?
The duodenal switch or the biliopancreatic diversion with the duodenal switch is a form of bariatric surgery that involves removing approximately 70-75% of the stomach and most of the duodenum (aka the initial one-third of the small intestines).
This procedure evolved from the biliopancreatic diversion without the duodenal switch which was first utilized in 1976. This procedure showed effectiveness in terms of weight loss, however, the rates of malnutrition or malabsorption of nutrients were very high.
So, in comes the addition of the duodenal switch! This improvement in the procedure was introduced in 1999 with the idea that preserving the pylorus, the opening of the stomach into the duodenum would help in both the digestion and absorption of nutrients.
How does the duodenal switch work?
The duodenal switch is an intricate procedure that reduces your body’s ability to absorb nutrients, including carbohydrates, fat, protein, and micronutrients.
In short, this procedure reroutes a portion of the small intestine by creating two separate pathways. The two separate pathways come together just before entering the large intestine, this merging of the two pathways is called the common channel. The common channel is relatively short, only about 75-150cm long.
The shorter of the two pathways is referred to as the digestive loop. The digestive loop takes food from the stomach to the common channel. The second pathway is much longer and is known as the biliopancreatic loop. This pathway takes bile from the liver to the common channel.
Bile is a digestive fluid produced by the liver that is normally stored in the gallbladder. Bile contains bile acids that are an essential part of the digestion and absorption of fats and fat-soluble vitamins in the small intestine. The duodenal switch interferes with this process as the contents from the digestive loop (food) mix with the contents of the biliopancreatic loop (bile) for a short period of time in the common channel before proceeding to the large intestine.
This new arrangement of your small intestines reduces the amount of calories and nutrients that are absorbed. It is important to note that the majority of fat and protein are absorbed in the small intestine, so this procedure majorly limits the amount of fat and protein that your body is able to absorb.
Simply put, this procedure works by reducing caloric intake and inducing fat malabsorption. The decrease in the size of your stomach reduces the amount of calories and food you may consume and the short period of time that food and bile spend in the small intestine reduces the amount of nutrients your body can absorb.
Who is the target population for the duodenal switch?
Morbidly obese people! Morbid obesity is defined as a BMI >40 kg/m2.
Although lifestyle changes and exercise are the ideal forms of weight loss, research has shown that it is not always a long-term and effective solution, especially among people struggling with morbid obesity.
The duodenal switch could be a potential long-term solution. One research study revealed 70% weight loss that was sustained for up to 10 years following surgery. Another study showed a significant reduction in BMI. At the start of the study, the average BMI was 53 kg/m2. One year later the average BMI of the participants was 30.1 kg/m2 and 9 years following the procedure the average BMI was 32 kg/m2. This means that there was an average of over 20 BMI units lost 9 years after the procedure was performed.
These studies have also shown long-term resolution of obesity related diseases like diabetes mellitus, hypertension, and obstructive sleep apnea.
Now you might be wondering, with statistics that impressive, why is this procedure not the most commonly utilized method of bariatric surgery?
Well for starters, the duodenal switch is a malabsorptive procedure. This means that it promotes abnormal or inadequate absorption of nutrients which is effective for weight loss but, your body NEEDS nutrients in sufficient amounts in order to function properly. The Biliopancreatic diversion and the duodenal switch are rarely used (< 2%) due to their high risk of nutritional complications.
This procedure is also longer and more technically demanding when compared to other forms of bariatric surgery. This surgery can be performed in an open format or laparoscopically. The laparoscopic form of surgery is a little more difficult and may take longer than the open form of surgery, but it has been shown to be safe and effective and will likely reduce your hospital stay following surgery.
General surgical complications that can occur following any surgery or procedure including the duodenal switch are…
- Blood clots/DVT (Deep Vein Thrombosis)
- Adverse reaction to anesthesia
- Lung or breathing problems
Surgical complications that are unique to the Duodenal switch include…
- Anastomotic leak (which can also occur with other forms of bariatric surgery like gastric bypass and the gastric sleeve)
- Potential injury to the pancreas and common bile duct
- Anastomotic stricture
- Hernias (Internal hernia and ventral hernia)
In a study conducted on 275 patients, there was a need for 36 reoperations within the first year following the duodenal switch. The most commonly performed procedures were ventral hernia in 10 patients (3.6%) and bowel obstruction/abdominal pain in 9 patients (3.3%).
The leak rate was 1.1% (3 patients). By the end of the 9-year study, 78 patients had bowel obstruction or pain (28.4%), 60 patients had to have their gallbladder removed (21.8%), and 35 patients had a ventral hernia (12.7%). The overall rates of complications and need for reoperation were astoundingly high.
An internal hernia can be a very serious complication that can result in a bowel obstruction or strangulation/death of the bowel. This complication may require the need for secondary surgery, as the surgeon may need to go in laparoscopically to explore or repair the area.
Symptoms of internal hernia include…
- Abdominal pain
- Obstipation (severe constipation)
Eating can often worsen symptoms. Obstipation and vomiting may be present in severe cases. You should go see the doctor immediately if you start experiencing any of these symptoms.
Long term nutritional complications following the duodenal switch can include…
- Hypoglycemia (low blood sugar)
- Anemia (low iron)
- Vitamin and mineral deficiencies
- Protein calorie malnutrition
- Dumping syndrome
- Need for nutrition support (tube feeding or TPN)
Vitamin and mineral complications
The duodenal switch promotes fat malabsorption, which may sound ideal, but there are certain vitamins that need fat in order to be absorbed and utilized properly. These are called fat-soluble vitamins. Essential fat-soluble vitamin deficiencies can occur due to fat malabsorption. This can lead to severe clinical consequences and alter calcium metabolism.
One study conducted on 170 patients found that 69% had a vitamin A deficiency, 68% a vitamin K deficiency, and 63% and vitamin D deficiency within 4 years of surgery. The incidence of vitamin E did not increase with time after surgery, but other studies have shown lower levels of vitamin E following the duodenal switch. The incidence of hypocalcemia also increased from 15% to 48% over the study period.
Classic deficiencies of fat-soluble vitamins can be clinically observed as night blindness (vitamin A), the softening of your bones (osteomalacia) (vitamin D), increased oxidative cell stress (vitamin E), and bleeding (vitamin K). Deficiencies in Vitamins A and D have also been indirectly linked to cancer, type 2 diabetes, and certain immune system disorders. It is important to monitor your vitamin and mineral levels following surgery to detect and prevent deficiencies.
Vitamin and Mineral Deficiencies can be prevented by taking the right supplements. If you are looking for a great vitamin and mineral supplementation following the duodenal switch or bariatric surgery you should check out Bari Life’s Vitamins. The founder of these vitamins is an educator for Ethicon Endo for the Duodenal switch. These vitamins are a great complete source of vitamins and minerals and they can help to prevent vitamin and mineral deficiencies that may occur following surgery.
Protein calorie malnutrition
Protein malnutrition is the most serious macronutrient complication that is associated with malabsorptive surgical procedures. It is estimated that up to 10% of patients will suffer from protein malnutrition following the duodenal switch. This is because the majority of protein is digested and absorbed in the small intestine.
Protein malnutrition causes an estimated 1% of hospitalizations per year and can lead to other diseases, medical conditions, and poor health outcomes. Severe protein-calorie malnutrition may lead to the need for tube feeding (enteral nutrition) or reversal of the procedure altogether.
Protein calorie malnutrition can be prevented by consuming adequate amounts of protein. It is recommended that you consume a minimum of 90g of protein per day following the duodenal switch.
There are plenty of ways to ensure that you are consuming enough protein following the surgery. Incorporating high protein foods and snacks, protein bars, and protein supplements are just a few examples of how you can increase your daily protein intake.
If you are struggling to meet your daily recommended protein intake check out this article. In addition to increasing your protein intake regular training and aerobic exercise are essential to preserving your lean muscle mass.
That’s a wrap!
The Duodenal switch is a malabsorptive procedure that has shown great results in terms of weight loss alone, but the overall rate of complications and need for reoperation is high. Many surgeons avoid this procedure due to concerns about complications and associated nutrient deficiencies.
If you are considering this surgery make sure to educate yourself about all the risks, work with a team of highly qualified surgeons, physicians, and registered dietitians, and follow the recommendations on how to reduce nutrient deficiencies like vitamin and mineral supplementation, high protein intake, and physical activity.