History of Duodenal Switch
The History of Duodenal Switch explains why this hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch (BPD-DS). Duodenal Switch is sometimes confused with old or outdated weight loss surgeries, but this is only being stated because Duodenal Switch has a long history starting in the 1950’s. By going over the history of this procedure and explaining the differences between Duodenal Switch and other procedures, hopefully it will clear up the misconception of Duodenal Switch being outdated.
Jejunoileal Bypass (JIB)
The Jejunoileal Bypass, a strictly malabsorptive procedure, was performed in the 1950’s and was the first surgery developed to achieve significant sustained weight loss. In the JIB, the stomach remains intact and all but 35 cm (18 in) of the small intestine is detached and set to the side where it is not reattached anywhere proximally, but is connected to the last segment (35cm section) far from the center of origin. With no liquid flowing through the bypassed intestine to cleanse it some potentially serious complications could develop, such as toxic bacterial overgrowth leading to sepsis, risk of developing severe malnutrition and liver failure from not effectively absorbing vitamin B complex and vitamin C. The JIB is no longer recommended as a bariatric surgical procedure and many patients have had this procedure reversed or revised.
Roux-en-Y Gastric Bypass (RNY, RYGBP or Proximal Gastric Bypass)
Roux-en-Y Gastric Bypass was pioneered by Dr. Cesar Roux, a Swiss surgeon, who described the procedure in 1892 for patients with obstruction of the stomach. Interestingly, by 1910, he had abandoned the Roux-en-Y (RNY) procedure because of the high rate of the associated marginal ulcers and the nutritional deficiencies. In late1960’s, Dr. Mason resurrected the gastric bypass with Roux-en-Y anastomosis for treatment of morbid obesity. In the gastric bypass, RNY, a small (15-30 cc) pouch is created at the top of the stomach to restrict food intake. The small bowel is divided about 45 cm (18 in) below the lower stomach and is re-arranged into a Y-formation. The pyloric valve at the bottom of the “blind” stomach and is not in use because food travels out of the top “pouch” stomach straight into the small intestine via the roux limb. For this reason, sugar moves quickly into the bowel and can cause “dumping”. Proximal patients have their roux limb measured approximately 80 – 150 cm (30 to 60 inches) from the top of the small intestine. Therefore, most of the small bowel absorbs nutrients and the malabsorption is mild.
A less common modification of the RYGBP is the Distal Gastric Bypass. Distal patients have the same “pouch” stomach as proximal patients, but have their roux limb measured approximately 100 to 150 cm from the bottom of the small bowel. As a result, Distal Gastric Bypass patients have increased malabsorption. Distal Gastric Bypass is a procedure where one combines all the side effects of the duodenal switch and the gastric bypass together with no measurable benefit.
Biliopancreatic Diversion (BPD)
Dr. Nicola Scopinaro introduced the Biliopancreatic Diversion in Italy during 1979.The procedure combines malabsorption with some gastric restriction. A large pouch between 250 and 400 ccs is created with the upper portion and the lower stomach is surgically removed (distal gastrectomy). The pyloric valve is circumvented so “dumping” often occurs. The duodenum (top part of the small intestine) is bypassed and the stomach pouch is connected to the lower 2-3 meters of the small intestine. Then, 4-metres of the small bowel (60%) is bypassed making the channel approximately 50 cm.
Stand-Alone Duodenal Switch
The Stand-Alone Duodenal Switch procedure (without the accompanying gastric bypass as used in weight-loss surgery) was developed by Dr. Tom R. DeMeester in the 1980’s to treat bile-reflux gastritis, a condition in which the stomach and esophagus are irritated by bile that goes back through the pylorus to the stomach.
Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
In 1986, Dr. Douglas Hess modified BPD and combined it with Duodenal Switch. This hybrid procedure is often referred to as the Biliopancreatic Diversion with Duodenal Switch, or GR-DS (Gastric Reduction- Duodenal Switch). Keep in mind; the BPD portion has been modified from the original procedure so the name can be misleading.
Duodenal Switch (DS)
DS surgeons and patients commonly refer to this procedure as the Duodenal Switch. Hess’s Duodenal Switch has the advantages of the BPD, but without some of the associated problems like marginal ulcers, stoma closures and blockages, dumping syndrome, and serious protein-calorie malnutrition; all of which can occur after other gastric bypass procedures.