Duodenal Switch for Super Morbid Obesity

Clinical data addressing Duodenal Switch for super morbid obesity (BMI > 50).

Outcome of laparoscopic duodenal switch for morbid obesity. 
Magee et al. Oct 2010
PubMed Abstract

BACKGROUND: The aim of this study was to determine the safety and efficacy of laparoscopic duodenal switch (LDS) as a treatment option in a selected group of patients with morbid obesity.

METHODS: This retrospective analysis of a prospective database assessed the frequency of all complications and alterations in weight, body mass index (BMI), co-morbidity and quality of life.

RESULTS: One hundred and twenty-one patients underwent LDS between April 2003 and March 2009. Median preoperative weight was 160 kg and median BMI 55 kg/m2. All procedures were performed laparoscopically. The in-hospital mortality rate was zero. No ileoduodenal anastomotic stenosis was encountered. There were four clinical leaks (3.3 per cent) managed by laparoscopic drainage and placement of a feeding jejunostomy. Median percentage excess weight loss was 75 per cent at 12 months and 90 per cent at 24 months. Thirty-six of 40 diabetic patients had complete resolution of diabetes within 1 year. There were significant improvements in other obesity-related co-morbidity. Only a few patients developed postoperative protein deficiency, and fat-soluble vitamin deficiencies were easily managed with oral supplementation.

CONCLUSION: The LDS procedure is a safe and effective treatment for morbid obesity and its associated co-morbidity in selected patients. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. 
Søvik et al. Feb 2010
PubMed Abstract 

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Registration number: NCT00327912 (https://www.clinicaltrials.gov). Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI > or = 50 kg/m2) compared with gastric bypass. 
Prachand et al. Feb 2010
PubMed Abstract 

OBJECTIVE: Increased body mass index is associated with greater incidence and severity of obesity-related comorbidities and inadequate postbariatric surgery weight loss. Accordingly, comorbidity resolution is an important measure of surgical outcome in super-obese individuals. We previously reported superior weight loss in super-obese patients following duodenal switch (DS) compared to Roux-en-Y gastric bypass (RYGB) in a large single institution series. We now report follow-up comparison of comorbidity resolution and correlation with weight loss.

METHODS: Data from patients undergoing DS and RYGB between August 2002 and October 2005 were prospectively collected and used to identify super-obese patients with diabetes, hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD). Ali-Wolfe scoring was used to describe comorbidity severity. Chi-square analysis was used to compare resolution and two-sample t tests used to compare weight loss between patients whose comorbidities resolved and persisted.

RESULTS: Three hundred fifty super-obese patients [DS (n=198), RYGB (n=152)] were identified. Incidence and severity of hypertension, dyslipidemia, and GERD was comparable in both groups while diabetes was less common but more severe in the DS group (24.2% vs. 35.5%, Ali-Wolfe 3.27 vs. 2.94, p<0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p<0.05). There were no differences in weight loss between comorbidity “resolvers” and “persisters”.

CONCLUSIONS: In comparison to RYGB, DS provides superior resolution of diabetes, hypertension, and dyslipidemia in the super-obese independent of weight loss.

Duodenal Switch Operative Mortality and Morbidity Are Not Impacted by Body Mass Index. 
Buchwald et al. Oct 2008
PubMed Abstract 

OBJECTIVE: This report examines the up to 30-day postoperative mortality and morbidity in our first 190 duodenal switch (DS) patients.

BACKGROUND DATA: DS is the most weight loss effective and the most difficult to perform bariatric procedure. Indeed, certain surgeons have advocated a 2-stage approach to minimize complications, especially in the super obese (body mass index [BMI] >/=50 kg/m).

METHODS: DS procedures were performed (n = 190) by either open (n = 168) or laparoscopic/robotic surgery in an academic setting: common channel 75 to 125 cm, sleeve gastrectomy (approximately 100 mL gastric pouch), closed duodenal stump, end-to-side duodenoileostomy hand-sewn in 2 layers, with most staple lines oversewn, and all mesentery defects closed.

RESULTS: For the 190 patients, 149 were female (78%) and the mean age was 43 years (range, 16-71). Mean preoperative weight 151.4 kg (range, 74.1-332.7); mean preoperative BMI 53.4 kg/m (range, 32-107), with 100 (52.6%) of the patients super obese (BMI >/=50 kg/m). Seventy-four patients had concurrent procedures, eg, cholecystectomy (n = 22), ventral or umbilical hernia repair (n = 19), and hiatus hernia repair (n = 10). Mean operating room time was 337 minutes (range, 127-771); mean hospitalization time was 6 days (range, 2-38). There were no deaths. Serious /=50 kg/m (NS). Surgical site infections occurred in 7 patients with a BMI <50 kg/m and in 12 with a BMI >/=50 kg/m (NS). Overall complication rate in patients with a BMI <50 kg/m was 14.4% (13 of 90) and 24% (24 of 100) with a BMI >/=50 kg/m (NS).

CONCLUSIONS: With attention to careful surgical technique, DS can be performed relatively safely in the morbidly and super morbidly obese, and does not require a 2-stage procedure.

Outcome of duodenal switch with a transitory vertical gastroplasty, in super-super-obese patients in an 8-year series. 
Di Betta et al. Feb 2008
PubMed Abstract 

BACKGROUND: In super-super obese (SSO) patients [body mass index (BMI) superior of 60 kg/m2] results of bariatric surgery are still controversial. This study evaluated safety and efficacy of open duodenal switch associated with transitory vertical gastroplasty (DS-TVG) after 8 years of follow-up.

METHODS: A prospective observational study of 32 SSO patients who underwent an open DS-TVG from January 1999 till March 2006 was performed. Study endpoints included preoperative comorbidities [diabetes, hypertension, and obstructive sleep apnea syndrome (OSAS)], postoperative morbidity and mortality, and long-term results of BMI and percent of excess weight loss (%EWL) (median 48 months).

RESULTS: Results in terms of BMI and %EWL were, respectively, after 12 months, 46.3 +/- 10.2 and 57.1 +/- 9.8; after 36 months (n = 21), 37.5 +/- 7.5 and 73.5 +/- 6.2; and after 84 months (n = 5), 31.7 +/- 2.8 and 76.0 +/- 4.1. With regard to comorbidities, we observed complete control of lipid alterations and type-2 diabetes (suspension therapy within 1 year). All patients with OSAS improved within 1 year without needing domiciliary oxygen therapy. Neither malnutrition nor mortality was observed during the follow-up. Major complications occurred in a total of 5 patients (15.6%): pulmonary embolism (2 cases-9.4%); gastrointestinal bleeding, requiring transfusions (1 case-3.1%); 1 case (3.1%) of abdominal rupture; and 1 case of acute pancreatitis (3.1%). Minor complications occurred in 4 patients (12.5%): 1 case of pneumonia, 1 urinary tract infection, and 2 wound infections.

CONCLUSION: Although this study evaluated the outcomes of a small series of patients after open DS-TVG, this procedure seems to be safe and effective in obese patients who have a BMI greater than 60 kg/m2. In our opinion, DS-TVG should be considered as a valid surgical option with two staged laparoscopic procedures.

Duodenal Switch Provides Superior Weight Loss in the Super-Obese (BMI >50kg/m2) Compared With Gastric Bypass 
Prachand et al. Oct 2006
PubMed Abstract 
Full Article 

OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB).

METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight.

RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05).

CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS.