Biliopancreatic diversion, more commonly known as the duodenal switch, can offer patients greater weight loss and other health benefits compared with more popular bariatric procedures, such as gastric bypass—if it’s performed by a surgeon experienced in the advanced laparoscopic techniques.
Duodenal Switch Procedure at MUSC Health
MUSC Health is currently the only site in South Carolina offering the duodenal switch procedure, according to Rana C. Pullattrana, M.D., an associate professor of surgery who specializes in general and gastrointestinal surgery at MUSC.
MUSC’s well-respected bariatric surgery program is the oldest in the region and includes bariatric surgeons, advanced practice practitioners, psychologists, dietitians and patient coordinators. Dr. Pullatt has performed more than 700 bariatric surgeries during his career, including nearly 20 duodenal switch procedures. From the success he’s seen thus far, he hopes that number continues to rise.
“It’s a cutting-edge procedure that very few centers in the country offer,” says Dr. Pullattrana. “Less than 1 percent of all bariatric procedures done in the United States right now are duodenal switch. That shows the rarity of the procedure and why it really needs to be performed by someone who specializes in it.”
Bariatric Surgery: Gastric Bypass vs. Duodenal Switch
In a gastric bypass procedure, surgeons create a smaller stomach by dividing it into two sections, one considerably smaller. They then rearrange the intestine to connect to both sections. As a result, patients need to limit the amount of food they eat at any given time.
In the duodenal switch method, surgeons create a smaller stomach but then remove the unused portion. They reroute the digestive tract, bypassing a portion of the intestine entirely. When using this approach:
- The pylorus remains intact, so patients do not experience dumping syndrome.
- The volume of the stomach stays a bit larger, so patients may be able to eat more.
- Patients may experience fat malabsorption.
According to Dr. Pullattrana, the duodenal switch is a technically challenging procedure, which may be why it accounts for such a miniscule percentage of bariatric surgeries to date.
“The first portion of the duodenum [small intestine] is surrounded by a lot of blood vessels as well as very critical structures, including the bile duct,” he explains. “A surgeon needs to be proficient with advanced laparoscopic techniques. Because this is performed on people with very high BMI, it is even more challenging.”
Duodenal switch surgery can take some surgeons 3 to 4 hours. Through their experience and expertise, the MUSC team has shaved an hour off of that, generally finishing a surgery in 2 to 3 hours. “Performing this surgery required some degree of adapting our technique to get especially skilled at it, and now we are,” explains Dr. Pullattrana.
Most patients go home after 2 days in the hospital and follow up with their doctor at regular intervals for the first year (at 1 week, 1 month and then every 3 months). MUSC Health sees patients annually after the first year, to monitor weight loss progress and ensure adequate nutritional intake.
Bariatric Surgery: Duodenal Switch Benefits
So far, results point to very effective weight loss with the duodenal switch. As of March, MUSC patients had an average BMI of 60 kg/m2 with an average weight of 388 lbs at the time of duodenal switch surgery. Average BMI after surgery dropped accordingly:
- 54 kg/m2 at 1 month
- 49 kg/m2 at 3 months
- 47 kg/m2 at 6 months
- 39 kg/m2 at 12 months
Patients’ overall health also improved. Whereas gastric bypass resolved diabetes in roughly 80 percent of patients, that number is closer to 93 percent after duodenal switch surgery.
“This is the best operation that we have for bariatric surgery,” says Dr. Pullattrana. “Like any bariatric surgery, patients do need to follow lifestyle as well as dietary and exercise guidelines.”
While the duodenal switch has traditionally been reserved for patients considered super obese (characterized as a BMI greater than 50), current opinion amongst bariatric surgeons is that
many who are a fit for other bariatric surgeries would likely benefit from duodenal switch as well.
In general, Dr. Pullattrana says ideal candidates include anyone with a BMI of 35 or greater who has another health condition (such as uncontrolled diabetes) or anyone with a BMI greater than 50 who desires a drastic weight loss.
This surgery is also an option for patients who’ve previously undergone a sleeve gastrectomy without adequate success.
Bariatric Surgery: Managing Expectations and Follow-Up
Dr. Pullattrana says duodenal switch surgery offers similar complication rates to other bariatric procedures. The most common concern is malnutrition.
Because the surgery affects nutrient absorption, patients need to eat a high-protein diet and supplement with vitamins regularly. To best manage this potential complication, Dr. Pullattrana recommends patients keep in regular contact with their bariatric specialty team, especially their registered dietitians. This includes getting nutritional lab panels every 6 months for the first 2 years and annually thereafter.
Emphasizing these post-surgery management details to patients as they’re considering the duodenal switch can help manage expectations and prevent complications in the long term.
Still, he says the potential for health improvement with this surgery is not to be understated. “This is a life-changing, life-altering procedure. Truly, we can make a dramatic difference in an obese person’s general medical condition,” he says.
For more information, contact Dr. Pullattrana at Pullattr@musc.edu.