DUODENAL SWITCH

What you need to know

What is Duodenal Switch?

• Duodenal Switch (DS)

• “double anastomosis” or classic DS

• “single anastomosis”

What is Duodenal Switch?

• DS (single and double) are alternative

procedures to traditional gastric bypass and

sleeve gastrectomy

• May be offered on a highly selective basis

when potential benefits clearly outweigh risks

• Very few surgeries at St Joe’s are DS

Why Consider Duodenal Switch?

• DS offers the best chance of

improvement/remission of type 2 diabetes

• DS can offer slightly better weight loss than

sleeve or bypass

• DS has a lower chance of weight regain in the

long-term

Why Consider Duodenal Switch?

However…

Why Consider Duodenal Switch?

• DS also has the highest level of surgical risk

• Often done as two surgeries

• DS requires significantly more attention to

prevent malnutrition

• DS has potential for significant side effects

Who May Be Eligible?

• Patients with severe diabetes that is difficult

to control

• Patients who have had a sleeve but who

could benefit medically from additional

weight loss.

• Patients with significant weight regain after

sleeve or gastric bypass

Who is Not Eligible?

• People with inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

• People with severe/frequent diarrhea

• People with severe and unmanaged psychiatric illness

• Age over 60 years old

• Many other patient-specific reasons may also rule out a DS

Normal Anatomy

• Food travels down the esophagus to the stomach

• It then goes into the small intestine and then the large intestine

• Digestive juices travel with your food to help absorption

Duodenal Switch

(double anastomosis)

Duodenal Switch

(double anastomosis)

• Creation of small stomach shaped like a sleeve

• Small intestine is disconnected from sleeve

• Lower part of small intestine attached directly to sleeve

• Large amount of small intestine bypassed

Image source: Ethicon Endo-Surgery, INC.

Duodenal Switch

(double anastomosis)

Image source: Ethicon Endo-Surgery, INC.

• Smaller stomach means

you feel full faster

• Hormonal/metabolic

changes lower your

appetite

• Do not absorb all of your

calories

• Do not absorb

vitamins/minerals

properly

Duodenal Switch

(single anastomosis)

Duodenal Switch

(single anastomosis) • Creation of small

stomach shaped like a

sleeve

• Small intestine is

disconnected from

sleeve

• Loop of small intestine

attached directly to

sleeve

• Smaller amount of small

intestine bypassed

• Common channel longer

than with DS

Duodenal Switch

(single anastomosis)

• Smaller stomach means you feel full faster

• Hormonal/metabolic changes lower your appetite

• Do not absorb all of your calories

• Do not absorb vitamins/minerals properly

Single vs Double Anastomosis

Single

• One connection

• Less risk

• Longer common channel

• (~250-300 cm, ~ 8-9 ft)

• Less malabsorption

• Fewer side effects

• Less research

Double

• Two connections

• More risk

• Shorter common channel

• (~100 cm, ~ 3 ft)

• More malabsorption

• More side effects

• More research

Bypass/Sleeve vs DS

Bypass/Sleeve

• Slightly less weight loss

• ~15-30% have weight regain

• Lower malnutrition risk

• Fewer side effects

• 7-9 pills/day (vitamins)

DS

• Slightly more weight loss

• ~10% have weight regain

• Higher malnutrition risk

• More side effects

• 13-15 pills/day (vitamins)

One Surgery or Two?

• If you have never had bariatric surgery:

• Usually done as two surgeries

• Can be done in a single-stage for select patients

(up to surgeon)

• If you previously had sleeve gastrectomy:

• DS is done as one surgery

• If you previously had gastric bypass:

• Typically done as two surgeries

Weight Loss

• Weight loss with DS is typically around 30-40% of

highest body weight when performed as a single-

stage or as an early second-stage

• Can be less when performed as after significant

weight regain with sleeve or bypass

• Is typically slower than with bypass or sleeve

• As always, health improvements are more

important than body weights

Side Effects

• Most people have more frequent bowel movements

• Soft or loose bowels

• Most people will have a BM 2-4 times per day but can be up to 10 times per day for the first 12-18 months

• Eating a very high fat meal can cause very bad diarrhea

• Many people complain of frequent and foul smelling gas

• Less common with single anastomosis

• Can be controlled to some extent through diet

• Worse with simple sugars and carbohydrates

Vitamin/Mineral Supplementation

Option 1 Option 2

Multivitamin High ADEK multivitamin

3x/day

Adult multivitamin

2x/day

Calcium 500-600 mg 3x/day 500-600 mg 3x/day

Iron 300 mg ferrous sulfate

1x/day

300 mg ferrous sulfate

1x/day

Vitamin B12

1000 mcg tablet 1x/day

OR

1000 mcg IM injection

1x/month

1000 mcg tablet 1x/day

OR

1000 mcg IM injection

1x/month

Vitamin A n/a 10,000 IU/day

Vitamin D 2000 IU/day 2000 IU/day

Vitamin E n/a 400 IU/day

Vitamin K n/a 300 mcg/day

Vitamin/Mineral

Supplementation Schedule Time Option 1 Option 2

Morning

ADEK multivitamin

Calcium

Vitamin B12

Calcium

Vitamin D

Vitamin A

Vitamin B12

Afternoon

ADEK multivitamin

Calcium

Vitamin D

Calcium

Vitamin D

Vitamin E

Evening

ADEK multivitamin

Calcium

Vitamin D

Calcium

Vitamin K

Bedtime Iron Iron

Multivitamin(s)

Total # Pills 13 15

Dietary Guidelines

• Protein goal is much higher

• ~120 grams per day (don’t absorb all)

• Need to eat protein 6 times per day

• Usually includes one protein shake per day

• Need to eat more calories than with

bypass/sleeve

• Don’t absorb them all

• Diet is relatively higher in protein and healthy

fats, and slightly lower in carbohydrates

Dietary Guidelines - Example Breakfast: omelette (2 eggs + 1 oz ham + onions/peppers/mushrooms) + 1 slice toast with ¼ avocado (smashed)

AM Snack: ½ cup 2% cottage cheese + 2 melba toast

Lunch: chicken salad wrap (4 oz chopped chicken + full fat mayo/green onion/celery + romaine + tortilla)

PM Snack: 2 oz cheddar cheese (regular) + 2-3 melba toast

Dinner: 4 oz salmon + ½ cup green beans + ¼ cup quinoa

HS Snack: ½ cup 2% plain Greek yogurt + ½ cup berries + 2-3 tbsp chopped nuts

Mental Health and DS

Common Mental Health Issues

• Eating Disorder History

• Trauma History

• Depression and Anxiety

• Substance Use (risk of post-addiction transfer)

• Body image concerns

• Self-harm, suicidality

• Important to have stability with symptoms • Specific guidelines and intervention for issues

such as substance use, inpatient admissions, suicide attempts, changes to medication etc.)

Mental Health and DS

Psychotropic Medication

• Understanding of absorption

• Follow-up monitoring for medication (e.g.,

adjustments)

• Closer monitoring of symptoms and stability

• Having a post-op care plan (e.g., family

physician, mental health resources)

Mental Health and DS

Adaptive Coping Strategies

• How to navigate difficult situations

• Regimented, ability to follow structure and routine

• Evaluation of significant stressors and strategies to reduce/manage stressors

• Importance of social supports and ability to access supports

• Compliance and motivation

Mental Health and DS

Social Issues

• Financial stability for costs associated with surgery

• Home life stability

• Open to accessing community resources

What If You Don’t Want DS?

• If you decide that you don’t want DS but are still

interested in other treatments, you could consider

medications instead

• SAXENDA (liraglutide) DIN # 02437899

• Daily injectable medication

• Suppresses appetite and increases fullness

• CONTRAVE (naltrexone HCI/bupropion HCl) DIN #

02472945

• Daily oral medication

• Suppresses appetite and food cravings

GETTING READY FOR

SURGERY

Before Surgery

• You will be assigned to a nurse navigator and

may meet them in person, or they may call you

over the phone

• Nurse will arrange your appointments and

testing

• Have many tests to make sure you can safely

have surgery. You may have:

•Gastroscopy •Ultrasound

•Sleep study •Blood tests

•Barium Swallow •Electrocardiogram

Before Surgery • You will attend many appointments to see members of the health care team. You will see the:

• Medical Internist

• Social Worker and/or Psychologist – sometimes several times

• Dietitian – you will have several appointments

• Surgeon

• Appointments will be on different days

• If appointments are on the same day you may have to wait between appointments

Before Surgery

• Team members will assess:

• your risks and benefits and may determine

whether DS is offered to you

• your knowledge and understanding of DS

• your ability to follow lifestyle

recommendations for DS

Missed Appointments

• If you miss 2 appointments without notifying

the clinic your name will be removed from the

list of candidates for surgery.

• Important to always notify clinic if you cannot

make an appointment

• There are many people waiting for

appointments

Before Surgery

• Stop smoking NOW! You must be 6 months smoke-free before your assessments start.

• This includes all forms of nicotine (e-cigarettes,vaping, Nicorette gum etc.)

• Smoking significantly increases your risks for surgery (poor healing and ulcers)

Preparing for Appointments

• If you previously had gastric bypass or sleeve gastrectomy at another hospital, we may need you to retrieve your operative note from that institution

1. Ask your nurse whether we can get it or not

2. If not, contact their Health Records Department

3. Ask if they still have your operative note on file

4. Will likely need to pay a fee

5. Obtain a paper copy of the report and bring with you to the clinic

What’s Next?

• How to let us know…

Resources

• Duodenal Switch Handbook

• Single anastomosis DS handout

• www.dsfacts.com

• Youtube:

• Search “duodenal switch animation” for

double anastomosis DS video

• Search “loop duodenal switch procedure”

for single anastomosis DS video

Getting Ready for RD

Appointments

• Review all resources provided

• Bring the following:

• At least 7 days of food records

• Bring “Getting Ready for Your DS

Assessment” worksheet

• Bring Duodenal Switch book and single

anastomosis DS handout

Questions