Duodenal Switch Surgery (DS): Analysis & Review

The duodenal switch (DS) procedure results in more weight loss than any other procedure. But what does this mean for you in terms of life-long commitments and surgery-related complications?

duodenal switch

Could Duodenal Switch Surgery Be Right for You?

DS or the “duodenal switch” has proven to be successful (result in at least 50% of excess weight loss) for about 85% of patients after 3 years.1

In addition, a meta-analysis (review and summary of many previous studies) conducted in 20042 showed that DS surgery was better than other types for improvement of…

  • Diabetes
  • Hyperlipidemia (elevation of fats in the bloodstream)
  • Hypercholesterolemia (high blood cholesterol)
  • Hypertriglyceridemia (high blood triglycerides)
  • Sleep apnea

More recent studies have confirmed its positive effects on diabetes and sleep apnea and have also found it to be more effective at improving hypertension (high blood pressure).3 

Duodenal switch surgery also results in greater weight loss over the short- and long-term, which we’ll get into further down the page.

With all of these positive results, why do patients seem to migrate towards other types of bariatric surgery?

First, if you have either of the following health conditions, they should be discussed with your surgeon before moving forward. They may or may not pose a threat:

  • Gastroesophageal reflux disease (GERD)
  • Inflammatory bowel disease (IBD)

Second, how good are you at following your doctors’ orders? Do you ALWAYS take medications exactly as prescribed? Your inability to do so after duodenal switch surgery could have severe implications to your health, as DS patients must religiously take bariatric vitamins and often other medications for the rest of their lives to avoid malnutrition.

Third, if you are a vegetarian and choose the DS, possible protein deficiency should be discussed with your surgeon. Vegetarians can do fine after undergoing the DS, but they must put more effort into getting adequate protein intake from non-meat sources.

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The Difference between Duodenal Switch and Other Bariatric Surgery Procedures

The duodenal switch (DS) may be the most effective bariatric treatment for improving diabetes, hyperlipidemia, high cholesterol, high triglycerides and sleep apnea.  It also results in more weight loss than any other procedure.

We’ll get into the exact percentages in the Results section below.

First, let’s review the studies that directly compared the DS to the more popular gastric bypass and adjustable gastric banding (lap band surgery).

We've outlined the studies' findings in the chart below.  The key points to consider when comparing gastric bypass and lap band surgeries with the duodenal switch are…

  1. Mortality rates are similar
  2. Weight loss is greater after DS
  3. Complication rates are higher with DS (more on this in the complications section below) which is most likely due to the fact that DS patients tend to have a much higher BMI and many more co-morbidities than patients undergoing lap band or gastric bypass surgery.
  4. Risk of bariatric vitamin deficiency (and malnutrition) is greater after DS, especially in the year following surgery
  5. You will almost certainly not get dumping syndrome or marginal ulcers after DS surgery, where one or both are likely at some point following gastric bypass surgery.
  6. Bowel movements following surgery can be similar to (but possibly worse than) after gastric bypass (more on this in the Life after Duodenal Switch section below)

Following are the study summaries (click here to jump past the chart)...

Summary of Findings When Comparing Duodenal Switch (DS) to Other Procedures Year of Study
References:  A, BCDE, F, R
*For simplicity, all acronyms and procedure names have been changed to a common name (i.e. LAGB and Laparoscopic Adjustable Gastric Banding were changed to Lap Band Surgery).
The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries.F 2011
Laparoscopic Gastric Bypass Surgery vs Duodenal Switch (DS)
The DS/BD is a robust procedure that engenders both superior weight loss and improvement of major comorbidities. Complication and adverse event rates are similar to those of RYGB.R 2012
Compared with gastric bypass, DS may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery.A  (Editor's note: See our Bariatric Vitamins page for more.) 2009
Although DS is associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass.B 2008
Despite an excessive rate of complications that were, in part, related to the learning curve in this series, DS resulted in greater weight loss compared with gastric bypass. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.C 2007
Direct comparison of DS to gastric bypass demonstrates superior weight loss outcomes for DS. Importantly, the likelihood of successful weight loss (excess weight loss >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%).D 2006
Lap Band Surgery vs Duodenal Switch (DS)
DS results in significantly greater weight loss than lap band surgery in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open DS.E 2004

For further comparison of duodenal switch surgery to other procedures, see our Types of Bariatric Surgery page.

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Results of Duodenal Switch Surgery

The studies above directly compared DS with other procedures.  The following two studies independently evaluated DS and also found it to be effective: 

Study Topic Summary of Findings Year
References:  FG
*For simplicity, all acronyms and procedure names have been changed to a common name (i.e. Longitudinal Gastrectomy and Duodenal Switch was changed to duodenal switch).
Duodenal switch feasibility study.F Two-step duodenal switch is feasible, safe, and effective. It leads to substantial weight loss and improvement in comorbidities over the short term for superobese individuals. 2008
Duodenal switch operation as treatment for morbid obesity.G The duodenal switch is a safe and effective primary procedure for the treatment of morbid obesity. It has the advantage of allowing acceptable alimentation with a minimum of side effects while producing and maintaining significant weight loss. These results are achieved without developing significant dietary restrictions or clinical metabolic or nutritional complications. 2003

So far we’ve shown that the duodenal switch is one of the best – if not the best – surgery for improving obesity related health problems, especially...

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  • Diabetes
  • Hypercholesterolemia (high blood cholesterol)
  • Hyperlipidemia (elevation of fats in the bloodstream)
  • Hypertension (high blood pressure)
  • Hypertriglyceridemia (high blood triglycerides)
  • Sleep apnea

But how much weight can you expect to lose?

In the first year following surgery, percent of excess weight lost following DS surgery is between 48% and 65%.  Over the long-term, patients lose as much as 75% of their excess weight.

Following are summaries of 5 studies that evaluated the percentage of excess weight lost following DS surgery (click here to jump past the chart)...

Studies # of DS patients in study Weight Loss (% of Excess Weight Lost at…) Year
References:  I, J, K, L, Q
Study Q 216 (5 year data); 210 (10 year data) 18 months - 91%

5 years - 91%

10 years - 75% (not yet published)
2010 (5 year); 2011 (10 year)
Study I 15 1 month – 48%

3 months – 57.6%

6 months – 64.6% 
2008
Study J 198 1 year – 64.1%

18 months - 71.9%

2 years – 71.6%

3 years – 68.9%
2006
Study K 23 2 years – 64.4% 2004
Study L 3,030 70.1% average for DS (DS studies ranged from 66.3% - 73.9%) 2004

As mentioned previously and reviewed in more detail below, all of these health and weight loss benefits come with trade-offs compared with other types of weight loss surgery.

Hear It Straight from the Source... For Free

Most surgeons offer free seminars that teach you about your options and their office's specific results. The seminars also allow you to get to know the surgeon prior to a one-on-one consultation (usually free as well).

Click here to find and schedule a free in-person seminar or one-on-one consultation with a qualified weight loss surgeon in your area.

Otherwise, continue below for the rest of the DS details, including risks, details about the procedure, recovery, life after surgery and cost.

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Duodenal Switch Complications & Risks

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Complicated procedures by nature have higher complication rates, and the duodenal switch is no exception.

The DS procedure, which is a combination/alteration of several other techniques, is more complicated than most other types of bariatric surgery.  While it results in more weight loss and greater improvement in comorbidities, the DS’s complexity is linked to higher complication rates.

Older studies indicated a higher risk of death (mortality rate), but a more recent study of 1,000 consecutive DS patients suggests that the DS mortality rate is on par with other bariatric surgeries (0.135% average mortality rate for all bariatric procedures):

Studies # of DS patients in study DS Mortality/ Complication Rate Year
References:  MN, O, P
Study Q 1,000 Mortality - 0.1% postoperative (30-day)
Major Complications - 7%
2011
Study M 15 Mortality - 0%
Complications - 6.7%
2008
Study N 190 Mortality - 0%

Serious complications: 6.7% (BMI less than 50) 12% (BMI equal to or greater than 50)

Overall complications: 14.4% (BMI less than 50) 24% (BMI equal to or greater than 50)
2008
Study O 198 Mortality - 0.5% 2006
Study P 3,030 Mortality - 1.1% 2004

As with other types of bariatric surgery, the complication rates rise with a higher BMI.  But the 6.7% to 7% rate of serious/major complications for patients with a body mass index under 50 is higher than other procedures.

The more serious and/or impactful complications related to the DS include…

A 2007 analysis compiled duodenal switch patient data from 1992 through 2002 and found that 5% of DS patients have their surgery reversed.5

It is important to recognize that in many cases, the patient is completely to blame for complications. Properly educating yourself prior to surgery and following the advice of your doctor and dietitian are both essential steps towards lowering your post surgery risks.

See our Bariatric Surgery Complications page to learn what’s necessary to succeed over the long run. The best bariatric doctors follow these guidelines, but unfortunately there are many doctors that do not… so it’s up to you to get the advice you need.

When deciding whether the complication and mortality risks associated with surgery are “worth it”, it’s smart to evaluate the risks associated with not having surgery. 

See our Life After Weight Loss Surgery, Obesity Health Problems and Cause and Effect of Obesity pages for more on this.

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Procedure - Duodenal Switch

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This 3 1/2 to 4 hour procedure could be classified as a Gastric Bypass/Gastric Sleeve combination with a twist. It is one of the most difficult and complex procedures to perform, but it’s also associated with some of the best results. And while it is still sometimes performed as an open surgery, it is routinely performed laparoscopically.

First we will explain it in writing, then we’ll help you better understand it with 3 different videos…

Imagine your digestive system as a series of pipes that food and digestive juices must pass through. Before surgery, food is swallowed and goes down a tube (the esophagus) to your stomach. From your stomach it passes through a small chamber called the duodenum, then through your 11 to 40 feet of small intestines (the small intestine length can vary from person to person by almost 30 feet!). 

While in your small intestines, your food is mixed with digestive juices that break it down to help your body absorb nutrients. The food and digestive juices then pass into the large intestines (colon) and out of your body.

With the duodenal switch…

  1. A large portion of the stomach is removed to create a cylinder-shaped pouch connecting the esophagus to the top of the small intestine.
  2. The top of the small intestine is cut, but the surgeon leaves part of the duodenum (the top part of the small intestine where most chemical digestion occurs) attached to the stomach.
  3. The surgeon then cuts the small intestine several feet up from the end where it meets the large intestine/colon. The part that is still attached to the large intestine (colon) is connected to the duodenum.
  4. The loose part of the small intestine (the part that was not just attached to the stomach) is then attached to the small intestine, allowing the digestive juices it creates to mix with the food coming from the stomach in roughly the last 15 - 20% of the small intestine.

Since the stomach is shrunk and only a small portion of the intestine has a chance to digest food before the food enters the colon, this procedure is both restrictive and malabsorptive.

The DS is effective both from the restrictive component AND the malabsorptive component. In fact, most of the early weight loss comes from the restriction and the long term weight loss maintenance (lack of weight regain) is from the malabsorption.

Following are two computer animated videos. Both show the DS procedure but each explains it in a slightly different way. Watching the animations one after the other will help you to better understand the process (click here to skip past all 3 videos or here to jump to a video of the actual procedure being performed)…

Computer Animated Video 1

Computer Animated Video 2

Video of Actual DS Procedure

Following is a video of the actual DS surgery being performed along with commentary from the surgeon (click here to skip past it)…

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Recovery from Duodenal Switch

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Patients are usually kept in the hospital for two to three days following surgery to make sure their new digestive system is working properly. Your surgeon will make sure that there are no staple leaks in your altered stomach prior to releasing you.

Your surgeon will want to see you for a follow up visit 4 weeks after surgery and every three months for the first year, then semi-annually after that. If you experience any issues, you will obviously need to be seen more frequently.

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Life After Duodenal Switch Surgery

The duodenal switch (along with gastric bypass) has an initial 12 to 18 month “honeymoon period” following surgery. During this time, patients usually experience a rapid and significant amount of weight loss.

The "extened honeymoon period" with the DS can last three to five years during which time patients will typically not experience weight regain.

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Do not let yourself veer off-course during this time. The pounds may continue to come off and stay off regardless of what you eat or whether you exercise, but eventually bad behavior will catch up with you. In addition to giving you problems such as malnutrition and other complications, getting away from your diet and exercise plan could prevent you from reaching your long-term goal weight.

As with other weight loss surgeries, life after duodenal switch surgery will be much different than it is now.

Our Life After Weight Loss Surgery page explains the changes patients experience for all types of bariatric surgery. Following are the changes specific to your life after duodenal switch surgery…

  • Diet – as mentioned above, due to the extent of malabsorption after surgery you will need to take 10 to 15 pills per day for the rest of your life. If you stop taking any prescribed vitamins, you will be twice as likely to develop vitamin deficiency.6

    To the average person, not getting enough vitamins doesn’t sound like a big deal. But when you change the architecture of your digestive system to the extent of the duodenal switch, it can become a life-threatening problem as our Bariatric Vitamins page explains.

    Your surgeon will most likely prescribe the following supplements after surgery…
    • Multi-vitamin/mineral supplement
    • Additional calcium
    • Additional iron
    • Fat soluble vitamins (A, D, E, and K) in a 'dry' form
    • Probiotics (beneficial bacterium found in the intestinal tract)

    Routine blood tests and follow ups with your doctor are essential to make sure your body is getting enough supplements. You’ll often be asked to meet with a nutritionist or dietitian around the same time as your check-ups with your doctor.

    See our Bariatric Diet section for more about your eating habits following surgery.
  • Difficulty swallowing – this could be an issue with any restrictive procedure as the food will have smaller digestive openings to pass through following surgery. Difficulty swallowing is caused by eating too much, eating too quickly or not chewing food well enough and can usually be taken care of by addressing these issues. (See our Bariatric Eating page to learn about proper eating techniques that will avoid problems.)
  • Bowel movements – bowel movement changes are more common with the DS than with other types of surgery... 
    • Frequency - On average, DS patients will have 2 to 3 bowel movements per day, but some patients have reported having up to 10 or even 20 per day.
    • Diarrhea or loose stools
    • Foul-smelling stools or flatulence
    • Constipation is possible but rare after DS surgery
    Bowel movements can usually be improved with an appropriate bariatric diet and by avoiding so-called “trigger foods”. Bowel movement problems could also be the result of lactose intolerance (not caused by bariatric surgery – simply went unnoticed prior to surgery) in which case you would need to avoid dairy products. 

Again, see our Life After Weight Loss Surgery page for other changes to expect.

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Duodenal Switch Cost

Depending on the location and experience of your surgeon, duodenal switch surgery can cost anywhere from $20,000 to $30,000 in the United States assuming there are no complications.

You should also be prepared to pay $1,500 or more per year on bariatric vitamins and supplements.

However, patients typically have far fewer medication costs after the DS than before because it is so effective in eliminating the comorbididties.  You'll need water soluble vitamens and mineral supplements after the DS, but the costs are typically a fraction of pre-surgery medication costs.

See one of the following pages for more information…

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Bariatric doctors specializing in Duodenal Switch (DS) surgery

DS may be the most complicated and technically demanding form of bariatric surgery. As reviewed in the Procedure section above, your digestive system is significantly altered during surgery. This leads to an increased risk of leakage and infection, among other complications.

Duodenal switch surgery can be especially appropriate and effective for the super-obese, but its higher complication rate coupled with a super-obese patient’s increased risk for complications demand careful consideration.

As with all bariatric procedures, you should find an experienced surgeon with a proven track record.

See our Bariatric Doctors page to learn how to interview and choose the best surgeon.

If you're ready to attend a free local seminar or schedule a free one-on-one consultation with a surgeon, click here to find a qualified surgeon in your area.

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References

  1. Prachand VN, et al. Duodenal Switch Provides Superior Weight Loss in the Super-Obese (BMI ≥50kg/m2) Compared With Gastric Bypass. Ann Surg. 2006 October; 244(4): 611–619.
  2. Henry Buchwald; Yoav Avidor; Eugene Braunwald; Michael D. Jensen; Walter Pories; Kyle Fahrbach; Karen Schoelles Bariatric Surgery: A Systematic Review and Meta-analysis JAMA. 2004;292(14):1724-1737.
  3. Gianfranco A, et al. Long-Term Effect of Biliopancreatic Diversion on Blood Pressure in Hypertensive Obese Patients.  Am Journ Hypertens 2005/06 (18):780-784.  
  4. Cossu ML, et al. Duodenal Switch without Gastric Resection: Results and Observations after 6 Years.  Obes Surg 2004 (14): 1354-1359.
  5. Hamoui N, Chock B, Anthone GJ. Revision of the Duodenal Switch: Indications, Technique, and Outcomes. J Am Coll Surg. Vol. 204, 603 - 608, 2007
  6. American Society for Metabolic and Bariatric Surgery. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. March 2008. Available at: http://www.asmbs.org/Newsite07/resources/bgs_final.pdf. Accessed: Sept 14, 2009.

[Last editorial review/modification of this page: 6/10/2013]

Disclaimer: The information contained in this web site is provided for general informational purposes only. It is not intended as nor should be relied upon as medical advice. Rather, it is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician(s). Before you use any of the information provided in the site, you should seek the advice of a qualified medical, dietary, fitness or other appropriate professional. Read More