Laparoscopic sleeve gastrectomy with duodenal switch surgery is being performed for many years in the western countries.
As per the IFSO-APC guidelines, if your BMI is more than 37.5 Kg/m2 (BMI- weight in kg/height in m2), you can undergo a bariatric surgery in the absence of any associated illnesses. You can also undergo bariatric surgery if your BMI is ≥ 32.5 Kg/m2 and you have 2 or more obesity associated diseases like type 2 diabetes, high blood pressure, high cholesterol etc. As per the new DSS guidelines formed by a group of international diabetes federations in London, bariatric/metabolic surgery may also be considered as a treatment option for control of diabetes in patients with class I obesity (BMI- 27.5-32.5 Kg/m2) if their diabetes is poorly controlled.
Laparoscopic sleeve gastrectomy with duodenal switch surgery is a surgical procedure in which a sleeve of stomach is created using staplers. In this surgery, most of the small intestine is bypassed and the distal part of small intestine called the ileum is joined to the first part of duodenum. When food is consumed, it comes via the food pipe into the stomach sleeve and then directly enters the small intestine.
Laparoscopic sleeve gastrectomy with duodenal switch surgery leads to weight loss by a combination of multiple mechanisms. First of all, because reduced size of the stomach, you will not be able to eat too much and your intake will be restricted. Secondly, you will feel full even after eating small quantities and will feel satiated much earlier. Thirdly, “ghrelin” the hunger inducing hormone which is produced from the fundus of the stomach, does not come in contact with the food and hence the sensation of hunger is curbed to a large extent. Fourthly, as most of the small intestine is bypassed in laparoscopic sleeve gastrectomy with duodenal switch surgery, it leads to high degree of mal-absorption. In addition to this there are GI hormones that play a big role in weight loss as well as control of diabetes. There are also other factors like bile acids, gut microbiota and certain unknown factors that augment the effect of surgery.
Bariatric/metabolic surgery is the only proven method for sustained weight loss in people suffering from clinically severe obesity. Most bariatric procedures will lead to an excess weight loss to the tune of 65 to 75% over a period of 18 to 24 months. Duodenal switch surgery is a very mal-absorptive surgery and leads to better weight loss results. Unlike other bariatric procedures it may lead to an excess weight loss of up to 80 to 90%. This weight loss journey is a partnership between the doctor and the patient and the results depend on the level of commitment from either party. Duodenal switch surgery leads to a significant improvement in type 2 diabetes, high blood pressure, high cholesterol, gout, obstructive sleep apnoea, joint pains, venous thrombo-embolism, PCOD, infertility and many other diseases related to obesity. Weight loss leads to a significant decrease in the risk for heart disease also. However, a laparoscopic duodenal switch surgery is an extremely mal-absorptive surgery and is nutritionally very demanding. A protein intake of 80 to 120 grams per day is mandatory after this surgery. The requirement for other nutritional supplements is also much higher as compared to other bariatric procedures. This procedure can have serious repercussions on your health if these nutritional needs are not met. Considering that the consumption of non-vegetarian food in India is not very high, this procedure is usually not recommended for Indian patients.
Laparoscopic duodenal switch surgery cost depends on disposable equipment being used in the forms of stapler guns, trocars, cartridges, energy sources etc. Duodenal switch surgery cost also depends on the number of days you need to stay in the hospital, type of room that you select as well as the hospital in which you get operated. The doctor will guide you about laparoscopic sleeve gastrectomy with duodenal switch surgery cost after assessing and evaluating all the above details.
Weight loss is a gradual process after this surgery. You will lose weight quite fast in the first 3 to 4 months after which, weight loss slows down. You will continue to lose weight for about 12 to 18 months after your surgery and can expect to lose about 80 – 90% of your excess weight.
It is important to note that bariatric/metabolic surgery is a tool that pushes you into a lifestyle change. While bariatric/metabolic surgery helps to lose massive amount of weight, it is also important to exercise every day and follow a healthy diet. Our experience shows that patients who embrace the lifestyle change along-with surgery, tend to do much better in terms of weight loss and weight maintenance.
This surgery is known to lead to improvement in type 2 diabetes. It has been observed that a lot of patients do not need to go back on their anti-diabetic medications after the surgery. For those who need to continue medications, the dose is reduced considerably and a lot of times patients who have been on insulin may not require it post-operatively. The outcomes of diabetes remission depend on a lot of factors like the duration of diabetes, type of diabetes (type 1/type 2), age of the patient, c-peptide levels, use of insulin etc. It also leads to improvement in other associated diseases like high blood pressure, high cholesterol, obstructive sleep apnoea, gout, joint diseases, PCOD, infertilty etc. The overall risk for heart disease goes down considerably due to significant weight loss and overall improvement in associated co-morbidities.
This surgery has been shown to lead to remission or improvement in obese diabetics. Most often their blood sugars come under control within a few months of surgery and a lot of times patients do not need to take medications.
If you are a diabetic but you are not overweight or obese, the chances are that this surgery may not help you for improvement of diabetes. The latest DSS guidelines recommend metabolic surgery for patients with a BMI greater than 27.5 kg/m2 if their diabetes is uncontrolled despite best medical management. Presently, there is no evidence to recommend bariatric/metabolic surgery to a diabetic patient with a BMI less than 27.5 kg/m2.
Once you see the doctor, you will need to undergo investigations and medical checks for fitness. Additionally, you may need to see a chest physician, an endocrinologist, a nephrologist or a cardiologist, based on your clinical profile. You will also need to be on a high protein liquid diet for about 5 to 7 days prior to surgery. We would want you to lose atleast 3 to 5 kg before you undergo any bariatric/metabolic surgery. This also helps to reduce the swelling on the liver, and makes surgery easier for the surgeon and in turn, safer for you. In a way, it is also a test of your compliance for long term follow up. It has been seen that patients who follow the pre-operative diet well, tend to get better results after any bariatric/metabolic surgery.
You will be admitted to the hospital one day before the surgery or in special cases as per the advice of the doctor. The surgery typically takes about 120 – 150 minutes to perform depending on the grade of difficulty. You are encouraged to walk within 4 to 6 hours of surgery. Most patients get discharged the next day, of course it will depend on your clinical condition and the doctor’s decision.
Follow up is the most important part of any bariatric/metabolic surgery. You will need to see Dr. Aparna Govil Bhasker 7 days after your surgery. After this in the first year, you need to do your tests and visit at 3 months, 6 months and at the end of 1 year. Post 1 year, all patients need to get investigated once a year and visit the centre for a check up. Life long follow up is advised after all bariatric/metabolic surgeries.
After the surgery you will be on liquid diet for 15 days followed by soft diet for the next 15 days. You can commence normal home food after a month of surgery but it will be restricted in quantity. This surgery is very nutritionally demanding and the patient must ensure to take atleast 80 to 120 grams of protein every day. Patient also need to be on iron, vitamin and calcium supplementation. As there is a very high degree of mal-absorption after this surgery, failure to comply with supplementation can have grave consequences. For this reason, this surgery is not routinely recommended for Indian patients as majority is unable to cope up with the nutritional protocol which is for life.
After any bariatric/metabolic surgery, you need to be on nutritional supplements. There are two reasons for that. Firstly, your intake will reduce considerably and secondly after a laparoscopic sleeve gastrectomy with duodenal switch surgery you will not absorb most of the nutrients due to its high mal-absorptive component. You may also need to be on other medications as advised by the doctor based on your clinical profile.
This is a safe surgery in good hands. Although it is more difficult to perform as compared to other bariatric procedures, its complication rates are much lower when compared to other major surgeries like cardiac bypass or surgery of the food-pipe or many other cancer surgeries. Apart from the immediate complications, it is the long term nutritional deficiencies and liver related complications that are worrisome after this surgery. It is best if the doctor discusses this in person with you during your consultation.
Smoking is a contra-indication for laparoscopic duodenal switch surgery. If you are a smoker, you need to give up smoking completely atleast 15 days prior to undergoing surgery. If you are not confident about being able to stop smoking altogether, then our advice is that you must not undergo bariatric surgery, in order to avoid serious complications in future.
Long term weight maintenance after duodenal switch surgery is better than most other bariatric procedures owing to high degree of mal-absorption that is produced. However, it is imperative to exercise and bear moderation in diet after the surgery.
If you have acid reflux (GERD) or hiatus hernia you must not undergo this procedure. In that case a Roux-en y gastric bypass will be a better procedure for weight loss. More importantly, if you feel that you will not be able to cope up with the protein and other nutritional supplementation after this surgery then you must not undergo this surgery. Supplementation is life long and inability to comply can land you in deep trouble.
Cost of duodenal switch surgery will depend on a host of factors like the duration of surgery and your stay in the hospital, type of room selected, equipment used etc. The cost of laparoscopic duodenal switch with sleeve gastrectomy surgery is almost the same as any other bariatric surgery.