Abstract
Background.
Despite providing superb excess weight loss and increased resolution of comorbid diseases, such as type 2 diabetes mellitus, compared to other bariatric procedures, the duodenal switch/biliopancreatic diversion (DS/BD) has not gained widespread acceptance among patients and physicians. In this study, we investigated outcomes, symptoms and complications among postsurgical DS patients compared to RYGB patients.
Methods.
We used propensity scores to retrospectively match patients who underwent DS/BD between 2005 and 2010 to comparable Roux-en-Y gastric bypass (RYGB) patients. We then reviewed patient charts, and surveyed patients using the University of Minnesota Bariatric Surgery Outcomes Survey tool to track outcomes, comorbid illnesses and complications.
Results.
One hundred ninety consecutive patients underwent primary DS/BD between 2005 and 2010 at the University of Minnesota Medical Center. There were 178 patients available for follow-up (93.7%) who were matched to 139 RYGB patients. Type 2 diabetes, hypertension, and hyperlipidemia all significantly improved in each group. Improvements were significantly higher in the DS/BD group. Percent total weight loss was not different between groups. Loose stools and bloating symptoms were more frequently reported among DS/BD patients. With the exception of increased emergency department visits among DS/BD patients (P < .01), overall complication rates were not significantly different between DS/BD and RYGB. There was no difference in mortality rates between the groups.
Conclusion.
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. (Surgery 2012;152:758–67.)
Compared to other bariatric procedures, duodenal switch/biliopancreatic diversion (DS/BD) results in the greatest sustained weight loss1,2 as well as the greatest improvement in comorbid conditions, such as type 2 diabetes mellitus (T2DM) and hypertension.1,3,4 Conversely, Roux-en-Y gastric bypass (RYGB) is associated with poor sustained weight loss and complications associated with marginal ulceration and post-RYGB hypoglycemia. Effective long-term benefits have also not been convincingly demonstrated for laparoscopic adjustable gastric banding and vertical sleeve gastrectomy. With the multiple reported advantages of the DS/BD, some have argued that it should become the criterion standard operation within the bariatric surgery field.5 However, as with all surgical procedures the DS/BD carries risks. Specifically these include nutritional deficiencies and gastrointestinal symptoms leading some physicians to believe that the DS/BD no longer be performed.6
When the biliopancreatic diversion with distal gastrectomy and gastroileostomy evolved to a sleeve gastrectomy with DS/BD and the length of the common channel was increased to 100 cm (from 50 cm), there were marked improvements in both patient symptoms and quality of life.7 While there are several excellent studies assessing the long-term outcomes after DS/BD,5,8 few studies have focused on adverse outcomes and symptoms that can affect daily life beyond the first 30 days.
In this study, we sought to quantify both long-term adverse events and daily symptoms that patients experience after the DS/BD through a survey. To compare, we surveyed a group of matched RYGB patients. These data provide an excellent source of information for both patients and surgeons when designing patient specific algorithms for the treatment of morbid obesity and its associated comorbidities.
METHODS
Patients.
All patients who underwent primary DS/BD between 2005 and 2010 at the University of Minnesota Medical Center were identified and matched to RYGB patients operated on between 2002 and 2008 from the University of Minnesota Bariatric Surgery Database. Duodenal switch patients were matched to RYGB patients using propensity score methods. Patients were surveyed prospectively with the University of Minnesota Bariatric Surgery Outcomes Survey (UMBSOS) tool during a clinic visit, via online survey, telephone, or by mail. This study was approved by the University of Minnesota Institutional Review Board (study 0510M76107).
Operations.
RYGB was performed as described previously.9 Briefly, a 15- to 30-mL gastric pouch was constructed with a 10–12 mm gastrojejunal anastomosis. The Roux limb measured 75–150 cm in length, and the biliopancreatic limbs measured 75–100 cm in length. Bougie size selection varies by surgeon and surgical approach; this varies between 24 and 48 French. For the DS/BD, a gastric tube was constructed using a Bougie as a template and was configured to be approximately 100 mL in volume. The common channel was 75–125 cm in length as described previously.10
Survey.
The UMBSOS was developed by the division of gastrointestinal surgery at the University of Minnesota. The survey was designed to collect data from bariatric surgery patients that would normally be obtained at standard, postoperative clinic visits. For patients with poor in-clinic follow-up because of relocation, financial and insurance limitations, or noncompliance, the instrument measures many of the outcomes we use to track patient progress over time.
The survey collected information on comorbidities, current weight, vitamin supplementation, social history, adverse events, complications, symptoms, reoperations, appropriate follow-up for laboratory assessment, and additional patient concerns that warrant discussion with a bariatric surgeon or nurse. All information regarding weight, comorbidities, adverse events, complications, and medication use was confirmed with the electronic medical record when possible. Survey data were entered into the University of Minnesota Bariatric Surgery Database.
Propensity score matching.
We used propensity score matching methods to create exchangeable groups for analysis. First, we generated a propensity score for the likelihood of undergoing DS/BD or RYGB based on a multivariable logistic model that described the association between preoperative patient characteristics and operative procedure. We propensity score–matched based on patient age, sex, body mass index (BMI), and the associated quadratic and interaction terms; this approach generated 2 groups that were comparable with regard to these characteristics. Specifically, we used the nearest neighbor method in ps2match in Stata software (version 12; StataCorp, LP, College Station, TX). Although we matched 1 DS/BD patient to 3 RYGB patients, the actual DS/BD to RYGB ratio among study cases varied between 1:1 and 1:3.
Analysis.
Descriptive statistics for the 2 groups were generated. For continuous measures, we used the arithmetic mean as the measure of central tendency unless the distribution was highly skewed. In this latter case the natural log of the variable was taken and used for generating the geometric mean and the associated t tests. For categorical variables, we generated proportions or percentages and used chi square tests, or when there were <5 observations in a cell, the Fisher exact test. Confidence intervals for some binary variables were constructed using the binomial distribution. Results were considered significant at an alpha of 0.05. All calculations were completed using Stata software (StataCorp LP).
Measures.
Total weight change percentage was calculated as [((consultation weight) − (weight at time t))/(consultation weight)] × −100%.
RESULTS
Patient populations.
One hundred seventy-three of 190 DS/BD patients were surveyed, with an overall follow-up of 93.7%. The mean follow-up was 3.7 ± 1.6 years in the DS/BD and 6.2 ± 1.8 years in the RYGB groups, respectively. Through propensity scoring, these patients were matched to 139 RYGB patients. Despite matching, RYGB patients were older (mean ± SD) than DS/BD patients (48.2 ± 10.8 years vs 45.2 ± 11.3 years; P = .01; Table I). There were no differences in BMI (P = .12) or the preoperative prevalence of comorbid diseases, such as T2DM (P = .36), hypertension (P = .83), and hyperlipidemia (P = .08). While 64% of DS procedures used an open approach, only 18% of RYGB procedures were similarly performed.
Table I.
Demographics and comorbid disease
| DS/BD (N = 173*) | RYGB (N = 136†) | P value | |
|---|---|---|---|
| Age (yrs; mean ± SD) | 45.2 ± 11.3 | 48.2 ± 10.8 | .01 |
| Female (%) | 78.0 | 78.7 | .89 |
| Preoperative BMI (kg/m2; mean ± SD)‡ | 51.6 ± 9.4 | 50.0 ± 9.1 | .12 |
| Duration of follow-up (yrs; mean ± SD) | 3.7 ± 1.6 | 6.2 ± 1.8 | <.05 |
| % Open (n) | 63.6 (110) | 17.6 (24) | <.01 |
| % Type 2 diabetes (n) | 35.8 (62) | 30.9 (42) | .36 |
| % Hypertension (n) | 57.8 (100) | 56.6 (77) | .83 |
| % Hyperlipidemia (n) | 54.3 (94) | 44.1 (60) | .08 |
| % GERD (n) | 43.9 (76) | 31.6 (43) | .03 |
One hundred seventy-eight total DS/BD patients accounted for, with 5 deaths.
One hundred thirty-nine total RYGB patients accounted for, with 3 deaths.
t test performed based on the geometric natural log of the means.
BMI, Body mass index; DS/BD, duodenal switch/biliopancreatic diversion; GERD, gastroesophageal reflux disease; RYGB, Roux-en-Y gastric bypass; SD, standard deviation.
Prevalence of comorbid disease.
Regarding T2DM, 36% and 31% of DS/BD and RYGB patients had the diagnosis before operation, respectively. At the time of survey, 82% of DS/BD patients diagnosed with T2DM before surgery self-reported resolution of their disease compared to 64% of RYGB patients (Fig 1, A). Hypertension was self-reported as resolved in 67% of DS/BD patients compared to 39% of RYGB patients (Fig 1, B). Resolution rates of hyperlipidemia were 81% and 55% among DS/BD and RYGB patients, respectively (Fig 1, C). Finally, gastroesophageal reflux disease was reported as having been resolved postoperatively in 53% and 77% of DS/BD and RYGB patients who reported having the disease before bariatric surgery, respectively (Fig 1, D).
Fig 1.
Comorbid disease after either duodenal switch/biliopancreatic diversion (DS/BD) or Roux-en-Y gastric bypass. (A) Type 2 diabetes mellitus, (B) hypertension, (C) hyperlipidemia, and (D) gastroesophageal reflux disease. Data are represented as mean ± 95% confidence intervals. Never indicates that the patients did not have the disease before or after bariatric surgery, resolved indicates the patients reported they had the disease preoperatively but no longer do, persistent indicates the presence of the disease both pre- and postoperatively; and new indicates development of the disease only after bariatric surgery. All survey claims regarding preoperative diagnoses were confirmed using the patients’ health record. DS, Duodenal switch; GERD, gastroesophageal reflux disease; RY, Roux-en-Y gastric bypass.
Vitamins.
There was no statistically significant differences between the 2 cohorts with respect to daily use of calcium, calcium plus vitamin D, iron, or a multivitamin (Table II). Daily use of vitamin ADEK was greater amongst DS/BD patients (58% vs 10%; P < .01), while daily use of vitamin B12 was greater among RYGB patients (35% vs 71%; P < .01).
Table II.
Vitamin and mineral supplementation
| Percent daily use per group, n | |||
|---|---|---|---|
| Vitamin/mineral | DS/BD (N =173) | RYGB (N = 136) | P value |
| Calcium alone | 40.5 (64) | 39.2 (49) | .82 |
| Calcium plus vitamin D | 53.7 (87) | 48.4 (62) | .37 |
| Iron | 39.9 (63) | 34.7 (44) | .36 |
| Multivitamin | 72.4 (118) | 76.3 (100) | .44 |
| Vitamin ADEK | 58.4 (94) | 10.3 (13) | <.001 |
| Vitamin B12* | 35.0 (56) | 71.3 (92) | <.001 |
Vitamin B12 supplementation was considered “daily” when the patient administered monthly injections.
Percentage of patients within each cohort taking vitamin and mineral supplements are shown.
DS/BD, Duodenal switch/biliopancreatic diversion; RYGB, Roux-en-Y gastric bypass.
Weight loss.
Percent total weight change was significantly greater among DS/BD patients at 42 and 48 months postoperatively; however, no significant difference exists at other time points (Fig 2). Similarly, there was no significant difference between DS/BD and RYGB cohorts with respect to preoperative BMI or BMI at time of survey (Fig 3).
Fig 2.
Percent total weight change of duodenal switch and Roux-en-Y gastric bypass patients over time. Data are presented as mean total body percent weight loss ±95% confidence intervals. Overlapping confidence intervals indicate no significant difference. Total percent weight changes was calculated as [((consultation weight) − (weight at time of survey))/(consultation weight)] × −100%. Each patient is represented only once at the time of survey completion.
Fig 3.
Body mass index (BMI) at the time of surgery and survey. Data are represented as mean BMI (kg/m2). There was no significant difference between groups at baseline or at the time of survey. Follow-up times differ for BMI collected at time of survey. BMI, Body mass index; DS, duodenal switch; RY, Roux-en-Y gastric bypass.
Adverse symptoms.
Among DS/BD patients,27.7% (n = 47) experience nausea on a monthly to daily basis compared to 30.9% (n = 42) of RYGB patients (Table III); 11.1% (n = 19) of DS/BD patients noted daily nausea compared to 4.4% (n = 6) of RYGB patients. Between the two groups there was no significant difference (P = .81) in the distribution of reported emesis with 3.9% (n = 7) and 2.2% (n = 3) of DS/BD and RYGB patients experiencing daily symptoms, respectively.
Table III.
Adverse symptoms
| Percent experiencing symptom (n) | |||
|---|---|---|---|
| Symptom | DS/BD (N = 173) | RYGB (N = 136) | P value |
| Nausea | .08 | ||
| Never | 56.7 (98) | 50.7 (69) | |
| Yearly | 15.6 (27) | 17.9 (24) | |
| Monthly | 8.3 (14) | 15.7 (21) | |
| Weekly | 8.3 (14) | 10.8 (15) | |
| Daily | 11.1 (19) | 4.4 (6) | |
| Vomiting | .82 | ||
| Never | 57.2 (99) | 57.5 (78) | |
| Yearly | 20.6 (36) | 17.2 (23) | |
| Monthly | 9.4 (16) | 13.4 (18) | |
| Weekly | 8.9 (15) | 10.0 (14) | |
| Daily | 3.9 (7) | 2.2 (3) | |
| Constipation | .003 | ||
| Never | 69.6 (120) | 53.4 (73) | |
| Yearly | 19.3 (33) | 15.8 (21) | |
| Monthly | 5.5 (9) | 14.3 (19) | |
| Weekly | 4.4 (8) | 14.3 (19) | |
| Daily | 1.1 (2) | 2.2 (3) | |
| Loose stools | <.001 | ||
| Never | 13.8 (24) | 40.3 (55) | |
| Yearly | 6.3 (11) | 13.4 (18) | |
| Monthly | 4.6 (8) | 9.7 (13) | |
| Weekly | 21.6 (37) | 21.6 (29) | |
| Daily | 58.6 (101) | 14.9 (20) | |
| Bloating | <.001 | ||
| Never | 32.6 (56) | 59.1 (80) | |
| Yearly | 6.1 (10) | 11.4 (15) | |
| Monthly | 7.7 (13) | 9.8 (13) | |
| Weekly | 22.1 (38) | 15.2 (21) | |
| Daily | 31.5 (54) | 4.5 (6) | |
| Heartburn | .03 | ||
| Never | 51.9 (90) | 70.7 (96) | |
| Yearly | 11.0 (19) | 9.8 (13) | |
| Monthly | 9.9 (17) | 6.0 (8) | |
| Weekly | 21.5 (37) | 7.5 (10) | |
| Daily | 14.9 (26) | 6.0 (8) | |
DS/BD, Duodenal switch/biliopancreatic diversion; RYGB, Roux-en-Y gastric bypass.
Constipation symptoms were more prevalent among RYGB patients (P < .01), while loose stools were significantly more prevalent among DS/BD patients compared to RYGB with 59% (n = 101) and 15% (n = 20) complaining of daily symptoms, respectively (P < .01).
Sensations of bloating were more common among DS/BD patients with 54.6% (n = 92) of patients reporting weekly or daily symptoms compared to 19.7% (n = 27) of RYGB patients (P < .01). Finally, heartburn symptoms were less common among RYGB patients with 71% (n = 96) and 52% (n = 90) never reporting any symptoms, respectively (P < .05). Daily heartburn symptoms were reported by 15% (n = 26) of DS/BD patients and 6% (n = 8) of RYGB patients.
Complications and mortality.
Patient visits to emergency departments that did not result in an admission were greater among DS/BD patients compared to RYGB patients (40% vs 25%; P < .01; Table IV). Reoperations and readmission rates were similar between the 2 groups. Gastrointestinal leaks occurred in 3 DS/BD patients and in no RYGB patients, but this study was not powered to detect a difference of this size. The use of supplementary nutrition either via parenteral or enteral routes for DS/BD patients approached significance (P = .08). Similarly, infusion therapy for dehydration was equivocal. Patients undergoing DS/BD were more likely to report symptoms of hair loss (67% vs 41%; P < .01) and to require pancreatic enzyme supplementation (11% vs 0.7%; P < .01); a greater percentage of RYGB patients underwent upper endoscopy compared to DS/BD patients (22% vs 13%; P = .06). Overall, the percentage of patients experiencing a surveyed complication (excluding pancreatic enzyme supplementation and hair loss) was greater among DS/BD patients (59% vs 49%; P = .07).
Table IV.
Complications, adverse events, and mortality
| Complication | DS/BD (N = 173), % (n) | RYGB (N = 136), % (n) | P value |
|---|---|---|---|
| Gastrointestinal leak* | 1.7 (3) | 0 (0) | .26 |
| ED visit | 40.1 (69) | 25.0 (34) | <.01 |
| Readmission | 25.4 (44) | 23.5 (32) | .70 |
| Abdominal reoperation* | 29.2 (51) | 23.0 (32) | .25 |
| Cholecystectomy | 18 | 17 | |
| Ventral hernia repair | 22 | 6 | |
| Small bowel obstruction | 6 | 0 | |
| Panniculectomy | 7 | 4 | |
| Revision | 0 | 1 | |
| Other | 3 | 5 | |
| TPN/tube feeds | 7.6 (13) | 2.9 (4) | .08 |
| Infusion therapy† | 28.5 (49) | 23.5 (32) | .33 |
| Diagnostic/therapeutic upper endoscopy | 13.9 (24) | 22.1 (30) | .06 |
| Pancreatic enzyme supplementation‡ | 10.5 (18) | 0.74 (1) | <.001 |
| Hair loss | 67.1 (112) | 40.9 (54) | <.01 |
| Total events§ | 59.0 (105) | 49.3 (67) | .07 |
| Mortality* | 2.8 (5) | 2.2 (3) | 1 |
Rates based on 178 DS/BD patients and 139 RYGB patients.
Outpatient infusion of intravenous fluids due to dehydration.
Pancrelipase (Creon [Abbot Laboratories, White Plain, NY] or Viokase [Aptalis, Birmingham, AL]).
Total number of patients experiencing any of the surveyed complications, excluding hair loss, enzyme supplementation, and mortality.
DS/BD, Duodenal switch/biliopancreatic diversion; ED, emergency department; RYGB, Roux-en-Y gastric bypass; TPN, total parenteral nutrition.
No mortalities occurred within 30 days for either procedure. The mortality rates up to follow-up were 2.8% (n = 5) and 2.2% (n = 3) for DS/BD and RYGB patients, respectively (Table IV). For DS/BD patients, deaths occurred at postoperative day 38 and months 5, 7, 16, and 66; for RYGB patients, deaths occurred at postoperative months 3, 7, and 72.
DISCUSSION
It is well established that bariatric surgery causes long-term weight loss1,2 and improves comorbid illnesses, such as T2DM1,3,11 and hyperlipidemia.4 Many operative techniques have come and gone over the years, including the jejunoileal bypass and vertical banded gastroplasty; these techniques have failed because of poor outcomes, adverse events, and, for the jejunoileal bypass, an unacceptable rate of morbidity and mortality. Currently, the safety profile of bariatric surgery is much improved with a 0.15% to a 0.3% 30-day mortality rate.12,13 However, there remain unanswered questions regarding bariatric surgery’s impact on long-term mortality14–16 and if the benefits of bariatric surgery outweigh the potential and real complications that can ensue. The purpose of this study was to address the latter of these 2 questions with particular focus on the DS/BD, which comprises approximately 1% of the bariatric operations performed at American Society for Metabolic and Bariatric Surgery Centers of Excellence.17
To date, 3 excellent studies have been published focusing on outcomes of the DS: a randomized, controlled trial investigating weight loss, a prospective comparator study investigating resolution of comorbid disease, and a large study without a comparison group investigating long-term outcomes including complications. The results of our study contribute to the current literature by focusing on long-term adverse symptoms, adverse events, and complications of the DS/BD with a matched comparison to the RYGB.
A recent Norwegian study has provided the best quality clinical data to date comparing weight loss and adverse events between the DS/BD and RYGB.18 Patients with a preoperative BMI between 50 and 60 kg/m2 were randomized to either DS (n = 29) or RYGB (n = 31) and then followed for 2 years. These investigators found that the overall adverse event rate was 32% for RYGB patients and 62% (P = .021) after DS/BD. This study was limited by the exclusion of patients <50 years of age and less experience among participating surgeons in performing the DS/BD operation. These findings were nonetheless concerning because of the much greater complication rate after DS/BD. In our case-matched study comparing RYGB to DS/BD, DS/BD patients were more likely to be read-mitted (14.8% vs 11.6%), and total complication rates were significantly greater among DS/BD patients (40.7% vs 15.1%) 1 year after surgery.3 The results of these 2 studies provide an impetus to further characterize the nature of complications experienced by DS/BD patients with comparison to a group of similar patients that undergo RYGB.
While the primary objective of this study was to focus on complications, we also investigated weight loss and comorbidity resolution. As with a previous study from our group and others,3,19 there was no significant difference in weight loss between the DS/BD and RYGB groups despite statistically similar BMIs at the time of operation. This finding is in marked contrast to previous studies.18,20 While every effort was made to confirm survey results with clinical data, results presented in this study could certainly be limited by the self-reporting of information that occurred in some instances. Despite comparable weight loss between groups, DS/BD patients had significantly greater improvement in T2DM, hypertension, and hyperlipidemia compared to RYGB patients. These results are not unexpected and have been reported in previous studies.4,21
Vitamin and mineral supplementation were similar between groups except for vitamin ADEK and vitamin B12. The more malabsorptive nature of the DS/BD dictates increased supplementation of fat soluble vitamins, as shown in previous randomized trials.22
Historically, when the length of the common channel was increased from 50 cm to 100 cm, there were marked improvements in patient symptoms after DS/BD, including fewer loose stools per day and less frequent vomiting.7 While many groups support the concept that DS/BD is associated with more frequent stools compared to RYGB,23 other previously published studies have indicated otherwise.24 The results presented here indicate a significant increase in the occurrence of loose stools, with 59% of DS/BD patients compared to 15% of RYGB patients reporting daily occurrence. In addition, bloating was also more common among DS/BD patients compared to RYGB with 31% vs 4% reporting daily symptoms, respectively. While not significant between groups, a concerning finding from this study were the many daily complaints of both nausea and vomiting in both patient cohorts (Table III).
The largest study to date examining long-term results after DS/BD was performed by Marceau and colleagues.8 They followed over 1,400 patients for an average of 7.3 years and found high resolution rates of comorbid disease accompanied with acceptable complication rates. Our study provides a matched comparison to a RYGB group and shows that overall complication and adverse event rates do not differ statistically between the 2 patient groups (Table IV). There was no difference in the rate of gastrointestinal leak, readmission, abdominal reoperation, or need for intravenous fluids to treat dehydration. Emergency department visits that did not result in readmission were greater among DS/BD patients, while the need for parenteral and enteral nutritional supplementation was greater among DS/BD patients but not significantly different from RYGB patients.
Overall, these results suggest comparable adverse event and complication rates between the DS/BD and RYGB with similar weight loss but superior improvement in comorbidity resolution among DS/BD patients. Should DS/BD therefore play a more prominent role in the treatment of morbid obesity and its comorbidities? Caution must be exercised because DS/BD has proven to be a much more malabsorptive necessitating more rigorous nutritional follow-up. Patients must be made aware of the high potential for daily symptoms of bloating and frequent, loose stools. Also, it must be iterated that the performance of bariatric operations, such as the RYGB and DS/BD, on high-risk patients may not impact long-term survival.16 Finally, a center with experience in performing this procedure at the surgeon level and a multidisciplinary team consisting of on-call providers, dieticians, and nursing staff trained in managing patients after DS/BD should be mandatory.
Our study has several limitations which constrain interpretation of the results. This study is limited by the self-reporting nature of the UMBSOS. While every effort was made to confirm survey results with patient records, this was not possible in all cases. Second, the increased use of the open approach in the DS/BD population may account for some of the increased complication rates. However, a recent study found no difference in open versus laparoscopic complications during the perioperative period when studying DS/BD patients alone.25 Third, this study was limited by different follow-up times between the 2 cohorts, with the RYGB follow-up being greater compared to the DS/BD group. The argument could be made that DS/BD patients experienced a similar complication rate over a shorter period of time, but longer-term follow-up of our DS/BD patients will be needed to compare complication rates among patients with similar follow-up. Fourth, laboratory values were not available in enough patients to report accurately on hypoglycemia and protein malnutrition. We are in the process of obtaining this information both from within our own clinic and the primary care providers of our patients who no longer live locally. Fifth, our study was not powered to detect a difference in all complication rates between patient groups. Lastly, quality of life was not determined in this study; this is an aspect we will add in future studies.
Our study has several strengths. First, >97% of the DS/BD operations were performed by surgeons with >10 years of experience with this procedure and even greater institutional experience with the RYGB. Therefore, complication rates were less likely to be confounded by surgeons with less experience. Also, the quality of matching performed in this study adds validity to the results, because we are comparing 2 very similar patient populations. Lastly, our follow-up rate is notably higher than many other similar studies because of the use of survey methodologies.
These results suggest that there may be similar rates of adverse events and complications between the 2 procedures and that the DS/BD may be a valid alternative to the RYGB, especially in the setting of comorbidities, such as T2DM and hyperlipidemia. Performance of this procedure, however, should be limited to surgeons and centers with experience in treating these types of patients, and patients should have clear understanding of anticipated symptoms before undergoing DS/BD.
Supplementary Material
Acknowledgments
Supported by research funds from the Department of Surgery, University of Minnesota.
Benjamin J.S. al-Haddad was supported by NIH MSTP grant T32 GM008244 and a Wetzel fellowship.
Footnotes
Presented at the 69th Annual Meeting of the Central Surgical Association, March 1–3, 2012, Madison, Wisconsin.
We would like to thank Nikki Voulgaropoulos for her assistance with collecting and entering survey data.
REFERENCES
- 1.Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009; 122:248–65. [DOI] [PubMed] [Google Scholar]
- 2.Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93. [DOI] [PubMed] [Google Scholar]
- 3.Dorman RB, Serrot FJ, Miller CJ, Slusarek BM, Sampson BK, Buchwald H, et al. Case-matched outcomes in bariatric surgery for treatment of type 2 diabetes in the morbidly obese patient. Ann Surg 2012;255:287–93. [DOI] [PubMed] [Google Scholar]
- 4.Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [DOI] [PubMed] [Google Scholar]
- 5.Hess DS, Hess DW, Oakley RS. The biliopancreatic diversion with the duodenal switch: results beyond 10 years. Obes Surg 2005;15:408–16. [DOI] [PubMed] [Google Scholar]
- 6.Livingston EH. Primum non nocere. Ann Intern Med 2011; 155:329–30. [DOI] [PubMed] [Google Scholar]
- 7.Marceau P, Hould FS, Simard S, Lebel S, Bourque RA, Potvin M, et al. Biliopancreatic diversion with duodenal switch. World J Surg 1998;22:947–54. [DOI] [PubMed] [Google Scholar]
- 8.Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, et al. Duodenal switch: long-term results. Obes Surg 2007;17:1421–30. [DOI] [PubMed] [Google Scholar]
- 9.Ikramuddin S, Kendrick ML, Kellogg TA, Sarr MG. Open and laparoscopic Roux-en-Y gastric bypass: our techniques. J Gastrointest Surg 2007;11:217–28. [DOI] [PubMed] [Google Scholar]
- 10.Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S. Duodenal switch operative mortality and morbidity are not impacted by body mass index. Ann Surg 2008;248:541–8. [DOI] [PubMed] [Google Scholar]
- 11.Leslie DB, Dorman RB, Serrot FJ, Swan TW, Kellogg TA, Torres-Villalobos G, et al. Efficacy of the Roux-en-Y gastric bypass compared to medically managed controls in meeting the American Diabetes Association composite end point goals for management of type 2 diabetes mellitus. Obes Surg 2012;22:367–74. [DOI] [PubMed] [Google Scholar]
- 12.Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361:445–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Dorman RB, Abraham AA, Al-Refaie WB, Parsons HM, Ikramuddin S, Habermann EB. Bariatric surgery outcomes in the elderly: an ACS NSQIP study. J Gastrointest Surg 2012;16:35–44. [DOI] [PubMed] [Google Scholar]
- 14.Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–52. [DOI] [PubMed] [Google Scholar]
- 15.Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–61. [DOI] [PubMed] [Google Scholar]
- 16.Maciejewski ML, Livingston EH, Smith VA, Kavee AL, Kahwati LC, Henderson WG, et al. Survival among high-risk patients after bariatric surgery. JAMA 2011;305:2419–26. [DOI] [PubMed] [Google Scholar]
- 17.DeMaria EJ, Pate V, Warthen M, Winegar DA. Baseline data from American Society for Metabolic and Bariatric Surgery-designated bariatric surgery centers of excellence using the bariatric outcomes longitudinal database. Surg Obes Relat Dis 2010;6:347–55. [DOI] [PubMed] [Google Scholar]
- 18.Søvik TT, Aasheim ET, Taha O, Engström M, Fagerland MW, Björkman S, et al. Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial. Ann Intern Med 2011;155:281–91. [DOI] [PubMed] [Google Scholar]
- 19.Deveney CW, MacCabee D, Marlink K, Welker K, Davis J, McConnell DB. Roux-en-Y divided gastric bypass results in the same weight loss as duodenal switch for morbid obesity. Am J Surg 2004;187:655–9. [DOI] [PubMed] [Google Scholar]
- 20.Prachand VN, Davee RT, Alverdy JC. Duodenal switch provides superior weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass. Ann Surg 2006; 244:611–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Prachand VN, Ward M, Alverdy JC. 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. J Gastrointest Surg 2010;14:211–20. [DOI] [PubMed] [Google Scholar]
- 22.Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr 2009;90:15–22. [DOI] [PubMed] [Google Scholar]
- 23.Laurenius A, Taha O, Maleckas A, Lonroth H, Olbers T. Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity-weight loss versus side effects. Surg Obes Relat Dis 2010;6: 408–14. [DOI] [PubMed] [Google Scholar]
- 24.Wasserberg N, Hamoui N, Petrone P, Crookes PF, Kaufman HS. Bowel habits after gastric bypass versus the duodenal switch operation. Obes Surg 2008;18:1563–6. [DOI] [PubMed] [Google Scholar]
- 25.Biertho L, Lebel S, Marceau S, Hould FS, Lescelleur O, Moustarah F, et al. Perioperative complications in a consecutive series of 1000 duodenal switches. Surg Obes Relat Dis 2011. Nov 15 [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.