This just in - one stage DS is better than two, and switch first is better than sleeve

DianaCox

Bad Cop
Obes Surg. 2014 May 17. [Epub ahead of print]
Biliopancreatic Diversion-Duodenal Switch: Independent Contributions of Sleeve Resection and Duodenal Exclusion.
Marceau P1, Biron S, Marceau S, Hould FS, Lebel S, Lescelleur O, Biertho L, Kral JG.
Author information

Abstract
BACKGROUND:
The choice of first-stage operation in bilio-pancreatic diversion with duodenal switch (BPD-DS) is controversial. There are no published long-term comparisons of one- and two-stage BPD-DS outcomes.

METHODS:
During 2001-2009, among 1,762 patients scheduled for BPD-DS 48 had duodenal switch (DS) and 53 sleeve gastrectomy (SG) as first-stage procedures. We compared prospectively updated outcomes of 42 DS (100 % open) and 49 SG (88 % laparoscopic), 13 of whom completed their second stage, to a control group of 91 patients with open one-stage BPD-DS.

RESULTS:
One-year mean percent excess weight loss (%EWL) was greater after SG than DS (47 ± 19 vs. 39 ± 13 SD; p = 0.01) with earlier nadir (16 ± 10 vs. 45 ± 30 months; p < 0.0001) but more rapid significant weight regain. After 5 years, %EWL was 12 ± 35 for 9 SG, 45 ± 19 for 30 DS (p < 0.0006), and 70 ± 18 for the first-stage BPD-DS (p < 0.0001). Weight loss was less after two- than one-stage procedures (p < 0.02). Comorbidities improved progressively between SG, DS and BPD-DS (p < 0.001 for trend). HbA1C decreased by 10, 19, and 31 %, respectively (p < 0.0001). Dyslipidemia was cured in 41, 82, and 100 %, respectively. Systolic and diastolic blood pressure decreased only after DS (12 %; p < 0.0002). Patient satisfaction was similar for SG and DS but greater after BPD-DS overall (p = 0.04).

CONCLUSIONS:
SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.
 

DianaCox

Bad Cop
I've asked Dr. Marceau for a copy of the paper - don't know why I didn't ask before .. I hope to post it soon.
 

Munchkin

Full of Fairy Dust
I've asked Dr. Marceau for a copy of the paper - don't know why I didn't ask before .. I hope to post it soon.
I hope you get the whole paper. Makes sense to me that if you are forced to do two ops, the switch first would go further to eliminate comorbidities than just the sleeve. The malabsorbtion is almost an instant fix where the improvements with the sleeve alone are weightloss dependent.

@more2adore needs to see this!
 

more2adore

Well-Known Member
Just saw it, Munchkin. I don't have a ton of confidence that this will be received well, but I'll definitely ask about it when I next talk to my surgeon. Thanks for tagging me!
 

Larra

Well-Known Member
@Munchkin, while the switch does do great things for type 2 diabetes, it doesn't provide a whole lot of weight loss, which @more2adore needs right now. The sleeve as a stand alone is not ideal for her but should get a bunch of weight off in the next 6-12 months, which will improve her health (and that recurrent leg infection) greatly and get her into better shape for the switch.
Most of the other major comorbidities - sleep apnea, in particular - are dependent on weight loss, though of course the full DS would help more with everything. There is no perfect solution here since she can't get the full DS done with the resources available to her. I think the sleeve first is the better option.
 

DianaCox

Bad Cop
@Larra - I can't recall off the top of my head whether diabetes is part of her comorbidities, but if it is, with all the issues that THAT presents to healing (both the leg and the bariatric surgery itself), would that change your opinion of which might be better to be first for someone in her situation? Not asking you for a recommendation of course, just curious whether diabetes would be a tipping issue in favor of the metabolic procedure first, rather than weight loss, in someone who is SSSMO.
 

Larra

Well-Known Member
@DianaCox I can't remember either, but off the top of my head I would say that unless the diabetes is severe I would still go for the sleeve first. My understanding of the rationale for doing the DS in 2 parts is to lower the risks of a high risk patient by getting them off the table and out of general anesthesia as fast as possible, while doing something that will help them to lose a significant amount of weight and then doing the rest of the DS when it's significantly safer. Doing the switch first won't accomplish that.
On the other hand, I could envision a scenario with a patient with severe type 2 diabetes causing worsening eyesight, peripheral neuropathy, significant circulatory problems causing risk if amputation, kidneys at risk, etc where you just have to get the diabetes under control as fast as possible. I think this would be an unusual situation, though. And of course I have absolutely no evidence based info on which to base my opinion.
 

Munchkin

Full of Fairy Dust
Just saw it, Munchkin. I don't have a ton of confidence that this will be received well, but I'll definitely ask about it when I next talk to my surgeon. Thanks for tagging me!
No worries. I just wanted to make sure you saw it! The sleeve first in a 2 parter is very standard. That's what everyone does. This is a piece of new thinking or at least the first time I've seen it.

My H had the switch only for his diabetes. A doc in Europe wrote about this procedure(Noyes) and H did exactly as this doc predicted. Noyes said he would lose about 30lbs and then regain it slowly over the next 2 years or so.
 

Munchkin

Full of Fairy Dust
@Larra I'm sure she will end up with the sleeve first. Just wanted to make sure she read this. Or better yet, that her doc reads it!
 

Larra

Well-Known Member
@Munchkin I'm sure she will end up with the sleeve first as well. Given the options available in Australia she's fortunate even to find a highly respected surgeon willing to do a 2 part DS. Doing the switch first would really be going out on a limb. But who knows, maybe a few years from now the thinking will be different, perhaps with more options to consider. Things are always changing.
 

more2adore

Well-Known Member
@DianaCox I actually don't have diabetes, fortunately. Not even insulin resistance. Nor do I have high cholesterol or high blood pressure. Asthma, sleep apnea, and lymphedema are my primary weight-related comorbids.
 
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