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Duodenal Switch Surgery

The duodenal switch (DS) may be the most effective bariatric treatment for improving diabetes, hyperlipidemia, high cholesterol, high triglycerides and sleep apnea. Dr. Michael Bilof discusses the duodenal switch and how it results in more weight loss than any other procedure.
Duodenal Switch Surgery
Michael Bilof, MD
Dr. Michael Bilof began his career as a vascular surgeon where he continuously saw chronically ill patients suffering from type 2 diabetes. Dr. Bilof was frustrated by the overwhelming acceptance of maintaining the comorbidities (e.g., obesity) associated with type 2 diabetes and believed there had to be something more doctors could do to help. In 2003, upon the urging of his wife, Dr. Bilof left his successful vascular practice and retrained in general surgery, specializing in bariatrics.  In April 2007, he founded Garden State Bariatrics and began offering lifesaving solutions for individuals with obesity and related diseases.

Learn more about Michael Bilof, MD

Bill Klaproth (Host): What is the Duodenal Switch and is it right for you? Well hang on, we’re going to answer that question with Dr. Michael Bilof, a bariatric surgeon. He is also the founder of Garden State Bariatrics and Wellness Center. So, Dr. Bilof, what is the Duodenal Switch?

Dr. Michael Bilof (Guest): Bill, the Duodenal Switch is a bariatric operation, a weight loss surgery that’s really the most effective of the surgeries that we have in terms of weight loss, both in terms of the amount of weight patients can lose and also in terms of resolving or improving the comorbidities, that is the medical problems that are associated with morbid obesity. The way I usually describe it to patients in very simple terms and this is definitely a simplification is the Duodenal Switch is essentially a gastric sleeve, which most patients have heard of and a gastric bypass, which also most patients have heard of. So, it’s sort of a combination of those two operations and again, that’s definitely a simplification that we describe in a lot more detail when a patient comes in for their actual consultation.

Bill: So, you called this the most effective.

Dr. Bilof: Correct.

Bill: So, this then as you said, it combines the gastric bypass and the gastric sleeve. So, does that mean this is the most intense of all of the gastric or bariatric surgeries?

Dr. Bilof: Yeah, I guess you could think of it that way. The patients – a lot of patients haven’t heard of this operation actually, so, I would assume folks listening to this podcast either have no familiarity or just a little bit of familiarity with this procedure. So, that’s why when I describe it to a patient in the office, I will – I describe it in terms of things that they are already familiar with which is the gastric sleeve and the gastric bypass. And again, that’s a simplification, but essentially, this operation is – we do a gastric sleeve and then we do second sort stage or step where we bypass about 2/3rds or so, 2/3rds to 3/4s of the intestines. And that’s why this is – this operation is the most effective of the procedures both in terms of the amount of weight patients lose and also in terms of resolving and improving the medical problems that these patients are dealing with and specifically diabetes. It’s the most effective in resolving diabetes.

Bill: Okay, that makes sense. So, let me ask you this, who is a good candidate for this then or why would someone choose this over the others?

Dr. Bilof: When I’m meeting with a patient for the first time, or if someone out there listening to this podcast is considering this; there are two groups of patients that I’ll generally make a point of discussing this surgery about. So, the first would be a diabetic. If someone is diabetic, this is and there is a fair amount of research about this, this operation is the most effective at improving their diabetes, that is making their diabetes more easily controlled and even for many patients, for actually just resolving the diabetes completely where their diabetes just goes away. They don’t have to take insulin, they don’t have to take pills, they don’t even have to monitor their sugars anymore. So, and that’s pretty exciting and obviously if you are a diabetic and that’s a possibility, that’s definitely something you want to consider. Obviously, that’s not the only factor in the decision but certainly if you are diabetic and there’s an operation that has a fairly good chance of making that diabetes go away, you want to think about that. That’s definitely something that should be in the equation so to speak, of what’s the best procedure for me, as the patient.

So, one group of patients is diabetics. Then the other group of patients would be folks who have a BMI over 50. BMI is essentially an abbreviation for body mass index and it’s a ratio of height to weight and it’s one of the things that we use first of all, to determine if someone is even a candidate for weight loss surgery but then assuming that they are a candidate, which procedure is sort of the best one for that particular patient. So, if someone has a BMI over 50 or if they are diabetic; that’s the situation where we would really – where I will kind of make a point of discussing this particular procedure with the patient and letting them know that this might be the best option for them.

Ultimately, it’s up to the patient and the patient needs to feel comfortable with the procedure and how the surgery works, the risk, the complications, the benefits, etc. But in those two groups of patients, for sure, we want to at least make them aware that this operation might be their best option.

Bill: That’s really good information. So, you mentioned good for a diabetic. So, does that mean type I and type II sufferers?

Dr. Bilof: Mostly it’s type II. There are typically, type I diabetics oftentimes are not actually overweight and those are the type of diabetics where they became diabetic either in childhood or in their teens or 20s and they have been diabetic for a long time and they have to take insulin. And oftentimes, those patients actually are underweight. Type II diabetes is really the type of diabetes that we see most frequently in our office. And those are folks who have usually been diagnosed a little later in life. They may or may not be on insulin. Some do need it, some don’t. But typically, those patients are overweight and in fact, the weight is really the – for most of those patients, the weight or the extra weight is really the cause of the diabetes. And so, when we do these surgeries that help them lose a significant amount of weight and may also interfere with the absorption of sugars, which this procedure does do; that really improves the diabetes pretty dramatically.

Bill: And Dr. Bilof, can you briefly tell us about the procedure and what the typical recovery is like?

Dr. Bilof: Sure. So, the surgery is done laparoscopically, really on our practice we do all of our surgeries laparoscopically, which means we make very small incisions. Typically, the incisions are anywhere from ¼ of an inch long to about an inch to an inch and a half long, is the longest incision. Typically, the patients will stay in the hospital one or two nights depending on how they are feeling and their blood work and other kind of tests that we do after surgery to make sure everything is okay. And then usually they are out of work for two to three weeks, that sort of thing and not much different than either the gastric sleeve or the gastric bypass. So, one of the – since people don’t really know a lot, oftentimes don’t know a lot about this procedure, they think it’s – they are going to be laid up, out of work for a very long period of time or in the hospital for a very long period of time. But really, that’s not the case. It’s essentially, the same as the other bariatric surgeries that we do. One or two nights in the hospital, two to three weeks out of work kind of thing. So, in that sense, it’s not that much different. The difference really is in the amount of weight loss and also in terms of resolving the medical problems, the diabetes, the high blood pressure, the sleep apnea, those sorts of things.

Bill: So, then after surgery and recovery, how much weight loss can someone expect?

Dr. Bilof: I’m personally always a little hesitant to make those kinds of predictions because it’s – there is a lot of variability there. From the research that has been done about this particular procedure, typically, patients will lose somewhere between 2/3rds and 3/4s of their excess body weight. So, that’s not 2/3rds of their body weight, it’s 2/3rds of the excess body weight that is 2/3rds of the weight above what is ideal for that particular person. So, if we say someone is 100 pounds overweight, 2/3rds of that would be about 60-70 pounds. So, typically with this surgery, the weight loss is about 2/3rds to 3/4s of the excess body weight.

Bill: And what about diet and life afterwards? Can you tell us about that?

Dr. Bilof: This operation is essentially a gastric sleeve plus a form of an intestinal bypass where we bypass about 2/3rds to 3/4s of the intestines. So, that will – that does imply some dietary changes although they are not as significant as I think people sometimes think that they are. Mostly, it would be a similar diet to what the patient would be on if they had the gastric sleeve or the gastric bypass. It’s not that much different. I would say with this – with the Duodenal Switch, the one thing that patients will often be sensitive to is fatty foods. So, if they eat high fat foods, that can sometimes cause diarrhea. Now we generally don’t recommend high fat foods anyway, so that shouldn’t really be a big problem because if the patient is kind of following the recommended nutritional guidelines; they wouldn’t really be eating a lot of fatty foods. But if for some reason they did, that can cause diarrhea. And so that’s the one thing I would say patients need to sort of be aware of with this surgery and there are vitamin deficiencies that can develop with any of the bariatric surgeries so lifelong vitamin supplementation is required with this surgery just like there is with the gastric bypass or the gastric sleeve.

Bill: And for someone researching this Dr. Bilof, what about the downsides? Can you share those with us?

Dr. Bilof: Sure, the one thing that people will discover if they kind of – I always say when they talk to Dr. Google, that is when they go out and sort of research on the internet about the different procedures. The one thing they are going to hear about or discover is diarrhea. So, that’s the thing that people will often claim is the big problem with this surgery. I would say a couple of things about that. One is it’s oftentimes, as I mentioned earlier, related to the diet so the thing that can cause that is excessive or extra consumption of fatty foods which we would recommend avoiding anyway. And so that – there is some – they do need to – the patients do need to be aware of and compliant with our postoperative dietary recommendations. And this is one of the things. All the patients meet with a nutritionist both before and after the surgery and this is – these are the types of things we discuss with them to make sure they have a full kind of understanding of the different – of the actual protocol they will need to follow after the surgery both to prevent complications like getting diarrhea but also to maximize the results and the weight loss.

Bill: Don’t listen to Dr. Google. Listen to Dr. Bilof. That’s what I say.

Dr. Bilof: Well, I wouldn’t say don’t listen to Dr. Google. That’s your first step in the research process, but then you come in and talk to the actual surgeon and get the actual facts, if you will. I mean I would mention that if you are going to go on the internet, WebMD is a relatively accurate site and most of the information on there is I would say is for the most part pretty accurate. So, if I do direct someone to anyplace I start with that and I would definitely avoid the chatrooms. The chatrooms are a bit of a problem because they often attract people who are unhappy or disgruntled for some reason and they give a very skewed view of what really happens with the average patient.

Bill: Is there anything else we need to know about the Duodenal Switch, Dr. Bilof?

Dr. Bilof: I think that’s a good overview. I would say if you are – the take home message I think is if you are someone out there who is considering the surgery and you are a diabetic, or if your BMI is over 50 and again getting your BMI is very simple if you just go on our website or any website, any bariatric website and just type in BMI it will easily calculate it for you. So, if your BMI is over 50 or if you have diabetes, this should be one of the procedures that you are thinking about and should discuss in more detail with the surgeon when you come in for your actual one on one consultation.

Bill: Well, Dr. Bilof, thank you so much for your time. We appreciate it. For more information, please visit the Garden State Bariatrics and Wellness Center website at that’s . This is Winning Through Losing a Weightloss Surgery Podcast with Garden State Bariatrics and Wellness Center. I’m Bill Klaproth. Thanks for listening.