DUODENAL SWITCH What you need to know What is Duodenal Switch?

• Duodenal Switch (DS) • “double anastomosis” or classic DS • “single anastomosis”

What is Duodenal Switch?

• DS (single and double) are alternative procedures to traditional gastric bypass and sleeve gastrectomy

• May be offered on a highly selective basis when potential benefits clearly outweigh risks

• Very few surgeries at St Joe’s are DS

Why Consider Duodenal Switch?

• DS offers the best chance of improvement/remission of type 2 diabetes

• DS can offer slightly better weight loss than sleeve or bypass

• DS has a lower chance of weight regain in the long-term

Why Consider Duodenal Switch?

However… Why Consider Duodenal Switch?

• DS also has the highest level of surgical risk

• Often done as two surgeries

• DS requires significantly more attention to prevent malnutrition

• DS has potential for significant side effects

Who May Be Eligible?

• Patients with severe diabetes that is difficult to control

• Patients who have had a sleeve but who could benefit medically from additional weight loss.

• Patients with significant weight regain after sleeve or gastric bypass Who is Not Eligible?

• People with inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

• People with severe/frequent diarrhea

• People with severe and unmanaged psychiatric illness

• Age over 60 years old

• Many other patient-specific reasons may also rule out a DS Normal Anatomy

• Food travels down the esophagus to the stomach • It then goes into the small intestine and then the large intestine • Digestive juices travel with your food to help absorption Duodenal Switch (double anastomosis) Duodenal Switch (double anastomosis)

• Creation of small stomach shaped like a sleeve

• Small intestine is disconnected from sleeve

• Lower part of small intestine attached directly to sleeve

• Large amount of small intestine bypassed

Image source: Ethicon Endo-Surgery, INC. Duodenal Switch (double anastomosis)

• Smaller stomach means you feel full faster

• Hormonal/metabolic changes lower your appetite

• Do not absorb all of your calories

• Do not absorb vitamins/minerals properly

Image source: Ethicon Endo-Surgery, INC. Duodenal Switch (single anastomosis) Duodenal Switch (single anastomosis) • Creation of small stomach shaped like a sleeve

• Small intestine is disconnected from sleeve

• Loop of small intestine attached directly to sleeve

• Smaller amount of small intestine bypassed

• Common channel longer than with DS Duodenal Switch (single anastomosis)

• Smaller stomach means you feel full faster

• Hormonal/metabolic changes lower your appetite

• Do not absorb all of your calories

• Do not absorb vitamins/minerals properly Single vs Double Anastomosis

Single Double

• One connection • Two connections • Less risk • More risk

• Longer common channel • Shorter common channel • (~250-300 cm, ~ 8-9 ft) • (~100 cm, ~ 3 ft) • Less malabsorption • More malabsorption • Fewer side effects • More side effects

• Less research • More research

Bypass/Sleeve vs DS

Bypass/Sleeve DS

• Slightly less weight • Slightly more weight loss loss

• ~15-30% have weight • ~10% have weight regain regain

• Lower malnutrition risk • Higher malnutrition risk

• Fewer side effects • More side effects

• 7-9 pills/day (vitamins) • 13-15 pills/day (vitamins)

One Surgery or Two?

• If you have never had bariatric surgery: • Usually done as two surgeries • Can be done in a single-stage for select patients (up to surgeon)

• If you previously had sleeve gastrectomy: • DS is done as one surgery

• If you previously had gastric bypass: • Typically done as two surgeries Weight Loss

• Weight loss with DS is typically around 30-40% of highest body weight when performed as a single- stage or as an early second-stage

• Can be less when performed as after significant weight regain with sleeve or bypass

• Is typically slower than with bypass or sleeve

• As always, health improvements are more important than body weights

Side Effects

• Most people have more frequent bowel movements • Soft or loose bowels • Most people will have a BM 2-4 times per day but can be up to 10 times per day for the first 12-18 months • Eating a very high fat meal can cause very bad diarrhea

• Many people complain of frequent and foul smelling gas • Less common with single anastomosis • Can be controlled to some extent through diet • Worse with simple sugars and carbohydrates Vitamin/Mineral Supplementation

Option 1 Option 2 High ADEK multivitamin Adult multivitamin Multivitamin 3x/day 2x/day Calcium 500-600 mg 3x/day 500-600 mg 3x/day 300 mg ferrous sulfate 300 mg ferrous sulfate Iron 1x/day 1x/day 1000 mcg tablet 1x/day 1000 mcg tablet 1x/day OR OR Vitamin B12 1000 mcg IM injection 1000 mcg IM injection 1x/month 1x/month Vitamin A n/a 10,000 IU/day Vitamin D 2000 IU/day 2000 IU/day Vitamin E n/a 400 IU/day Vitamin K n/a 300 mcg/day Vitamin/Mineral Supplementation Schedule Time Option 1 Option 2 Calcium ADEK multivitamin Vitamin D Morning Calcium Vitamin A Vitamin B12 Vitamin B12 ADEK multivitamin Calcium Afternoon Calcium Vitamin D Vitamin D Vitamin E ADEK multivitamin Calcium Evening Calcium Vitamin K Vitamin D Iron Bedtime Iron Multivitamin(s) Total # Pills 13 15 Dietary Guidelines • Protein goal is much higher • ~120 grams per day (don’t absorb all)

• Need to eat protein 6 times per day • Usually includes one protein shake per day

• Need to eat more calories than with bypass/sleeve • Don’t absorb them all

• Diet is relatively higher in protein and healthy fats, and slightly lower in carbohydrates Dietary Guidelines - Example

Breakfast: omelette (2 eggs + 1 oz ham + onions/peppers/mushrooms) + 1 slice toast with ¼ avocado (smashed)

AM Snack: ½ cup 2% cottage cheese + 2 melba toast

Lunch: chicken salad wrap (4 oz chopped chicken + full fat mayo/green onion/celery + romaine + tortilla)

PM Snack: 2 oz cheddar cheese (regular) + 2-3 melba toast

Dinner: 4 oz salmon + ½ cup green beans + ¼ cup quinoa

HS Snack: ½ cup 2% plain Greek yogurt + ½ cup berries + 2-3 tbsp chopped nuts Mental Health and DS Common Mental Health Issues • Eating Disorder History • Trauma History • Depression and Anxiety • Substance Use (risk of post-addiction transfer) • Body image concerns • Self-harm, suicidality

• Important to have stability with symptoms • Specific guidelines and intervention for issues such as substance use, inpatient admissions, suicide attempts, changes to medication etc.)

Mental Health and DS Psychotropic Medication

• Understanding of absorption

• Follow-up monitoring for medication (e.g., adjustments)

• Closer monitoring of symptoms and stability

• Having a post-op care plan (e.g., family physician, mental health resources)

Mental Health and DS Adaptive Coping Strategies

• How to navigate difficult situations

• Regimented, ability to follow structure and routine

• Evaluation of significant stressors and strategies to reduce/manage stressors

• Importance of social supports and ability to access supports

• Compliance and motivation

Mental Health and DS Social Issues

• Financial stability for costs associated with surgery

• Home life stability

• Open to accessing community resources

What If You Don’t Want DS?

• If you decide that you don’t want DS but are still interested in other treatments, you could consider medications instead

• SAXENDA (liraglutide) DIN # 02437899 • Daily injectable medication • Suppresses appetite and increases fullness

• CONTRAVE (naltrexone HCI/bupropion HCl) DIN # 02472945 • Daily oral medication • Suppresses appetite and food cravings

GETTING READY FOR SURGERY Before Surgery

• You will be assigned to a nurse navigator and may meet them in person, or they may call you over the phone • Nurse will arrange your appointments and testing • Have many tests to make sure you can safely have surgery. You may have: • Gastroscopy • Ultrasound • Sleep study • Blood tests • Barium Swallow • Electrocardiogram Before Surgery • You will attend many appointments to see members of the health care team. You will see the: • Medical Internist • Social Worker and/or Psychologist – sometimes several times • Dietitian – you will have several appointments • Surgeon

• Appointments will be on different days

• If appointments are on the same day you may have to wait between appointments

Before Surgery

• Team members will assess:

• your risks and benefits and may determine whether DS is offered to you

• your knowledge and understanding of DS

• your ability to follow lifestyle recommendations for DS Missed Appointments

• If you miss 2 appointments without notifying the clinic your name will be removed from the list of candidates for surgery.

• Important to always notify clinic if you cannot make an appointment

• There are many people waiting for appointments Before Surgery

• Stop smoking NOW! You must be 6 months smoke-free before your assessments start. • This includes all forms of nicotine (e-cigarettes,vaping, Nicorette gum etc.) • Smoking significantly increases your risks for surgery (poor healing and ulcers)

Preparing for Appointments

• If you previously had gastric bypass or sleeve gastrectomy at another hospital, we may need you to retrieve your operative note from that institution

1. Ask your nurse whether we can get it or not 2. If not, contact their Health Records Department 3. Ask if they still have your operative note on file 4. Will likely need to pay a fee 5. Obtain a paper copy of the report and bring with you to the clinic What’s Next?

• How to let us know… Resources

• Duodenal Switch Handbook • Single anastomosis DS handout • www.dsfacts.com • Youtube: • Search “duodenal switch animation” for double anastomosis DS video • Search “loop duodenal switch procedure” for single anastomosis DS video

Getting Ready for RD Appointments

• Review all resources provided • Bring the following: • At least 7 days of food records • Bring “Getting Ready for Your DS Assessment” worksheet • Bring Duodenal Switch book and single anastomosis DS handout

Questions