Research Original Investigation
Five-Year Outcomes After Gastric Bypass and Duodenal Switch in Obese Patients
Invited Commentary
Weighing the Risks and Benefits of Bariatric Surgery Choose Your Own Adventure Oliver A. Varban, MD; Justin B. Dimick, MD, MPH
Bariatric surgery offers patients an explicit choice, a tradeoff between risks and benefits. Making the right choice is a complex balance between the risks of surgery (eg, short-term and long-term complications) and the benefits of weight Related article page 352 loss (eg, resolution of comorbid diseases and increased longevity). When compared with other bariatric procedures, biliopancreatic diversion with duodenal switch offers maximal weight loss, yet it continues to be the least common operation performed.1 The Risstad et al2 study reminds us why. We learned from Risstad et al2 that 1 or more adverse events occurred in nearly 80% of patients during the first 5 years after duodenal switch. This included a 14% hospitalization rate for protein and vitamin malabsorption as well as a reoperation rate of 45% to address problems of the initial procedure. The high rate of adverse events with duodenal switch is consistent with other reports.3 Moreover, the benefits of undergoing duodenal switch hardly seem worth the sacrifice when compared with gastric bypass. In this study, duodenal switch resulted in significantly more weight loss and lower serum levels of lipids but there were no significant differences in blood ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor. Corresponding Author: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: February 4, 2015. doi:10.1001/jamasurg.2014.3585. Conflict of Interest Disclosures: Dr Dimick cofounded ArborMetrix. No other conflicts were disclosed. Funding/Support: Dr Dimick received grants from the National Institutes of Health, the Agency for
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pressure, type 2 diabetes mellitus, metabolic syndrome, and pulmonary function. Given the high complication rates of duodenal switch in the study by Risstad et al, it is difficult to recommend duodenal switch as a first-line weight loss procedure. At the very least, patients seeking this procedure should receive ample warning regarding the very high risks of adverse nutritional outcomes and the high reoperation rate. Patients with poor compliance and poor follow-up should not be offered this procedure because they could be at risk of fatal complications if postoperative problems are not addressed in a timely fashion. Despite its narrow role in clinical practice, duodenal switch may find a resurgence in the future as a second stage procedure for patients who have failed weight loss after sleeve gastrectomy.4 Sleeve gastrectomy, which is part of the duodenal switch operation, is now the most common bariatric procedure performed in many regions of the country. Many surgeons advocate revising patients with inadequate weight loss after sleeve gastrectomy to a duodenal switch. Risstad et al remind us that this strategy should only be used with great caution and only in a select group of patients with excellent follow-up and compliance.
Healthcare Research and Quality (AHRQ), and the Blue Cross Blue Shield of Michigan Foundation. Role of the Funder/Sponsor: The funders had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication. REFERENCES 1. Reames BN, Finks JF, Bacal D, Carlin AM, Dimick JB. Changes in bariatric surgery procedure use in Michigan, 2006-2013. JAMA. 2014;312(9):959-961. 2. Risstad H, Søvik TT, Engström M, et al. Five-year outcomes after laparoscopic gastric bypass and
laparoscopic duodenal switch in patients with body mass index of 50 to 60: a randomized clinical trial [published online February 4, 2015]. JAMA Surg. doi:10.1001/jamasurg.2014.3579. 3. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8:CD003641. 4. Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A. Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis. 2014.
JAMA Surgery April 2015 Volume 150, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 07/03/2015
jamasurgery.com
Five-Year Outcomes After Gastric Bypass and Duodenal Switch in Obese Patients
Invited Commentary
Weighing the Risks and Benefits of Bariatric Surgery Choose Your Own Adventure Oliver A. Varban, MD; Justin B. Dimick, MD, MPH
Bariatric surgery offers patients an explicit choice, a tradeoff between risks and benefits. Making the right choice is a complex balance between the risks of surgery (eg, short-term and long-term complications) and the benefits of weight Related article page 352 loss (eg, resolution of comorbid diseases and increased longevity). When compared with other bariatric procedures, biliopancreatic diversion with duodenal switch offers maximal weight loss, yet it continues to be the least common operation performed.1 The Risstad et al2 study reminds us why. We learned from Risstad et al2 that 1 or more adverse events occurred in nearly 80% of patients during the first 5 years after duodenal switch. This included a 14% hospitalization rate for protein and vitamin malabsorption as well as a reoperation rate of 45% to address problems of the initial procedure. The high rate of adverse events with duodenal switch is consistent with other reports.3 Moreover, the benefits of undergoing duodenal switch hardly seem worth the sacrifice when compared with gastric bypass. In this study, duodenal switch resulted in significantly more weight loss and lower serum levels of lipids but there were no significant differences in blood ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor. Corresponding Author: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: February 4, 2015. doi:10.1001/jamasurg.2014.3585. Conflict of Interest Disclosures: Dr Dimick cofounded ArborMetrix. No other conflicts were disclosed. Funding/Support: Dr Dimick received grants from the National Institutes of Health, the Agency for
362
pressure, type 2 diabetes mellitus, metabolic syndrome, and pulmonary function. Given the high complication rates of duodenal switch in the study by Risstad et al, it is difficult to recommend duodenal switch as a first-line weight loss procedure. At the very least, patients seeking this procedure should receive ample warning regarding the very high risks of adverse nutritional outcomes and the high reoperation rate. Patients with poor compliance and poor follow-up should not be offered this procedure because they could be at risk of fatal complications if postoperative problems are not addressed in a timely fashion. Despite its narrow role in clinical practice, duodenal switch may find a resurgence in the future as a second stage procedure for patients who have failed weight loss after sleeve gastrectomy.4 Sleeve gastrectomy, which is part of the duodenal switch operation, is now the most common bariatric procedure performed in many regions of the country. Many surgeons advocate revising patients with inadequate weight loss after sleeve gastrectomy to a duodenal switch. Risstad et al remind us that this strategy should only be used with great caution and only in a select group of patients with excellent follow-up and compliance.
Healthcare Research and Quality (AHRQ), and the Blue Cross Blue Shield of Michigan Foundation. Role of the Funder/Sponsor: The funders had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication. REFERENCES 1. Reames BN, Finks JF, Bacal D, Carlin AM, Dimick JB. Changes in bariatric surgery procedure use in Michigan, 2006-2013. JAMA. 2014;312(9):959-961. 2. Risstad H, Søvik TT, Engström M, et al. Five-year outcomes after laparoscopic gastric bypass and
laparoscopic duodenal switch in patients with body mass index of 50 to 60: a randomized clinical trial [published online February 4, 2015]. JAMA Surg. doi:10.1001/jamasurg.2014.3579. 3. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8:CD003641. 4. Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A. Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis. 2014.
JAMA Surgery April 2015 Volume 150, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 07/03/2015
jamasurgery.com
