The surgical method known as Duodenal Switch is an operation performed by taking 75-80% of the stomach as in sleeve gastrectomy and by making changes in the gastrointestinal tract such as in gastric by-pass. Perform a sleeve gastrectomy in which it is turned into a thin tube. As a result, the stomach with a volume of 1.5-2 L takes the form of a thin and long tube with a volume of about 120 ml. This part of the surgery is an irreversible surgical procedure. The consumed foods are normally directed to the lower part of the small intestine after the sleeve gastrectomy and go to the lower part of the small intestine. This sleeve is the short portion of the small intestine that is separated after gastrectomy. The other pathway, which consists of the longer part of the small intestine, is the part where bile and other digestive enzymes mix with food and lead to absorption, the length of which is reduced to 250 cm. As a result, because the stomach volume is too small, the patient gets a sense of satiety by eating less and because the nutrients are absorbed less as the pathways of the small intestine are shortened, the amount of calories left in the body becomes less. It is an effective method in the treatment of diabetes, hypertension and high cholesterol diseases due to overweight. Since it is an application that reduces fat absorption, it is an effective operation in patients consuming fatty foods. Although obesity surgery is one of the surgical methods that provide the most weight loss, it is not used very frequently due to the high number of complications during and after surgery. After this surgery, vitamin and protein deficiencies due to malodorous chronic diarrhea and reduced fat absorption are common.

Another advantage is that duodenal Switch surgery is good for solving obesity-related health problems such as high blood pressure obstructive sleep apnea and high cholesterol. The operation takes approximately 2 hours. This situation may vary according to your anatomical structure and surgical history. Unless otherwise, the case is closed (laparoscopic), the patient’s post-hospitalization period does not exceed 2-3 days after the rapid recovery process and patients experience a low pain is seen in patients. Occasionally, complications include incisional pain, infection, and sagging.

 

Advantages of Duodenal Switch surgery;

– 90% weight loss

– The definitive solution for type 2 diabetes patients

– A good method for morbidly obese patients

– 5-10% risk of weight gain again

– No Dumping syndrome.

– Normal ulcer risk

– Intact pylorus (provides control over gastric emptying)

– No blind gastric residue

 

Disadvantages of Duodenal Switch surgery;

– A more difficult technique compared to other bariatric and metabolic surgical methods

– Longer operation time compared to other bariatric and metabolic surgical methods

– A more expensive surgical method compared to other bariatric and metabolic surgical methods

– Vitamin and protein deficiencies are more common compared to other bariatric and metabolic surgical methods

– Calcium and micronutrient deficiencies are more common when compared to other bariatric and metabolic surgical methods

– Compared to other bariatric and metabolic surgical methods, GI complaints are high (such as gas and diarrhea).

Loop Duodenal Switch (SADI-S)

The first stage of the surgery is the removal of 75-80% of the stomach as in tube gastric surgery. This section has the effect of restricting food intake and also reduces the secretion of Ghrelin (fasting hormone). In the second stage, the intestine is cut a few centimeters ahead of the ring-shaped muscle layer called the pylori at the gastric outlet and slightly behind the spill of the bile-pancreatic fluid. The gastric outlet is intestine with small intestine 250-300 cm from the small intestine-large intestine junction. That is, the length of the intestine where bile and other digestive enzymes are mixed with food and lead to absorption is reduced to 250 – 300 cm. Thus, it reduces the absorption of fats and calories in foods. At the same time, direct contact of nutrients with a lower part of the small intestine greatly reduces insulin resistance in muscle tissue, allowing long-term treatment of persistent Type 2 diabetes. Like Duodenal Switch, it is both restrictive and dis-absorbent. The only difference is that duodenal Switch has a double anastomosis line, while SADI-s has a single anastomosis line. The simplified version of the Duodenal Switch operation is SADI-s. The second route for bile in Duodenal Switch surgery is not available in SADI-s surgery. In SADI-s, after the stomach is turned into a tube, the gastric outlet is separated from the duodenum after the pylorus and the last 250 cm of the intestine is connected to it without cutting. Single anastomosis means simpler and less risky SADI-s surgery.

Advantages of SADİ-S Surgery;

– Control obesity-related diseases such as diabetes, hyperlipidemia, sleep apnea, and hypertension.

– The difference with duodenal switch operations is the application with a single anastomosis.

– Dumping syndrome is not seen because the pylorus is protected.

– Because pylorus is preserved, diet is better tolerated than other surgeries.

– It has all the advantages of other bariatric and metabolic surgical methods.

– No Dumping syndrome.

– No increased risk of ulcers

– Low incidence of internal hernia

– Technically simple than BPD / DS

– Shorter operation time

– Single anastomose line

– Less vitamin deficiency and protein deficiency compared to other bariatric and metabolic surgery methods

– A better method than by-pass in super-morbidly obese

– Less Ghrelin effect

– Less bile reflux

WHAT ARE DISADVANTAGES?

– Patients may need to take vitamin supplements (A, D, E, K, and minerals) throughout life.

– Frequent control and monitoring are required.

– The gallbladder may be swollen and the risk of gallbladder development is greater than normal.

– Surgical risks are similar to other obesity techniques. (such as intestinal perforation, anastomotic leakage, infection, abscess, venous thrombosis, and pulmonary embolism, or long-term intestinal obstruction).

 

Ileal Interposition

The term ileal interposition is the process of replacing the last part of the small intestine and the starting part. This operation works by the principle of disabling the hormones that cause insulin resistance and increasing the levels of hormones that increase insulin sensitivity. L cells in the part of the insulin sensitivity hormones called GLP-1 are secreted. The main target of this process is to reduce the resistance hormones, to increase the sensitivity hormones. Also in order to strengthen the effect of ileal interposition surgery to create other hormone changes, the upper left upper part of the stomach (fundus) is removed. From this part of the stomach, a hormone called h ghrelin sal is secreted.

The hormone Ghrelin has two important functions:

To create a sense of hunger by sending stimuli to the center of the brain called the hypothalamus that controls the feeling of hunger.

Intracellular insulin resistance.

The mechanical restriction is static and is an obstacle that makes it difficult to pass food in every spoon of food intake and is unreasonable from a physiological point of view. On the other hand, ileal proximal station and activation of ileal peptides may result in “functional restraint” and “metabolic saturation değil that limit stocking, not food intake.

Metabolic surgery should avoid static restriction and focus on functional restriction. The only way to do this is to activate the ileum-induced appetite suppressant hormones in the early stages of nutrition. If the saturation signals from the intestine come too weak or too late, then the person may consume too much food until metabolic saturation occurs.

There is another important reason for disabling this part of the stomach during ileal interposition surgery: If only the small intestine is displaced and no procedure is performed on the stomach, gastric dilatation called ”Gastric Dilatation ve and related stubborn nausea and vomiting can be seen. For these three reasons, the upper left outer part of the stomach called the “fundus” is removed.

In addition to the displacement of the small intestine in ileal interposition surgery, ghrelin hormone levels decrease to very low levels especially in Type 2 Diabetes by taking the fundus region of the stomach. In this way, in the postoperative period, our patients may not feel too much hunger even if they do not eat for a long time.

In ileal interposition surgery, the main purpose of removing a part of the stomach is not to reduce the volume of the stomach. The aim is to reduce the secretion of the ghrelin hormone that triggers a feeling of hunger and to prevent the “gastric dilatation” which may occur due to stubborn nausea and vomiting due to displacement in the intestine. Therefore, in the ileal interposition operation, the larger stomach is left than the “tube stomach” operation performed as morbid obesity operation. The reason that allows patients to eat less is the new hormonal regulation. For these reasons, ileal interposition surgery is an anatomically advanced digestive system surgery, but it is a “Metabolic Surgery” procedure in terms of the mechanism of action.

Each step performed in ileal interposition surgery has a hormonal target. These targets are evaluated for each patient by considering various factors and, if necessary, changes are made according to the patient’s condition. In this sense, Ileal Interposition can be considered as a dynamic decision-making process. Ileal Interposition has been developed for the treatment of Type 2 Diabetes since the beginning. The definition of metabolic syndrome includes Type 2 Diabetes, hypertension, hyperlipidemias (elevated cholesterol and triglycerides) and excess weight. It is possible to treat all of the components of Metabolic Syndrome by ileal interposition surgery.

Ileal interposition surgery is not an obesity operation. It is an operation aimed at treating all of the health problems in the scope of Metabolic Syndrome, especially in the treatment of Type 2 Diabetes. Therefore, obesity is not among the criteria for ileal interposition surgery. However, ileal interposition surgery is used in the treatment of obesity and morbid obesity, causing severe absorption disorder Mini-Gastric Bypass (Single Anastomosis Gastric Bypass), Roux-Y Gastric Bypass (Stomach Bypass), BPD (Biliopancreatic Diversion) ± DS (Duodenal Switch), It should not be confused with surgical methods such as DJB (Duodenojejunal Bypass). They are observed in terms of the course of these diseases during the hospitalization process after surgery. The majority of patients are discharged without using any of these drugs. In some, the metabolic effect is maintained until the waiting for a few weeks to a few months until a few and controlled doses of drugs gradually decreasing. When the measurements are normal, all of these drugs are discontinued.