Duodenal Switch Surgery

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm super excited to have Dr. Jesse Gutnick on, who is a bariatric and metabolic surgeon, general surgery specialist here at the Department of General Surgery at the Cleveland Clinic. And we're going to talk a little bit about the duodenal switch surgery. So, Jesse, welcome to Butts and Guts.

Dr. Jesse Gutnick: Hi, and thanks for having me.

Dr. Scott Steele: So, we always like to start off first with just getting to know you a little bit better. So, tell us where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Jesse Gutnick: Well, I grew up in Northern California in a small town called Fort Bragg, which is on the coast about four hours north of San Francisco. I came to Cleveland Clinic to do my residency, and then after residency, I trained in bariatric surgery at Duke. And I came back here because I love living here.

Dr. Scott Steele: Fantastic. A Dukie, all along with all the college basketball world. So today we're going to talk a little bit about the duodenal switch surgery. So, to start, can you give us just a little bit of an overview about what this means so our listeners can have a little bit of background?

Dr. Jesse Gutnick: And, this is also probably a good time to talk about some of the different terminology that's around it. So, duodenal switch is one of the bariatric surgery options and it's one of those that has a lot of different acronyms and names thrown around about it. So, the full name of it, and one that patients may come across, is called the biliopancreatic diversion and duodenal switch. So, they may see that, especially if they're looking at, for example, their insurance policy and seeing what's covered, it's often spelled out in that way. If you're looking at it online on patient forums, they might be calling it the duodenal switch or the DS. There's also a type of the duodenal switch that's been growing in popularity, although it's less commonly performed, called the SADI or the SIPS, and there's a lot of acronyms around that one. So, if you are doing your own research online and in forums and talking to other patients, most often people call it the DS or the switch or the duodenal switch.

Dr. Scott Steele: So, to take a step up from here, let's just talk about bariatric surgery in general. So, who qualifies for this surgery, what role does surgery play and how do we put this all together?

Dr. Jesse Gutnick: Really to qualify for surgery, you need to have a certain amount of obesity that is affecting your health or is significant enough that it'll likely affect your health in the future. And historically that's been defined as a BMI of 40 or a BMI of 35 with other health issues that are caused by obesity, like sleep apnea, high blood pressure, diabetes, these kinds of things. Now more recently, several organizations, bariatric surgical societies, some of the diabetes societies have recommended changing those to lower thresholds. However, at this point most, insurance companies haven't followed suit as yet. So, bottom line for most people that are working with insurance, it's a BMI of 35 if they have other health issues or a BMI of 40.

I think your second question is when would we consider the duodenal switch. This takes a step back in terms of figuring out how do we figure out what operation might fit best for each patient? And often a patient will ask me, well, what's the best one? And there's no best one, but there's usually the best one for a particular patient. And so that's really what your first meeting with a surgeon's all about, is finding out about a patient's past history because there might be a medical reason that a particular operation's not a good idea. And so, we need to make sure we're not planning on that one. And then from there, of the ones that are good options, it's really educating the patient about what are the trade-offs that this one has, like how effective may it be in terms of getting them to a weight loss goal. And then what potential trade-offs in terms of lifestyle might you expect with that particular operation.

So, I'll give you an example that that might make this clearer and that actually just came up with a patient I was seeing right before we had this conversation. There's a patient that was coming to me and this patient was very interested in having gastric bypass, which is one of the other operations. However, this patient needs to use NSAID type medicines, like ibuprofen, on a regular basis. And NSAIDs can't be used if you have a gastric bypass because they'll give you an ulcer. And so, for the amount of weight loss that she wanted plus needing to use those NSAIDs for symptom control, the duodenal switch was a better option because you can still use those NSAID medications with the duodenal switch. So that's just one example, but that's some of the decision-making that happens when you choose an operation.

In general, the things that we look for is one, the NSAIDs that I talked about. Number two, it is more potent than the gastric bypass in terms of the amount of weight loss that can be expected, all other things being equal. It's more powerful for diabetes control, and so in particular, if people are looking for some diabetes control, that may be a good option. There's also less weight regain than with the other options. So, that's another important consideration.

Dr. Scott Steele: So, Jesse, I remember going back through my surgical residency, which has been quite a while now, but just some of the history of the weight loss surgeries and whether it's the vertical banded gastroplasty or the Scopinaro procedure, or some of these other ones, they've been differing degrees of success in terms of weight loss, but it also then contrasted or sometimes aligned with safety. So can you talk a little bit about how this duodenal switch especially. Is it safe? What were the downsides of this? Is there some things that you worry about or have to follow in these patients that get it? Because you had such a high degree of experience and expertise in this. How do you put this all together?

Dr. Jesse Gutnick: Yeah, and I'll try to go through this without getting too much into the history. That's always a danger for me because I love the history of surgery, so I'll try to talk through this without getting into that too much. You brought up the Scopinaro procedure, and that was the biliopancreatic diversion. And the duodenal switch is the biliopancreatic diversion with a duodenal switch. The main downside of the biliopancreatic diversion, the biggest downside of it, is it was a very high rate of patients got ulcers. And so, there were two different surgical groups, one in Canada and one actually in Bowling Green, Ohio that at almost the same time came up with an idea to modify that to be the duodenal switch with a biliopancreatic diversion and almost completely remove that ulcer risk. And so, that's how we came to this procedure as we do it today. Although of course they were doing it open then and we do it laparoscopically now.

With this operation and with actually all of the operations, we have to follow patients lifelong for vitamin levels because with all of them there is some component of micronutrient malabsorption. With the duodenal switch, we talked about some of the upsides earlier in terms of how potent it is. The flip side of it is we have to measure more vitamin levels than with, for example, the gastric bypass. And so, that doesn't really make a big difference in terms, it's not like you have to get more pokes with your blood draw, but they do have to take off more tubes to check more vitamin levels over the long term. There are also some potential trade-offs in terms of your overall lifestyle with your gastrointestinal system. When you're looking at the different operations, they all have trade-offs with your daily life living with your gastrointestinal system. So, for example, with the sleeve, some patients get new heartburn after that one. Gastric bypass, some patients get a thing called dumping syndrome, which is an intolerance to sweets. The sweets make you feel sick and give you abdominal cramps. Also with gastric bypass, sometimes there's more intolerance of certain textures of foods. Duodenal switch, one of the benefits is you don't get as much of that intolerance of certain food textures as much, but you do have softer bowel movements and you may need to watch what you eat a little bit carefully in terms of making sure you don't have more frequent bowel movements.

Dr. Scott Steele: Truth or myth: duodenal switch surgery can help reduce the risk of certain diseases like cardiovascular disease, respiratory diseases, and metabolic diseases.

Dr. Jesse Gutnick: That's true. And of all the operations, it's the most that we have and actually of all the treatments that we have, it's the most potent in terms of treating diabetes, high blood pressure and the other metabolic diseases that you mentioned.

Dr. Scott Steele: So, Jesse, my brother used to be a used car salesman, so I know that results may vary. But what is a typical patient outlook in terms of weight loss and in how they're doing after the duodenal switch? How much weight do you expect that they lose?

Dr. Jesse Gutnick: Well, so as you said, results may vary and we don't have a crystal ball, but we can look in terms of percentages. And, these are round numbers that I typically will quote to patients that are what I feel are a good approximation of the research that's out there because they vary from study to study, as well. But in terms of weight-loss, bariatric surgeons talk in terms of what's called excess weight loss. And what that means is the difference between what you would weigh for your height at what's called a BMI of 25, which is a ratio of your height and weight and where you are now and that difference would be called excess weight. So, that's how we talk about weight loss and how we compare the operations.

And for duodenal switch, the typical person is in an excess weight loss in the range of around 80 percent, so getting fairly close to that BMI of 25. And remember, that's the typical person. So, there's going to be a few that are less, there's going to be a few that are more in actually getting down to that BMI of 25. If you compare that again in round ways to, let's say, gastric bypass, you're typically in the range of 60 to 70 percent. And sleeve gastrectomy, I would say typically somewhere in the range of 40 to 50 percent.

Dr. Scott Steele: Well, of course results may vary, but that's actually very good rough ballpark numbers to go on. So, you get asked a lot of questions all the time. So, are there any other frequent questions you hear from patients about this surgery, something you can touch on or shed some light on?

Dr. Jesse Gutnick: So often the patients that come to me that are interested in duodenal switch are the ones that have spent significant time learning about the surgeries on their own ahead of time because it is done the least frequently of all the operations that are out there and they've come to me because they've sought me out to undergo this surgery. And so, they're often asking very nuanced questions about the surgical techniques and limb lengths. And so, if people have those kinds of questions, I'm happy to answer them in person. The ones that people are totally new to this want to ask is what is life like living with the different operations because that's obviously how you end up living one year later, four years later, five years later. And as best as I can answer, because this is based on what the research is and talking to my own patients, meeting them, and also talking to patients that have had surgery 10, 20 years ago, after duodenal switch over the long term, most patients are eating a moderate amount of food that is of a regular type of and consistency of food. They're typically having relatively normal bowel function, although softer than before they have the surgery and they are needing to follow up for their vitamin levels. So, that's the lifestyle that most patients are living one year and further out after surgery of this type.

Dr. Scott Steele: So, are there any other advancements on the horizon when it comes to duodenal switch surgery?

Dr. Jesse Gutnick: I think I spoke earlier about the SADI procedure and how there is a lot of talk about this both among patients and doctors and sometimes there's some confusion about what's what, because there's a lot of acronyms that have been associated with these. And so, what the SADI procedure is, is a duodenal switch has one connection instead of two. So, the traditional duodenal switch has two and the SADI has got one connection, so it's got a loop-type configuration. There are some definite advantages to that in that the operation is faster because there's less work to do. And so, there's some advantage to that in terms of the risk of time under anesthesia. And so that has become more and more popular. There isn't very, very long-term data out there like there is for the duodenal switch. The DS, there's over 10 years of very, very high-level data. Personally, I see patients that have had it 20 or more years ago that I do follow up on. Of course, they weren't my own patients, they were operated on by other doctors.

So, we don't have that yet for the SADI, but it looks extremely promising in the early follow up and based on the way it's performed, we have every reason to suspect that it would have very good long-term results that are probably slightly less powerful than the duodenal switch, which is what we're seeing in the short term. And by short term, I mean one to five years is what we have right now. So, that's the biggest thing that's out there. It's covered by some insurances, but not all. But that's a moving target. So, if someone listens to this podcast six months or year from now, that could be very different in terms of the insurance coverage because it has been recommended by the Bariatric Surgical Society to be considered one of the standard surgical procedures, even though not all of them are covering it yet.

Dr. Scott Steele: Well, that's super exciting and it's great to see that there's things that are continuing to evolve in this kind of field. And so, now it's time to get to know you a little bit better through our quick hitters. So first of all, we're talking about bariatric surgery. So, what's your favorite food?

Dr. Jesse Gutnick: My favorite food is all types of Indian food and I can't even pick a favorite because I would just exclude too many that I like.

Dr. Scott Steele: No problem. What's your favorite sport to play and/or to watch?

Dr. Jesse Gutnick: Favorite sport to watch is auto racing, most especially Formula One racing. And I'm not much of a team sport person, myself. I like hiking.

Dr. Scott Steele: Okay, so you're standing in front of a group of people and you say the place that you need to go travel to because it's one of your favorites is where?

Dr. Jesse Gutnick: One of the places that I am most looking forward to going back to as my kids get older is Acadia National Park because it has some really nice biking trails. And so, as kids get older, they may not want to hike for quite as long as you want to, but hopefully they want to bicycle along with you as long as you want to bicycle with them. And so, I think that's the next place that I really want to go back to.

Dr. Scott Steele: That's fantastic. And so, tell us something you like about living here in Northeast Ohio.

Dr. Jesse Gutnick: The thing that's best obviously is family. My wife's family is here and they've become my family and, of course, the people. I live on the west side of Cleveland, which I have to recommend for a lot of different reasons. Most of all, there's just a little bit less snow than on the east side.

Dr. Scott Steele: Fantastic. And so, give us a final take home message for our listeners about the duodenal switch or bariatric surgery in general.

Dr. Jesse Gutnick: The duodenal switch is a great option, and I'm really excited that we're able to offer it to patients here at Cleveland Clinic. But, it's just one option among bariatric surgery in general. Bariatric surgery is by far the most effective treatment for obesity and all the other health issues that come along with it. And so, if someone's considering weight-loss surgery, I think the first step is learning more. We obviously have good options online where we do educational seminars. There's written information online on our own website. There's plenty of other great educational websites out there. That's a first step. If you're more interested than just learning more, we're happy to meet with you and finding out what operation might be right for you to treat your specific situation.

Dr. Scott Steele: Well, that's fantastic. And to learn more about the Bariatric and Metabolic Institute here at the Cleveland Clinic, please call 216-445-2224. That's 216-445-2224. You can also visit clevelandclinic.org/bariatrics for more information about bariatric surgery at the Cleveland Clinic. Again, that's clevelandclinic.org/bariatrics. Jesse, thanks for joining us on Butts and Guts.

Dr. Jesse Gutnick: Thanks so much for having me. It's been my pleasure.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.