Laparoscopic Duodenal Switch (DS or SADI)
Long known as the procedure most likely to completely reverse diabetes, the DS procedure never caught on as a widely performed procedure because it was viewed as a bit complex for surgeons, had more digestive side-effects and was overtaken by simpler procedures. But its role is growing.
For many years duodenal switch has played an important, but small role in the practice of weight loss surgery. It has consistently delivered the best results for the permanent remission or resolution of type 2 diabetes, but this procedure, as it was performed in the past, led to more profound micro nutrient deficiencies, so there are few centers which continue to perform the DS or one of its related procedure like the bilio-pancreatic diversion (BPD), or a more modern single-anastamosis duodeno-ileostomy (SADI) as the primary procedure. That is, for someone undergoing their first ever bariatric surgical procedure. But for many of us experts in the field, we reserve this somewhat more invasive procedure for two scenarios: The first scenario is revisional surgery – cases in which there has been a procedure done before and now the diabetes or the weight has come back. We refer to this as “Step 2.” The second scenario is when the diabetes is severe and the BMI is very high, say, over 50.
In the United States, most surgeons in experienced practices have seen dramatic reductions in the rates of complications or adverse events among patients undergoing weight loss surgery, such that today the risks are lower than the risks of cesarean section, knee arthroplasty and many other common procedures. This improved safety record has happened as a result of repetition through hundreds and then thousands of procedures, and attention to continuous quality improvement. Most recently, the move toward the gastric sleeve procedure has further reduced complications, especially those involving micro nutrient deficiencies, which are milder with the sleeve procedure.
So why is the duodenal switch playing a more important role today? The answer is the techniques for this procedure have also improved, and become less invasive, with less complications, and there is a high success rate and great compatibility with someone who has previously had a sleeve gastrectomy. For a patient who has experienced a return of the diabetes or regained weight years after a sleeve gastrectomy, single anastomosis laparoscopic duodeno-ileostomy (SADI) may be the best procedure to once again induce diabetes resolution and weight loss success. And there are some variations of DS/SADI which one day may prove to garner better results or less side effects which are still emerging as first-stage options.
Five-year data on the SADI procedure demonstrates excellent success, and vitamin deficiencies now appear rare with this more modern version of DS. While more long-term studies are emerging, the single anastomosis loop duodenal switch appears to lead to less vitamin deficiencies and still delivers reversal of type 2 diabetes and massive weight loss success.