DS Research Study

A new paper by Marceau et al. detailing 15 years of DS results:
Obesity Surgery, 17, 1421-1430 (2007)
Duodenal Switch: long-Term Results
Picard Marceau, MD, PhD1;Simon Biron, MD, MSc1; Frederic-Simon Hould, MD1; Stefane. Lebel, MD1; Simon Marceau, MD1; Odette Lescelleur, MD1; Laurent Biertho, MD1; Serge Simard, MSc2
'Department ofSurgery, Laval University, Laval Hospital, Quebec, Canada; 2Biostatistician Laval Hospital Research Center

Results: Survival rate was 92% after DS. The risk of death (Excess Hazard Ratio (EHR) was 1.2, almost that of the general population. After a mean of 7.3 years (range 2-15), 92% of patients with an initial BMI > 50 kg/m2 obtained a BMI <35>50 obtained a BMI <40.>5 was decreased by 86%. Patients' satisfaction in regard to weight loss was graded 3.6 on a basis of 5, and 95% of patients were satisfied with the overall results. Operative mortality was 1% which is comparable with gastric bypass surgery. The need for revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%). Failure to lose >25% of initial excess weight was 1.3%. Revision for failure to lose sufficient weight was needed in only 1.5%. Severe anemia, deficiency in vitamins or bone damage were exceptional, easily treatable, preventable and no permanent damage was documented.

Conclusion: In the long term, DS was very efficient in terms of cure rate for morbid obesity and its comorbidities. In terms of risk/benefit, DS was very sucessful with an appropriate system of follow-up.

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Discussion
In our view, morbid obesity is a metabolic disease that extends beyond uncontrolled appetite and abnormal food intake. For the past 25 years, our goal has been to change the basic physiology of these patients, allowing for excess weight loss, maintenance of weight loss and continuation of a normal life. We consider that it is important for quality of life to be able to eat normally. We felt that it was preferable not to concentrate our effort on food restriction, giving a false impression that the only problem is a lack of control of food intake, but rather to target correction of the metabolic dysfunction. In these patients, the difficulty has never been to attain weight loss, but to maintain that weight loss. Morbid obesity should be considered a chronic disease, which requires treatment for life.

The first 8 years (1982-1990), BPD as described by Scopinaro was the procedure of choice within this center. While the results were positive, a decrease in side effects with improvement of absorption were further targets. The procedure was modified successfully. For the last 15 years (1992-2007), DS has been our primary procedure for all patients. This choice has been reinforced with additional knowledge on important involvement of intestinal hormones in the etiology of obesity. It was also reinforced by the high long-term failure rates reported for numerous other procedures.

The present study could be considered exceptional. The Canadian medical system has facilitated an efficient follow-up of a large unselected cohort. We are not aware of any comparable study, using a consistent procedure with such an extended and thorough complete follow-up.

Our review shows excellent long-term results after 15 years. Both the weight loss and its maintenance compared favorably with any other procedure. It has the best "cure rate" where cure rate is defined as the absence of morbid obesity: 83% of those with an initial BMI >50 maintained a BMI <40 and 92% of those with an initial BMI <50 maintained a postoperative BMI <35.

DS also targeted co-morbidities. It "cured" most diabetic and dyslipidemic patients. For other associated morbidities, results were related to the extent of weight loss, where DS was as efficient as any other procedure.

The reluctance for using DS has been the concern over long-term risks. The present review should be reassuring. The procedure saves lives. A 15-year survival rate of 92% is much better than that of nonoperated morbidly obese subjects and perhaps even better than after RYGBP.8 The operative mortality was found to be comparable to that of RYGBP.13

The long-term risk for malnutrition is real but preventable. Deficiency in albumin, iron, calcium and fat-soluble vitamins requires compliance and medical attention. These deficiencies were rare, they appeared slowly, and were always reversible without permanent damage.
The procedure was relatively secure for bone maintenance. It is possible that with the medical attention provided after surgery, including increased physical activity, better alimentation and appropriate nutritional supplements, the procedure may even be beneficial for bone metabolism, rather than representing a risk.

The negative side-effects with DS were not benign. The unpleasant odor of stool and gas and the frequent abdominal bloating were the price to pay for these patients and it was a major preoccupation for many of them. However, 95% of patients declared themselves satisfied despite this handicap and no one has required reversal of the procedure for this reason.
The present evaluation has an important characteristic, in that it is comprised of a non-selected group of patients. No pre-selection was done on the basis of age, BMI, eating behavior, financial or psychological conditions, merits or expected difficulties for follow-up. With appropriate support, the procedure was found to be useful for all groups.

Thus, the global applications should be appreciated. We conclude that with a structured and devoted treatment team, DS is a very efficient bariatric operation, to the great satisfaction of both the patients and the care-providers.

Finally, one of the striking conclusions of this study is that, in spite of the inherent mortality risk of the bariatric surgery, the long-term outcomes are more positive than the mortality risk without surgery. Furthermore, in spite of the side-effects which are not minimal, the overall patient satisfaction dominates. These two points highlight the profound effect that morbid obesity has, not only on mortality, but also on quality of life.