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8 Nonalcoholic Steatohepatitis (NASH)
32. Mathurin P, Hollebecque A, Arnalsteen L, Buob D, Leteurtre E, Caiazzo R, Pigeyre M, Verkindt H, Dharancy S, Louvet A, Romon M, Pattou F. Prospective study of the long­term effects of bariatric surgery on liver injury in patients without advanced disease. Gastroenterology. 2009;137(2):532–40. https://doi.org/10.1053/j.gastro.2009.04.052. Epub 2009 May 4.
33. Taitano AA, Markow M, Finan JE, Wheeler DE, Gonzalvo JP, Murr MM.Bariatric surgery improves histological features of nonalcoholic fatty liver disease and liver brosis. J Gastrointest Surg. 2015;19(3):429–36; discussion 436–7. https://doi.org/10.1007/s11605- 014- 2678- y. Epub 2014 Dec 24.
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Chapter 9
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Patient Selection
AinitzeIbarzabalOlano, JavierOsorioAguilar, andAmadorGarciaRuizde Gordejuela
Duodenal switch is one of the most powerful bariatric procedures we have, despite this, it only represents 2% of the total bariatric procedures performed worldwide [1]. It was described in the late 1980s-early 1990s by Hess [2] and Marceau [3] as an evolution of the biliopancreatic diversion (BPD) in order to deal with its side effects. BPD had shown excellent weight loss results but some severe side effects as marginal ulceration, excessive diarrhea, and malnutrition.
The rst papers about duodenal switch (DS) were focused on technical facts and the rationale for vertical gastrectomy and the length of the limbs, but they did not discuss too much about patient selection [35]. Nowadays, there is overall consen­sus about the benets of this procedure in heavier patients, but special indication in super-obesity. The greater benets in terms of comorbidity improvement compared to other procedures are also well known [6, 7]. Finally, it is important to remark that even if it is a safe procedure, as other hypo-absorptive surgeries, DS is not indicated for all potential candidates, because factors like social conditions, incomes, access to supplementation, and good follow-up have to be taken also into account.
A. I. Olano (*) Gastrointestinal Surgery Department, Hospital Clinic, University of Barcelona, Barcelona, Spain e-mail: aibarza@clinic.cat
J. O. Aguilar Bariatric Surgery Unit, General Surgery Department, Bellvitge University Hospital, University of Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
A. G. R. de Gordejuela Endocrine, Metabolic and Bariatric Surgery Unit, Vall d’Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_9
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A. I. Olano et al.
9.1 Potential Candidates forDuodenal Switch
DS is one of the most powerful bariatric tools we have. It combines the restriction of a sleeve gastrectomy with the malabsorption of a distal intestinal bypass. The most common constructions of the bowel limbs consider a total alimentary limb of 250–300cm, with a 75–100cm common channel. Some original descriptions also took into consideration percentages of the total limb length, leaving a 50% of total alimentary limb where 10% of the bowel was left as common channel.
In an overall view, DS is considered for the same population as other bariatric procedures:
• BMI > 40 kg/m2 or BMI > 35 kg/m2 plus other medical condition related
to obesity
• Failed non-operative treatments for weight loss
• Mental health clearance
• No contraindications for surgery
Super-obese patients (SOP) are usually considered the best candidates for hypo­absorptive procedures. Restrictive procedures may have limited effect on this popu­lation. DS has important advantages to BPD and distal Roux-n-Y gastric bypass (RYGB) as it is a less ulcerogenic procedure and because vertical gastrectomy allows better food tolerance. The earlier descriptions of the duodenal switch already show good and sustained weight loss results in this population.
Risstad etal. [8] presented in 2015 a randomized controlled trial comparing DS vs RYGB y patients with BMI 50–60kg/m2. They found after 5years of follow-up that DS achieved sustained greater weight loss, plus greater improvement in lipid prole. Quality of life did not differ between both procedures, but DS was associ­ated with more surgical, nutritional, and gastrointestinal adverse effects. There are also some other comparative studies that show similar results.
The Clinical Guidelines cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists in its last review from 2019 [9] consider DS as an effective procedure for patients with very high BMI.
However, BMI 50kg/m2 does not represent a frontier line to indicate or not indi­cate DS.Patients with lower BMI may also benet from this powerful tool. The metabolic benets of this procedure have been widely published [1012], so it may also be indicated in patients with BMI 40–50kg/m2 with strong metabolic comorbid conditions.
9 Patient Selection
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9.2 Selection Algorithms
Buchwald presented a very interesting patient selection algorithm in 2002 [13]. Even though this paper may have severe limitations, it describes the aim of the potential candidate for duodenal switch. This algorithm considers 6 items: body mass index (BMI), age, gender, race, body habitus, and comorbidities. Following this algorithm, the more complex the patient, the more suitable he may be to a DS.
Himpens has also presented some algorithms with the same rationale. The Himpens Obesity Severity Score follows the same rules from the Buchwald’s algo­rithm but referring to other factors established the severity of the disease. Some years ago, the same author published his personal long-term experience with the DS [7]. In this publication, it is referred to a personal algorithm about his personal selection protocol. This protocol reected that DS was considered for metabolic patients, without GERD, and with binge eating.
9.3 Contraindications forDuodenal Switch
Contraindications for DS may be considered the same for all bariatric procedures:
• Pregnancy
• Severe psychiatric illness
• Eating disorders
• Patient-related contraindications to undergo surgery (cardiovascular risk, anes-
thetic risk)
• Substance misuse (alcoholism)
• Severe coagulopathies
We may also add contraindications for sleeve gastrectomy as severe reux (esophagitis greater than B) or big hiatal hernias; and contraindications for hypo­absorptive procedures:
• Inammatory bowel disease
• Immunosuppressant therapies
• Hypo-absorptive syndromes
• Familial polyposis colonic disease
• Colonic resections
• Fecal incontinence
Some of these contraindications should be considered relative contraindications, and a tailored approach is mandatory in those cases.
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The main specic contraindication for DS is related to its potential side effects. As a hypo-absorptive procedure, with high risk for protein malnutrition and a sig­nicant association with micronutrient deciencies, DS patients will have to follow a strict supplementation program [14, 15]. Some of these supplementations may be expensive and patients need to be conscious preoperatively. Patient adherence to the follow-up program by the multidisciplinary team is crucial to avoid long-term side effects. Even though it is difcult to predict how the patients will behave after sur­gery, it is important to try to detect those who may fail postoperative consultations.
In this procedure social conditions and incomes may also play a role as a poten­tial contraindication for DS. Patients with poor incomes with difcult access to supplementation, or they may be reluctant to continue the follow-up program, should not be considered for DS.
A. I. Olano et al.
9.4 Duodenal Switch asaStaged Procedure
DS is considered one of the most complex bariatric procedures technically speak­ing, as it includes sleeve gastrectomy, dissection and section of the rst portion of the duodenum, and two anastomoses. It is commonly indicated to higher BMI patients, so it is a difcult combination to deal with. From the paper of Regan and Gagner in 2003 [16] staging the bariatric surgery in those complex patients is a strategy to take into account.
Staged DS is thought to convert a high-risk procedure into two low-moderate risk procedures. Sleeve gastrectomy is challenging in these patients, but the dissec­tion of the duodenum and the duodeno-ileal anastomosis may be very difcult (heavy and short mesenteries, high volume liver). After a strong weight loss, the procedure is quite straightforward.
There are some papers [6, 1719] that demonstrate that DS is not charged with extra morbidity or mortality in patients with BMI up to 60kg/m2, so the real benet for this staged strategy might be for BMI over 60kg/m2. Second stage allows at the end the same weight loss as a primary procedure. This second stage can be sched­uled 12 to 24months after surgery, but the ideal time interval has not been dened.
On the other hand, there are also some patients initially planned for staged pro­cedures that continue losing weight and do not require a second stage [20]. They represent around 10–15% of the primary sleeve gastrectomies.
9.5 Duodenal Switch asaRescue forFailed
Primary Procedure
DS has also been described as an indication to rescue a failed primary procedure [21]. SG, RYGB, and single anastomosis DS (SADI-S) can be converted into DS.
9 Patient Selection
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SG to DS is a straightforward procedure. Failed SG, especially when SG had not been properly indicated, can be rescued by converting into DS.It is important to perform an adequate preoperative workup. GERD has to be excluded prior to going to the operating room, as it cannot be clearly stated if it may be related to over­weight or to sequelae of the SG.On the other hand, it is also important to evaluate potential dilation of the gastroplasty as the restrictive component may also be restored.
Failed RYGB can also be converted into DS [22, 23]. It has been stated that con- version into DS is the most effective solution for a failed RYGB, but it is also the most challenging. Conversion from RYGB to DS is a complex procedure that can be performed in one or two stages. We may nd several series of cases in the literature but high morbidity but with good weight loss results.
Finally, SADI-S can be converted into DS just by adding a Roux anastomosis. This is the most effective solution in case of bile reux after SADI-S, but it has also been proposed to fail weight loss. There is just a little evidence about the potential benet from this conversion.
References
1. Welbourn R, Hollyman M, Kinsman R, etal. Bariatric surgery worldwide: baseline demo­graphic description and one-year outcomes from the fourth IFSO global registry report 2018. Obes Surg. 2019;29:782–95.
2. Hess S, Hess W.Biliopancreatic switch diversion with a duodenal. Obesity. 1998:267–82.
3. Lagacé M, Marceau P, Marceau S, Hould F-S, Potvin M, Bourque R-A, Biron S.Biliopancreatic diversion with a new type of gastrectomy: some previous conclusions revisited. Obes Surg. 1995;5:411–8.
4. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267–82.
5. Marceau P, Biron S, Bourque RAR, Potvin M, Hould FS, Simard S.Biliopancreatic diversion with a new type of gastrectomy. Obes Surg. 1993;3:29–35.
6. Biertho L, Lebel S, Marceau S, Hould F-SS, Lescelleur O, Moustarah F, Simard S, Biron S, Marceau P. Perioperative complications in a consecutive series of 1000 duodenal switches. Surg Obes Relat Dis. 2013;9:63–8.
7. Bolckmans R, Himpens J.Long-term (>10 Yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg. 2016;264:1029–37.
8. 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. JAMA Surg. 2015;150:352–61.
9. Mechanick JI, Apovian C, Brethauer S, etal. Clinical practice guidelines for the periopera­tive nutrition, metabolic, and nonsurgical support of patients undergoing bariatric proce­dures—2019 update: cosponsored by American Association of Clinical Endocrinologists/ American College of Endocrinology. Obesity. 2020;28:175–247.
10. Marceau P, Biron S, Hould F-SS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S.Duodenal switch: long-term results. Obes Surg. 2007;17:1421–30.
11. Biron S, Hould F-S, Lebel S, Marceau S, Lescelleur O, Simard S, Marceau P.Twenty years of biliopancreatic diversion: what is the goal of the surgery? Obes Surg. 2004;14:160–4.
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12. Obeid NR, Malick W, Concors SJ, etal. Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data. Surg Obes Relat Dis. 2016;12:11–20.
13. Buchwald H.A bariatric surgery algorithm. Obes Surg. 2002;12:733–46; discussion 747–50.
14. Backes CF, Lopes E, Tetelbom A, Heineck I. Medication and nutritional supplement use before and after bariatric surgery. Sao Paulo Med J. 2016;134:491–500.
15. Nett P, Borbély Y, Kröll D.Micronutrient supplementation after biliopancreatic diversion with duodenal switch in the long term. Obesity Surg. 2016;1–6.
16. Regan JP, Inabnet WB, Gagner M, Pomp A.Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–4.
17. Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S.Duodenal switch operative mortality and morbidity are not impacted by body mass index. Ann Surg. 2008;248:541–7.
18. Topart P, Becouarn G, Ritz P.Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI 50 kg/m2? SOARD. 2010;6:59–63.
19. Rezvani M, Sucandy I, Klar A, Bonanni F, Antanavicius G.Is laparoscopic single-stage bilio­pancreatic diversion with duodenal switch safe in super morbidly obese patients? Surg Obes Relat Dis. 2014;10:427–30.
20. Hidalgo M, Vilallonga R, Ruiz de Godejuela AG, etal. Effectiveness of laparoscopic sleeve gastrectomy in super-obese and non-super-obese patients. Surg Laparosc Endosc Percutan Tech. 2020;30:403–7.
21. Cheung D, Switzer NJ, Gill RS, Shi X, Karmali S.Revisional bariatric surgery following failed primary laparoscopic sleeve gastrectomy: a systematic review. Obes Surg. 2014;24:1757–63.
22. Parikh M, Pomp A, Gagner M.Laparoscopic conversion of failed gastric bypass to duo­denal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis. 2007;3:611–8.
23. Trelles N, Gagner M. Revision bariatric surgery: laparoscopic conversion of failed gastric bypass to biliopancreatic diversion with duodenal switch. Minerva Chir. 2009;64:277–84.
A. I. Olano et al.
Chapter 10
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Psychological andPsychiatric Workup
HélioTonelli andAndréiaTonelli
10.1 Introduction
Bariatric surgery is the most effective treatment for morbid obesity [1], a condition that is increasingly common worldwide and that affects children particularly. Shortly, the costs of preventing and treating obesity, as well as its metabolic compli­cations, shall not be fully covered by health systems [2]. Biliopancreatic diversion with duodenal switch (BPDDS), along with gastric bypass (RYGBP), is among the surgical techniques leading to weight loss and its maintenance over time [3]. BPDDS includes three specic components: (1) a longitudinal gastrectomy, provid­ing caloric restriction and decreasing acid production, while maintaining normal gastric emptying; (2) a 250cm total alimentary limb whose role is to reduce caloric absorption; and (3) a 100cm common channel where the bolus mixes with biliopan­creatic juices, resulting in decreased absorption of protein and fat [4]. Although long-term data on health-related quality of life (HRQL) after BPDDS is scarce, Aasprang et al. [5] accessed HRQL through a self-administered questionnaire, before and 1, 2, 5, and 10years after BPDDS, showing long-term improvement in physical and mental scores. Søvik etal. [6] showed a reduction in uncontrolled and emotional eating behaviors, as well as an improvement in psychosocial function both after duodenal switch and RYGBP. Despite these results, 20% of patients undergoing bariatric surgery fail to maintain weight loss 2years after surgery [1]. A signicant number of these patients suffer from dysfunctional eating behaviors
H. Tonelli (*) Psychiatrist at the Caetano Marchesini Clinic, Invited Professor of Psychopathology, Neuroscience and Social Cognition at FAE Business School, Curitiba, Brazil
A. Tonelli Neuroscience and Social Cognition at FAE Business School, Curitiba, Brazil
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_10
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(DEB) leading to a recurrence of obesity after bariatric surgery [7], which makes the prompt identication and treatment of DEB in bariatric patients imperative. This chapter aims to discuss the many psychological and psychiatric variables that may jeopardize BPDDS short-, medium-, and long-term outcomes. It is important to highlight that the literature on psychological and psychiatric aspects specically related to BPDDS is still scarce; hence, many of the points discussed here stem from studies not necessarily performed with patients undergoing BPDDS.
H. Tonelli and A. Tonelli
10.2 Important Psychological Aspects ontheEvaluation
andFollow-Up ofCandidates forBariatric Surgery
Despite the countless benets currently documented of bariatric surgery, not only related to signicant weight loss and its long-term maintenance, but also regarding measures of quality of life and psychopathology, less is known about the origin of post-surgical undesirable psychological and behavioral outcomes affecting patients’ eating behavior [8]. Data on patients undergoing BPDDS are even more scarce. Undesirable psychological and behavioral outcomes possibly reect psychological and behavioral problems present before surgery, which, if not properly identied and treated, will certainly interfere negatively with BPDDS results. Nevertheless, it is important to remember that obesity is a complex pathological condition in which behavior is only one of the many dimensions to be addressed for obesity’s suitable comprehension. Biological factors such as chronic low-grade systemic inamma­tion triggered by obesity [9], alterations of the intestinal microbiome [10], and brain insulin resistance [11] have been widely described as protagonists in the patho­physiology of obesity, which are known to impact the brain and the minds of patients with obesity. Such impacts are reected, for instance, in the ability to control food consumption and adhere to physical activity programs [8]. It is possible that these factors have an even broader participation in how they modify the mind of people with obesity, altering their cognition [12], emotions [13], motivation [14], self­regulatory processes [15], and even their ability to identify emotions and other men­tal states in others [7].
Neuroimaging studies show that bariatric surgery can reverse anomalous recruit­ment and connectivity patterns in different brain areas related to both the processing of pleasure and reward associated with eating, and brain areas associated with cog­nitive control [16, 17]. This strongly suggests that bariatric surgery may help nor­malize several neuropsych pathological processes favoring DEB such as binges, emotional eating (EE), and food addiction (FA). Potential mechanisms for regulat­ing brain activity by bariatric surgery include, in addition to improving inamma­tion, changes in the expression of dopaminergic receptors in key areas such as the ventral striatum, putamen, caudate, thalamus, and hypothalamus, as well as post­surgical changes in the concentration of peptides such as ghrelin, GLP-1, and pep­tide YY [18]. Findings like these are, however, still controversial. Therefore, the
10 Psychological andPsychiatric Workup
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complexity of the mechanisms through which obesity and bariatric surgery can affect the mind and behavior requires that the mental health professional working with bariatric patients have a broad knowledge about the countless variables at stake, which, when not properly controlled, may threaten the surgical results.
The processing of emotions seems to be affected by obesity, favoring BED, which interferes in the results of BPDDS and all other surgical techniques. Indeed, patients with obesity frequently say that their emotions drive or determine their eat­ing behaviors. These patients usually state that they consume food—usually caloric ones—in order to relieve emotions—typically the unpleasant ones.
Emotions are dened as short-term affective responses triggered by environmen­tal stimuli, situations, or events with reinforcing potential [19]. They have different motivational functions and contribute to the control of basic behavioral systems in animals and humans. Emotions may affect all eating behavior, including motivation to eat, affective responses to food, food choices, chewing, speed of eating, amount of food ingested, and even metabolism and digestion [19]. Thus, emotions and eat­ing behavior are closely linked; however, the nature of this connection is not yet fully understood. Hunger is indeed a potent emotional modulator. In fact, hungry animals and humans tend to be more alert and irritable and diverse stimuli elicit dif­ferent emotional responses in individuals with and without hunger [20]. Nevertheless, there is an individual variation in how emotions may affect eating behavior. Several experiments have shown that individuals restricting food in order to decrease or maintain weight eat more in response to fear and negative moods than individuals who do not [19]. These studies also show that emotional eaters tend to consume more sweet and fatty foods in response to emotional stress, and compulsive eaters tend to have binges when facing negative emotions [19]. Negative emotions need to be regulated and it is possible that, in at least a percentage of individuals with obe­sity, they will be anomalously regulated with caloric foods. Emotion regulation (ER) is a multidimensional construct encompassing the ability to respond to per­sonal and social demands with acceptable and exible behaviors and emotions, as well as the ability to postpone and even suppress spontaneous reactions when this is necessary or convenient. ER is achieved through psychological processes such as monitoring, appreciating, and changing the magnitude of emotional reactions [21].
Many patients compare their relationship with food with that displayed by addicts to psychoactive substances, a similarity with an irresistible intuitive appeal, since individuals who consider themselves addicted on food present behavioral phe­nomena such as cravings, feelings of loss of control, excessive consumption, toler­ance, and even signs of food withdrawal. Indeed, obesity and addictions share neurobiological processes that result in compulsive consumption, which are conse­quences of problems on the suitable functioning of reward processing circuits, where dopamine plays an essential role.
The particularly reinforcing character of food in obesity characterizes its addic- tive dimension [22]. The neurobiological factors traditionally studied in both condi- tions include three interconnected brain systems that control eating behavior: the hypothalamus (which responds to internal signals about the energy balance); limbic