I'm Rana Pullat. I'm the clinical director of Bariatrics and Robotic Surgery at the Medical University of South Carolina. The duodenal switch operation is a weight loss procedure, among the many approved procedures for weight loss. This duodenal switch procedure is the most effective procedure for diabetic patients and for the super obese patients. And by super obesity, we mean a body mass index greater than 50. But even if patients are not diabetic and desire a significant amount of weight loss, this operation has the most amount of weight that a patient can lose. For a duodenal switch, we first perform a sleeve gastrectomy, which is narrowing of the stomach by taking out the greater curvature of the stomach. So the sleeve is calibrated with a 48 or a 50 French bougie. And this reduces the amount of food the patient can intake, as well as reduces the amount of ghrelin, because the fundus is removed. So ghrelin is an anorexigenic hormone. So the patient stimulus to eat is reduced by taking out the ghrelin.
And then once we do that operation, then the technically more demanding part comes. We would dissect the first portion of the duodenum of this patient and transect the duodenum just past the pyloris. Once we do that, we then measure the bowel at about 300 centimeters from the ileocecal junction. We would create and anastomosis between the duodenum and the ileum. And then a common channel of 125 centimeters is measured out from the ileocecal junction to anastomose to the biliary limb. And this is how we perform the surgery. The advantage is pyloric preservation. We know that pyloric preservation helps in glucose homeostasis. So there's no dumping. There's no rapid excursions of glucose and rapid excursions of insulin. We know that a steady state insulin secretion aids in weight loss, rather than the excursions that can happen. For example, in gastric bypass patients there's a huge excursion of glucose. And if you notice, there's some pretty significant amount of recidivism in gastric bypass patients. And we do think that this recidivism of weight is from these glucose excursions that patients get. It's an aggressive form of dumping where the food load goes from the gastric pouch directly into the bowel, thereby stimulating insulin release and patients becoming hypoglycemic. And this then causes a circle where the patient eats more to satiate their hypoglycemia. So the surgery is a judgment issue. We always look at the weight loss as a counter factor to the amount of risk we take. Obviously, the liver being super heavy would necessitate the patient to have a two-stage procedure.
We've done this successfully as a single stage procedure in BMIs as high as 88. Our heaviest patient weighed close to 600 pounds while doing this procedure.
The critical thing that as a surgeon I determine is the amount of liver weight. If the liver is extremely heavy, then retracting that becomes technically very difficult and dissecting the duodenum in those patients can be technically extremely challenging. We also look for the bowel, how well the ballot will reach up to the duodenum. So those are technical factors that we watch out for. It's important to understand that any kind of weight loss surgery is just another tool. People sometimes think of weight loss surgery as a cop out. But I tell people that obesity should be viewed as a disease process. You wouldn't just tell a diabetic or a hypertensive, we're not going to treat you with medications.
You are going to give them medications. And obesity should be treated the same way.
And surgery is the best form of treatment that we have. It's very frustrating to tell a patient to go lose weight on their own, because we know long-term studies have shown that the great majority of those patients will fail and probably gain all their weight back, even if they did a bunch of diets. The surgery itself, it's not a cop out, but it's a required form of treatment for these patients who then are able to get a level playing field as far as their metabolic disease is concerned, and it would be less frustrating for them. We still place a huge impetus on the patient to stick to diet and exercise.
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