Duodenal Switch vs RNY: Both Have Major Problems; Pick Your Poison

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BMJ 2011; 343 doi: 10.1136/bmj.d5798 (Published 14 September 2011)

Cite this as: BMJ 2011;343:d5798
 

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Sovik and colleagues (1) are to be congratulated on performing one of
the few RCTs comparing bariatric surgical procedures, but their paper has
serious flaws which were not identified in the accompanying editorial (2)
nor the subsequent reports in other journals(3) and specialist websites.

What Sovik’s data actually illustrates is that if duodenal switch
(DS) is performed on randomly (instead of carefully) selected patients by
relatively inexperienced surgeons and if patients are then given sub-
optimal vitamin replacement (more suited to a short-limb Roux-en-Y gastric
bypass) and infrequent follow-up, post-operative problems are not
uncommon. In fact with this study design it was remarkable that so few
adverse events were seen.

Our experience of 125 DS patients followed for up to 5 years(4)
confirmed Sovik’s report that the DS is indeed associated with reversible
nutritional deficiencies (particularly vitamin D). However, we and others
recognize that the DS is not a universally applicable operation because it
requires an exceptional level of post-operative patient compliance. Few
patients are capable of this and without careful selection problems can
occur, particularly if, as in this study, their nutrition is only being
monitored once every 6-12 months during the crucial mid-late post-
operative period. The very notion of randomizing potentially non-compliant
patients to a DS is flawed.

Sovik previously reported (5) that most of the difference in
complication rates between the two operations occurred in the first 30
days after surgery and was related to technical complications (including
an unusually high leak/abscess rate of 10.3%) or complications
attributable to the DS’s prolonged operative time. Their current paper
confirms this to be the case as only an additional 4 gastric bypass and 7
DS patients developed complications between 30 days and 1 year post-op.
Although not statistically significant, the most common adverse event in
the DS group was vomiting (3/7), which is understandable given the
extremely tight (30-32F) sleeve gastrectomy the authors performed. In
year two, a further 5 gastric bypass patients developed adverse events,
compared to just 3 DS patients (two due to trauma rather than surgery).

The DS is a technically challenging procedure and mandates a strict
post-operative regime with intensive support from the bariatric team. It
is clear that to keep the frequency of adverse events to a minimum in the
early and late post-operative periods the DS should only be offered to
carefully selected patients treated in specialist centres. Sovik’s paper
simply confirms this and adds little more.

DD Kerrigan

CJ Magee

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