A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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B16 Bariatric Times • November 2016 • Supplement B FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH I n some cases, the sleeve gastrectomy (SG) procedure may not be sufficient in achieving long- term results in patients with obesity and other metabolic diseases, especially type 2 diabetes mellitus (T2DM). The classical complement to SG, the duodenal switch (DS), leads to the best results in resolving obesity and other metabolic diseases, including T2DM, with the minimal incidence of relapses among all bariatric procedures. Despite the most potent results, SG+DS never gained popularity, mainly because of complexity and the malabsorption that it produces is hazardous. The positive results of a Roux-en-Y gastric bypass (RYGB) were initially attributed to restriction and to malabsorption. However, recently, it was found that there was no significant caloric malabsorption in a RYGB. The positive results are now attributed mainly to metabolic changes. 1 RYGB excludes the proximal gut aiming, initially, at caloric malabsorption. This exclusion, however, reduces the proximal gut neuroendocrine activity while simultaneously enhances distal gut activity. In the case of RYGB, a non- existent caloric malabsorption was taking credit for positive results that were due to metabolic changes. 2 The very same phenomenon might be happening to SG+DS. Its strong positive results are attributed to the significant caloric malabsorption that it causes. But, as it provokes a whole proximal gut neuroendocrine deactivation and major nutritive stimuli to the distal gut, this metabolic change may be the major factor responsible for the positive results. Now, many, if not most, bariatric surgeons believe that all the significant good results that come from the many types of surgeries developed to treat obesity are indeed metabolic. Minimal gastric pouches, narrow anastomoses, rings, and bands are mechanical restriction, and they are always there, even in the first bite. They are an obstacle for the passage of food. Mechanical restrictions are not physiological. All normal humans present restrictive mechanisms but they are functional. After meals, food is sent to the gut and just after eating a significant amount, gut signals slow down the gastric emptying 3 so that the next portions will be stored in the gastric chamber. As the storage capacity is limited, at a certain point, internal gastric pressure is high and the meal will be finished. Meals therefore are biphasic: first you are hungry, and food is going fast to the gut; later, intestinal signals (the intestinal satiety) appears, hunger is gone and gluttony keeps you eating until the stomach is full (the gastric satiety). Observe that the functional restriction appears only later and not after the first bite, 4 and it is very much dependent on gut signals. Mechanical restrictions limit ingestion; functional restrictions limit stocking. A metabolic surgery can provoke an earlier functional restriction and avoid a static mechanical restriction. This is a major • Sleeve gastrectomy (SG) many times is not sufficient to achieve long-term results in obesity and other metabolic diseases, especially type 2 diabetes. • Duodenal switch, the most effective complement to a SG, never gained popularity due to surgical complexity and the malabsorption it provokes. • There is solid evidence for a proximal-distal gut endocrine imbalance, with a proximal hyperactivity and distal hypoactivity in metabolic syndrome. • Transit bipartition (TB) creates a new proximal-distal balance by bringing nutrients rapidly into the whole ileum and by shifting food from the proximal to distal gut. • Pure Metabolic Surgery: simple and safe, SG+TB avoids malabsorption and excluded segments, still maintaining the long-term potency similar to biliopancreatic derivations. KEY POINTS Transit Bipartition—A Simple and Potent Metabolic Complement to the Sleeve Gastrectomy Sérgio Santoro, MD, TCBC, TCBCD Bariatric Times. 2016;13(11 Suppl B):B16–B18. AUTHOR AFFILIATIONS: Sérgio Santoro, MD, TCBC, TCBCD, is from Hospital Albert Einstein, São Paulo, Brazil ADDRESS FOR CORRESPONDENCE: Dr. Sérgio Santoro, Rua São Paulo Antigo 500, apt 111B são Paulo, SP, Brazil 05684-011; Phone: 55-11-99137- 0930; Fax: 55-11-3758-4054; E-mail: firstname.lastname@example.org FUNDING AND DISCLOSURES: No funding was provided. Dr. Santoro reports no conflicts of interest relevant to the content of this article.