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Often referred to as simply a ‘duodenal switch’ procedure, this particular form of bariatric surgery is in fact a vertical sleeve gastrectomy to which a duodenal switch is added. This procedure is also sometimes referred to as a biliopancreatic diversion with duodenal switch.

Of all of the different forms of weight loss surgery available today this is perhaps the most controversial and, though widely performed, there are many surgeons who will not carry out the procedure because of concerns about its long-term effects on a patient’s health.

The first part of the procedure is a vertical sleeve gastrectomy in which the stomach is divided vertically and approximately eighty-five percent is removed. The small remaining ‘sleeve shaped’ stomach, which retains the original outlet to the intestines, functions very much as a normal stomach and this part of the surgery is designed purely to restrict the quantity of food which can be consumed. This part of the operation is a form of ‘restrictive’ surgery and cannot be reversed.

The second phase of the operation is to create a duodenal switch and this is a form of ‘malabsorption’ surgery which is largely reversible. Whereas restrictive surgery creates weight loss by physically preventing the patient from eating too much food, malabsorption surgery is designed to restrict the body’s ability to absorb calories from a meal as it passes through the digestive tract.

During the procedure the intestine is divided and a small section (usually about 150 cm in length) is used to create a bypass from the duodenum, which is close to the stomach outlet, to a point near the end of the intestinal tract, thus bypassing the bulk of the digestive tract (typically about 500 cm will be bypassed). The result of this bypass (or duodenal switch) is that food passing through the intestine will only mix with the body’s digestive juices in the short final section of the intestine below the switch, giving the digestive juices very little time to digest the food and absorb calories from it into the body.

While duodenal switch weight loss surgery has the advantage of providing the patient with weight loss through both restriction and malabsorption, it is the degree to which the malabsorption element predominates in the duodenal switch which gives rise to much of the controversy surrounding this form of surgery. By comparison, the traditional Roux-en-Y operation has a much shorter bypass and the distance over which food mixes with the digestive juices in the intestine is in the region of five times greater.

The argument which many surgeons use against the duodenal switch is simply that so little absorption takes place that there is too great a risk of anemia, protein deficiency and metabolic bone disease. The vertical sleeve gastrectomy with duodenal switch is also arguably the most complex form of weight loss surgery and many believe that it carries an unacceptably high risk of complications.

Despite the risks however, the duodenal switch remains a surgical option and can be very effective, especially in patients with a very high body mass index (BMI).

No, those are not refugee orcs from “Lord of the Rings”. Leptin and ghrelin are hormones, and research is indicating that, while they didn’t have a role in the movie, they DO seem to have a role in weight gain and weight loss.

Two studies, one at the University of Chicago in Illinois and the other at Stanford University in California, indicated that sleep deprivation tended to alter the levels of these hormones in such a way that they did not efficiently fulfill their normal functions of controlling feelings of hunger and fullness. The short answer from these studies appears to be that being short on sleep, generally less than 8 hours a night, interferes with the work of these hormones, and that people getting less than 8 hours a night tended to be fatter than those who got the appropriate amount of sleep.

Here’s a couple of important points:

1. Just getting more sleep is not the only answer to the weight loss problem. While getting more sleep can improve the body’s ability to function in many ways, exercise and proper nutrition should still be components of any weight loss program. In fact, looking at it another way, some researchers have opined that getting a good night’s sleep might help some people feel more energetic and this may cause them to become more active as well, thus aiding in weight loss and overall feelings of well-being. One researcher also pointed out that those short on sleep may resort to high calorie, empty carbohydrate snacks and meals to help them get through the day.

2. The number of hours of sleep may be important, but so is the quality of that sleep. For example, sleep apnea, a condition which tends to be more common in those who are overweight, can interfere with the quality of the person’s sleep, so that even after what seems like 8 hours of sleep, they still are tired and worn out.

SLEEP, CORTISOL, AND WEIGHT LOSS

Cortisol is another hormone associated with appetite and weight loss and weight gain. Surely you have seen the ads in which it is referred to as “nasty”. In actuality, it is nothing of the sort any more than blood is “nasty”. It serves a purpose, in fact several purposes, but it is out of place in many of our modern situations, and the over production of cortisol can influence weight gain, and hamper attempts at weight loss.

The problem is that high levels of cortisol tend to help people pack on pounds. An elevation of cortisol commonly occurs when a person is physically or psychologically stressed. It is not enough that modern society produces a string of stressors which tend to kick the body into cortisol production mode. This is partly due to the body’s inability to distinguish between a caveman being attacked by a bear, and a modern office worker being attacked by a “bear” of a boss! The roar of an attacking lion can produce an effect similar to the honking of angry drivers in road rage situation…particularly if you are the target.

Failure to get the proper amount, and quality, of sleep tends to increase the production of cortisol, contributing to the body’s mistaken attempt to compensate for what it sees as an attack. Most real attacks would require vast expenditures of energy which would need to be replaced, so, cortisol signals the body to ingest large quantities of food to help replace the missing energy and perform repairs to the body. The problem is that if no energy has been expended, and you are merely suffering from lack of sleep, the body is going to get the same message as if you had escaped an attack, and the food taken in will just be stored as fat rather than being used to replace missing energy stores.

Lack of sleep also tends to produce its own state of agitation, which can induce the production of cortisol, and, to make things worse, worrying about your tiredness and inability to get a good night’s sleep can initiate its own cycle of stress, thus…you guessed it, encouraging the body to produce more cortisol, which makes you want to eat more…

While this seems like a vicious cycle, and it is, it is not unbreakable. No one immediate action is likely to have you waking up tomorrow fit as a fiddle and twenty pounds lighter, but you can take steps to slow down the hamster wheel and eventually get off for good.

Plan to get more sleep. Plan to get more exercise. Plan to eat a healthier diet. Once you have planned, however, you must implement these steps. Do not expect to change everything all at once. Make a small change here, and, once that has taken hold, make a small change there. Trying to do everything all at once sets you up for failure and creates another stress in your life at the very time you are trying to reduce stress.

Go to bed a little earlier. Turn the TV off sooner. Learn a little bit about meditation. Take a walk. Lift that bag of sugar a couple of extra times (in each hand) before you put it in the cupboard. Park a few feet further away from your office or the grocery store than you did last time. You learned to walk one step at a time, and you fell down a lot, but you didn’t let it bother you and you kept on until you finally achieved your goal and tottered a few feet on your own (and slept like…well…a baby). Don’t let this get in your way either.