Ashraf Haddad Bariatric surgery is on the rise worldwide especially after the introduction of laparoscopic procedures with their high safety low complication profile. Metabolic and bariatric surgery is the only durable and effective treatment for obesity. Worldwide trends have shown the sleeve gastrectomy (SG) and the Roux‐en‐Y gastric bypass (RYGB) to be the most commonly performed procedures worldwide accounting for more than 83% of all bariatric procedures. Other (alternative procedures) include biliopancreatic diversion (BPD), duodenal switch (BPD‐DS), single anastomosis duodenal switch (SADIS), duodeno‐jejunal bypass (DJB) and one anastomosis gastric bypass (OAGB) (Figure 18.1). The BPD was first performed in humans by Dr Nicola Scopinaro more than 30 years ago. It is unanimously considered the most effective surgical treatment available for morbid obesity. In 2002, Dr Scopinaro published his BPD laparoscopic technique and results. The BPD consists of a distal gastrectomy with a Roux‐en‐Y reconstruction. Although the initial series of patients had varying length of small bowel bypassed, the BPD has become a very standardised procedure throughout the years (Figure 18.2). The volume of the gastric reservoir is usually between 200 and 500 ml. A volume of 150 ml or less is associated with up to 30% malnutrition rate. The gastric volume is important as it controls the transient time of food. The second key factor is the alimentary limb length (AL). The AL was made between 200 and 300 cm. Later on, it was standardised to 250 cm as it offered a superior weight‐loss outcome and a relatively low malnutrition rate. Finally, the common channel (CC) has been standardised to 50 cm. It is lengthened to 75–100 cm only in those with body mass index (BMI) < 35 kg m−2 with the intention to treat type 2 diabetes. Essentially, the BPD combines the restriction and increased gastric emptying of gastric volume reduction with intestinal bypass and reduced caloric absorption. However, this procedure is rarely performed nowadays. Table 18.1 summarises the outcomes of resolution of co‐morbidities after BPD. BPD‐associated complications are divided into either immediate or specific late complications (Table 18.2). One issue worth discussing is that most BPD patients in general will have up to four foul soft bowel movements daily. All have foul smelling stool, and most will have flatulence. Protein calorie malnutrition is the most serious late complication requiring surgical revision. Figure 18.2 A distal gastrectomy is performed. Small bowel is divided 250 cm proximal to ileocecal valve and anastomosed to the stomach. The biliopancreatic limb (BPL) is anastomosed 50 cm proximal to the ileocecal valve to form a 200 cm AL and a 50 cm CC. Source: Nicola Scopinaro 2006 / with permission of Springer Nature. Figure 18.1 Number of the main primary bariatric/metabolic surgical procedures from 2008 to 2016: AGB adjustable gastric banding, RYGB Roux‐en‐Y gastric bypass, SG sleeve gastrectomy, BPD‐DS biliopancreatic diversionduodenal switch and OAGB one anastomosis gastric bypass. Source: Based on Angrisani et al. (2018). Table 18.1 Long‐term rate of resolution of co‐morbidities after BPD. Table 18.2 Immediate and late specific complications of BPD. a Combined rate of 1.2–2.7%. Scopinaro’s BPD had excellent weight‐loss and metabolic results; however, the associated side effects, such as post‐gastrectomy syndrome, marginal ulcers, gastrointestinal symptoms, dumping syndrome and malnutrition, led surgeons to develop modifications of the technique. In the late 1980s, this technique was developed to include a Longitudinal gastrectomy thus preserving the pylorus and first part of duodenum, and a 100 cm CC. Although the BPD evolved into the BPD‐DS, some authors believe that they are different procedures with different safety profile, thus the wordy association of BPD‐DS has to be removed. We refer to the procedure as DS in this chapter. The first step is creation of the longitudinal SG stomach with a volume of 100–150 cc. This is followed by dissection of the first part of the duodenum (care is exercised as the common bile duct, head of pancreas and gastroduodenal artery lie in the vicinity). The duodenum is transected 2–4 cm from the pylorus (Figure 18.3). Figure 18.3 SG is performed followed by duodenal transection. AL of 150 cm and CC of 100 cm are created (100 cm CC or 10% of TSBL; 150 cm BP limb or 40% of TSBL). The next step is determining the limb lengths, and there are two techniques to do that. The first technique uses fixed limb lengths where the small bowel is transected 250 cm proximal to the ileocecal valve (ICV) and the enteroenterostomy is fashioned 100 cm from the ICV. This creates a 150 cm AL limb and 100 cm CC. The second technique uses percentages where the total length of the small bowel (TSBL) is measured. Then the AL is measured as 40% of the TSBL, while the CC is measured as 10%. The DS was designed to harness most of the metabolic power of the BPD with less complications, namely malnutrition and the post gastrectomy syndromes. The use of percentages in DS carries a lesser risk of malnutrition on the expense of slightly lesser weight loss compared to the fixed limb length DS. The percentage of excess weight loss (%EBWL) is reported 75% at 10 years. Table 18.3 summarises the outcomes of resolution of co‐morbidities after DS. Complications are summarised into immediate post‐operative complications and late complication, which are mainly nutritional in nature (Table 18.4). Both BPD and DS require intense vitamin supplementation, including calcium, iron, vitamin A, vitamin D and multivitamins. Table 18.3 Resolution of co‐morbidities after DS. Table 18.4 Immediate and late specific complications of DS.
18
Alternative Bariatric Procedure
Introduction
Biliopancreatic Diversion (BPD)
History
Technique
Outcomes
Complications
Co‐morbidity
Resolution (%)
Pickwickian syndrome
100
Somnolence
100
Hypertension
81
Fatty liver
87
Hypercholesterolemia
100
Hyperglycaemia
100
Type 2 DM
100
Hyperuricemia
94
Immediate complications
Specific late complications
Operative mortality (<0.5%)
Anaemia (up to 40% of patients)
Bleedinga
Stomal ulcers
Wound dehiscencea
Bone dimerinelisation
Wound infectionsa
Peripheral neuropathy and Wernicke’s encephalopathy
Protein calorie malnutrition and malnutrition
Duodenal Switch (BPD‐DS or DS)
History
Technique
Outcomes
Complications
Co‐morbidity
Resolution or improvement (%)
Asthma
88
Obstructive sleep apnoea
90–95
Hypertension
81
Hyperlipidaemia
99
Hyperglycaemia
85
Type 2 DM
90–92
Immediate complications
Specific late complications
Operative mortality (0.5–1%)
Long‐term mortality (could be due to malnutrition, gastrointestinal bleeding or intestinal obstruction)
Leak (0.7%)
Anaemia (14% risk of moderate anaemia, <1% risk of sever post‐operative anaemia)
Bleeding (<2%)
Calcium
Insufficiency 20%
Deficiency 1.3%
Wound infections 7.8%
Protein calorie malnutrition and malnutrition
Wound dehiscence 0.9%
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
