Biliopancreatic Diversion with Duodenal Switch Alfons Pomp, MD FACS Weill Medical College of Cornell University New York Presbyterian Hospital

apomp@med.cornell.edu Disclosure Consultant/speaker bureau Covidien Ethicon Endo Surgery W.L.Gore Associates apomp@med.cornell.edu

Surgical Procedures: Biliopancreatic Diversion (BPD) Nicola Scopinaro, Genoa, Italy 1976 Large gastric pouch Alimentary limb 250 cm Biliopancreatic limb Common channel 50-75 cm Mechanism: mildly restrictive malabsorptive

Surgical Procedures: Biliopancreatic Diversion (BPD) Problems: Marginal ulcer Diarrhea Excessive flatus Malnutrition This has not stopped surgeons from using it!

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Surgical Procedures: BPD with Duodenal Switch (BPD/DS) Doug Hess, 1988 Picard Marceau “Sleeve” gastric pouch Alimentary limb 40% of bowel (250-300 cm) Common channel 50-100 cm (arbitrary) Benefits over BPD: no dumping decreased marginal ulcer better tolerated

Reroute the intestinal tract into long alimentary and bilio-pancreatic limbs Weight loss is generally secondary to mal-absorption of nutrients (better to say metabolic effects!) rather than gastric restriction The length of the common channel appears proportional to the risk of nutritional deficiencies Greater weight loss but higher operative risk and more long term sequelae than the gastric “bypass” procedures (Ca, fat soluble vitamins, protein deficiencies, etc)

Lap Biliopancreatic Diversion with Duodenal Switch

Technique Sleeve gastrectomy Duodenal transection Identification of ileocecal valve (vs ligament of Treitz) Duodenal – ileal anastomosis

Sleeve Gastrectomy

Surgical Procedures: Laparoscopic BPD/DS: Technique Technique of duodeno-ileostomy Transgastric (duodenal) EEA anvil Transabdominal Linear stapler Hand sewn

DS – Anvil Technique

DS – Hand Sewn

Weight Change SOS so not EBWL

The Super Obese MacLean et al., Ann Surg, April 2000

Super-obese BPD-DS delivers superior weight loss outcomes in superobese compared to RYGB* *Prachand et al. Ann Surg 2006

DS Complications and BMI

BPD-DS for Super-Super Morbidly Obese Patients 23% 17% 6.5% 3.5%

First Stage Second Stage Normal Range

Sleeve gastrectomy RYGB 8 / 73 patients GERD = 3; Weight regain = 5 Interval 33 months 36F bougie All patients had resolution of GERD 1 postoperative leak; treated with stent Langer FB, et al; Obes Surg; Online April 15, 2010

Sleeve gastrectomy RYGB Mean weight reduction = 15 + 8kg (range = 6-25kg) Langer FB, et al; Obes Surg; Online April 15, 2010

British Journal of Surgery 2010;97(2):160-166 24

Results Peri-operative results (<30 days) No mortality Mean (SD) operative time: LRYGB: 91 (33) min LDS: 206 (47) min ….. (p<0.001) Conversion rates: 1 LDS procedure, 0 LRYGB Complications: LRYGB n=4 LDS n=7 .…. (p=0.327) Median (range) LOS LRYGB 2 (2-15) days LDS 4 (2-43) days .…. (p<0.001)

Results Weight loss:

Conclusion Large difference in BMI at 1 year (6 kg/m2 lower in LDS group), and stability of weight loss after DS shown by other groups, suggest that LDS is better at promoting short- and long-term weight loss in super-obese patients

Biertho et al, SOARD 2010;6(5):508-514 28

Aim To determine safety & efficacy of DS as a primary weight loss procedure in patients with BMI < 50 kg/m2 Usually reserved for super-obese (BMI >50) because of increased risk of nutritional complications

Results 810 consecutive patients (1992-2005): BMI< 50 637 women (78.6%) Mean age: 41.1 years Mean preop BMI: 44.2 kg/m2 (Range 33-49) Comorbidities: DM 28% (n=227) Hypertension 37% Sleep apnea 25% Mean follow-up: 103 months (Range 36-201) Mean hospital stay: 6.9±5.4 days followed up for a mean of 103 49 months (range 36–201). Their mean age at surgery was 41.1 10.5 years. The mean weight and BMI was 120 16.5 kg and 44.2 3.6 kg/m2 (range 33–49), respectively. Before surgery, 230 patients (28%) were being treated for diabetes, 302 (37%) were being treated for hypertension, and 205 (25%) used an apparatus for sleep apnea.

Results Complications: * * * * Intra-op: 0.7% (n=7) Liver laceration (1) Splenic injuries (6) Major post-op: 4.9% (n=40) 5 operative deaths (<30 days) Minor complications: 8% (n=66) Wound infections Respiratory infections Intestinal disturbance * During surgery, 7 complications (.9%) occurred, including 1 liver laceration and 6 spleen injuries, necessitating splenectomy in 3. Major postoperative complications occurred in 40 patients (4.9%) and included 5 operative deaths (.6%) within 30 days of surgery (2 patients died of pulmonary embolism, 2 of septicemia, and 1 of metabolic acidosis; Table 1). A total of 66 minor complications (8%) occurred, including 12 wound infections, 15 pulmonary infections, and 35 intestinal disturbances, presenting as ileus, food intolerance, or gastric retention. The mean hospital stay was 6.9 5.4 days. * * *

Results Long-term outcomes Weight loss: At mean of 8.6 years: EWL 76% ± 22.3% Only 11% had EWL <50% BMI was <35 in 92%, and < 30 in 71% After a mean of 8.6 years, only 11% of patients had an excess weight loss of 50%. The BMI was 35 kg/m2 and 30 kg/m2 in 92% and 71% of patients, respectively.

Results Comorbidity status postoperatively: Patient satisfaction DM: 92.5% ‘cured’ (requiring no medications) Hypertension: 60% no longer requiring anti-hypertensives Sleep apnea: Only 2% still require an apparatus Patient satisfaction 63% very satisfied with weight loss; 91% very satisfied overall outcome

Results Long-term complications Rehospitalization required in 15.8% (n=127) In 35 patients (4%), the rehospitalization was for malnutrition. In 90%, the readmission occurred within the first year after surgery, and they required only medical treatment. In 12 patients (1.5%), surgery for malnutrition was required (feeding jejunostomy in 3, lengthening of the common channel in 9, and reversal of the intestinal switch in 2). The lengthening of the common channel (typically from 100 to 200 cm along the biliary limb) was successful in 6 patients. The other 3 patients required another procedure to increase the common channel further. Revision by lengthening of the common channel was also required for diarrhea in 2 patients. In 12 patients (1.5%), revision was done for insufficient weight loss and consisted of repeat gastrectomy in 4, intestinal shortening in 5, and repeat gastrectomy with intestinal shortening in 3.

10 years post duodenal switch Deficiencies are infrequent and correctable (25 years gives no sign of latent damage) 10 years post duodenal switch Normal Inadequacy Deficiency n range % Vitamin A mmol/l 325 >1.2 91.4 7.7 <0.7 0.9 Vitamin D nmol/l 307 >50 72.3 21.0 <30 6.5 Calcium mmol/l 367 >2.10 85 12.0 <2 .00 3 Iron mmol/l 363 >8 84.3 12 <4 3.8 Ferritine Ug/l 348 >9 83.6 13.8 2.6 Hgb g/l 365 >120 10.4 <110 6 PTH pmol/l 338 <90 79.2 16.5 >150 4

Henry Buchwald JAMA 2004 GB GBP BPD Improved diabetes % 47.9 83.7 98.9 FBS (mmol/l) -3.1 -3.4 -5.8 Insulin (pmol/l) -49.5 -153.7 -115.3 Cholest tot (mmol/l) -0.3 -0.96 -1.97 LDL (mmol/l) -0.11 -0.89 -1.36 Trig decreased 77% 91% 100% HTA resolved 43.2% 67.5% 83.4% Meta-analysis Buckwald JAMA 2004

Risk/benefit ratio comparison between procedures GB GBP BPD Operative mortality % 0.1 0.3 1 Operative complication % 9 15 Success rate % 50 60 90 Reoperation rate % 20 10%+ 2

Manageable side effects Bacterial overgrowth % Treatment Mild (bloating discomfort) 20 dietary counselling probiotics Moderate (proctitis, nocturnal diarrhea, abdominal distension) 2 metronidazole Severe (bypass enteritis) 0.4 reversal Current Surgery 2003; 60: 274-277

Mechanisms of diabetes control after BPD/DS The exclusion of the duodenal nutrient passage may offset an abnormality of gastrointestinal physiology responsible for insulin resistance and type 2 diabetes « Proximal mechanism » 

Mechanisms of diabetes control after BPD/DS Nutrients reach the distal ileum within minutes of the ingestion of food and this stimulates the secretion of GLP-1 by L-cells located in this area « Distal  mechanism »

Summary - BPD Resolution of most co-morbidities Excellent long-term weight loss (65% + ) Resolution of most co-morbidities 100% DM (ok its really 98%), 80% HTN Potential malnutrition or mineral/vitamin deficiency requires intense life-long monitoring Laparoscopic approach can be done safely

Super Obese (>50 or >60 BMI) Band is not be the best option DS results are superior to GBP long term data does not support sustained weight loss BMI <35 in this group High risk group Staged procedure may be best option “lower” risk procedure, evaluate patient

Surgical Options- Pomp Laparoscopic Adjustable Gastric Banding + low surgical morbidity/complexity - vomiting, high maintenance, port/device problems, less weight loss (especially with high BMI) Roux-en-Y Gastric Bypass/Sleeve Gastrectomy + low maintenance, excellent weight loss - ulcer/stricture rate, leak management (sleeve) - significant weight regain (esp. super obese) Biliopancreatic Diversion/Duodenal Switch) + sustained weight loss; all BMI categories - surgical complication rate, post-op maintenance

Information-Knowledge-Wisdom This operation is not for every patient (nor for every surgeon) “TRIFECTA” -motivated, intelligent patient -financial resources ($1000-1500/year) -compulsive (12-15 supplements/5 doses)

Surgery for Obesity How does it work? 4 operations Restriction Malabsorption/metabolic 4 operations Lap band Sleeve gastrectomy Gastric bypass Duodenal switch

Thank you apomp@med.cornell.edu