Biliopancreatic Diversion with Duodenal Switch Steven Pham Graduate Nutrition and Dietetic Student Coordinated Program Georgia State University

Biliopancreatic Diversion w/ Duodenal Switch (BPDDS) Large portion of the stomach is removed (similar to SG) Duodenum is cut and pylorus remains intact Small Intestine is cut about halfway Bottom section is connected to top part of the duodenum Separated section is reattached to the ileum with about 3 feet left from the ileocecal valve (forming the common channel) Food bypasses most of the small intestine Bile and pancreatic enzymes meet the food at the common channel Video

Alimentary Limb Biliopancreatic Limb Common Channel

Statistics and History Least commonly performed bariatric procedure worldwide (2.2%) More commonly performed in South America Brazil is the leading nation in BPDDS procedures 26.5% of all of Japan’s bariatric procedures were BPDDS (out of 170) Trends: Globally- <3% of all cases USA/Canada- stable around 1% Europe- Decrease in favor of RYGB/SG South America- Increase in total number and % Asia/Pacific- Marked increase in total number and %

Indications and Advantages Restrictive and malabsorptive Most malabsorptive procedure available BMI > 50 kg/m2 Multiple comorbidities Diabetes Mellitus Hyperlipidemia Heart disease Hypertension Sleep Apnea Etc. Failed Sleeve Gastrectomy or Lap Band Patients can expect ~70% excess weight loss maintain good health with a healthy diet, proper vitamin + mineral supplementation, and exercise.

Risks & Disadvantages Surgical complications with every surgery Higher risk of gallstones and gallbladder disease Bowel movements become more liquid (can clear over time) Abdominal bloating and foul-smelling stool/gas Increased intestinal irritation and ulcer risk Lifelong follow-up with physician and dietitian Necessary diet changes for healthy weight loss Certain foods can cause discomfort, nausea, or vomiting Sugary foods can cause dumping syndrome- lower risk than RYGB Lifelong vitamin and mineral regimen Overeating can stretch the stomach pouch

The biliopancreatic diversion with a duodenal switch (BPDDS): how is it optimally performed? Vage et. al. 2011 METHODS: All patients eligible for a 2-year follow-up (n = 182) were included in the study. Group A- 35 patients had a gastric remnant with a volume of approximately 200 ml, an alimentary limb (AL) of 250 cm, and a common channel (CC) of 100 cm Group B- 147 patients had a gastric remnant of 100-120 ml, an AL of 40%, and a CC of 10% of the small bowel length Preoperative variables, such as body mass index (BMI), sex, age, and factors that might influence weight loss, and postoperative weight loss and side effects were registered and compared. RESULTS: Preoperatively, the BMI was 50.6 in group A and 52.1 in group B with no difference in age, sex, or variables that might influence weight loss. At 2 years, the BMI was 33.1 in group A and 28.5 in group B with an adjusted difference in weight loss of 5.6 BMI units between the groups (p < 0.001). Vitamin D status was also better in group B than in group A at follow-up CONCLUSIONS: Patients with a remnant stomach of 100-120 ml, and AL and CC with individually adapted lengths had a larger weight loss and better vitamin D status postoperatively without an increase in side effects.

Complications Anemia – most common (impaired iron absorption) Zinc deficiency – common due to fat malabsorption Hypocalcemia Hypoalbuminemia Fatsoluble vitamin deficiencies (ADEK) – Dry or water miscible forms of fat soluble vitamins are recommended Vitamin B12 deficiency Osteoporosis –supplement with calcium and vitamin D Protein-calorie malnutrition – Increased protein needs Thiamine deficiency Copper deficiency – associated with anemia Kidney stones

American Society for Metabolic and Bariatric Surgery (ASMBS) Recommendations for BPDDS Physicians should exercise caution when recommending BPD-DS because of the greater associated nutritional risks related to the increased length of bypassed small intestine (Grade A). All patients should undergo an appropriate nutritional evaluation by an RD, including micronutrient measurements, before any bariatric surgical procedure. In comparison with purely restrictive procedures, more extensive perioperative nutritional evaluations are required for malabsorptive procedures (Grade A). After consideration of risks and benefits, patients with, or at risk for, demonstrable micronutrient insufficiencies or deficiencies should be treated with the respective micronutrient (Grade A). Follow up with patients 1 month, 3 months, 6 months, and PRN after surgery.

ASMBS Supplement Recommendations Vitamin A, starting 2 to 4 weeks after surgery Vitamin D, starting 2 to 4 weeks after surgery Vitamin K, starting 2 to 4 weeks after surgery Multivitamin to meet 200% of the daily values, starting the first day after discharge from the hospital Minimum of 18 mg to 27 mg of iron, and up to 50 mg to 100 mg a day for menstruating women or adolescents at risk for anemia, starting the first day after discharge Calcium supplements, usually taken as 3 doses to 4 doses of 500 mg to 600 mg doses, starting on the first day after your discharge or within the first month after surgery. Note: Don't take these at the same time as iron supplements; wait a couple of hours. Vitamin B12 supplements containing 350 mcg to 500 mcg; some people will need to give themselves B12 injections Optional B-complex vitamin Up to 3 servings of calcium-rich dairy beverages

Nutritional Management of the BPDDS Patient -AND Weight Management Dietetic Group 2014 Mimi Harrison MS RD CDN CDE Iron – 150-200 mg elemental iron Copper – 2 mg elemental copper Zinc- 15 mg zinc gluconate Selenium – 200 mcg Calcium – 1800-2400 mg calcim citrate with vitamin D and Mg (divided doses of 500 mg) Vitamin D – 3000 IU Vit D3 Vitamin A – 10,000 IU retinol Vitamin K – 300 mcg Vitamin E – 10 mg Folate - >400 mcg Vitamin B12 - >350 mcg Thiamin – 4-6 mg Protein – >90 grams

Quebec Group’s Supplement Regimen 1 multivitamin (centrum forte) Calcium Gluconate 500 mg Ferrous Sulfate 300 mg Vit D 50,000 IU Vit A 20,000 IU Calcium and Vitamin D needs may go up over time Monitor labs 3 month, 6 month, 9 month, 12 month, annual, and PRN

Proposed Vitamin and Mineral Supplements for GMC 2 Centrum Chewable multivitamin Additional 18 mg iron for menstruating women or anemia 3,000 IU Vitamin D3 daily or 50,000 IU per week 8,000 IU Vitamin A daily – Nature Made 500 mg calcium citrate 4x per day – Nature Way (take 2 hours apart from iron supplement) 500 mcg Vitamin B12 –Nature’s Bounty Monitor labs and treat deficiencies accordingly

Questions?

References 1. Våge V, Gåsdal R, Laukeland C, et al. The biliopancreatic diversion with a duodenal switch (BPDDS): how is it optimally performed? Obes Surg. 2011;21(12):1864-1869. doi:10.1007/s11695-011-0496-9. 2. Innovations in Surgery - Duodenal Switch: On the Rise? -- Ep 9.; 2013. https://www.youtube.com/watch?v=2jVLfNIezUc&feature=youtube_gdata_player. Accessed April 1, 2015. 3. Duodenal Switch Surg. Banner Health - WwwBannerHealthcom. http://www.bannerhealth.com/services/bariatric+surgery/surgical+options/duodenal+switch+surgery.htm. Accessed April 26, 2015. 4. Duodenal Switch - Complete Patient Guide. Bariatr Surg Source. http://www.bariatric-surgery-source.com/duodenal-switch.html. Accessed April 26, 2015. 5. Nutritional Management of the Biliopancreatic Diversion-Duodenal Switch Patient | WM DPG. http://wmdpg.org/issues/wm-matters-newsletter/summer-2014/nutritional-management-of-the-biliopancreatic-diversion-duodenal-switch-patient/. Accessed April 1, 2015.