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

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

4. 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

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

6. 6

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

8. 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)

9. Lap Biliopancreatic Diversion with Duodenal Switch

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

12. Sleeve Gastrectomy

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

14. DS – Anvil Technique

15. DS – Hand Sewn

16. Weight Change SOS so not EBWL

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

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

19. DS Complications and BMI

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

21. First Stage
Second Stage
Normal Range

22. 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

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

24. British Journal of Surgery 2010;97(2):160-16624

25. 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)

26. Results
Weight loss:

27. 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

28. Biertho et al, SOARD 2010;6(5):508-51428

29. 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

30. Results 810 consecutive patients (1992-2005): BMI< 50
637 women (78.6%)
Mean age: 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 )
Mean hospital stay: 6.9±5.4 days
followed up for a mean of months (range 36–201). Their mean age at surgery was years. The mean weight and BMI was kg and 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.

31. 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 days. * * *

32. 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.

33. 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

34. 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.

35. 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

36. 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

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

38. 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:

39. 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 » 

40. 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 »

41. 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

42. 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

43. 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

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

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

46. Thank you apomp@med.cornell.edu