Biliopancreatic diversion with transitory gastroplasty preserving duodenal bulb: 3 years experience

Biliopancreatic diversion with transient gastroplasty and duodenal switch: long-term results of a multicentric study

BACKGROUND

Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS.

METHODS

Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments.

RESULTS

The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null.

CONCLUSION

Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Long-term results of biliopancreatic diversion with or without gastric preservation for morbid obesity

We aimed at comparing our long-term results after biliopancreatic diversion (BPD) with or without gastric preservation for morbid obesity. Between 1999 and 2009, we performed 540 BPD: 287 patients (group A) underwent BPD with distal gastric resection (BPD-AHS) and 253 (group B) underwent BPD associated with transitory vertical gastroplasty (TGR) with duodenal switch (DS). The results have been analyzed in terms of weight loss, improvement of comorbidities, and quality of life (Bariatric Analysis and Reporting Outcome System). The mean follow-up was 7.4 ± 2.9 years. One year after surgery, mean initial excess weight loss percentage was 69% for patients in group A (n = 287) and 65% for group B (n = 253); after 2-5 years, it was 74% for patients who underwent BPD-AHS (n = 130) and 75% for patients who underwent BPD-TGR-DS (n = 116); it was 71% and 74% for patients in group A (n = 157) and B (n = 137), respectively, followed up for >5 years (P = 0.27). Among the diabetic patients in both groups (191 patients), 64% discontinued the medication with insulin (P = 0.25), and 98% had stopped oral drugs within 1 year from surgery (P = 0.29). We did not observe deficiencies of vitamins and proteins. The overall incidence of incisional hernias was 38% (P = 0.35). We recorded 13 anastomotic ulcers (2.4%; P = 0.28). BPD represents, in spite of the side effects, an effective technique for treatment of morbid obesity and its associated diseases. Moreover, our results showed that patients who underwent BPD-TGR-DS had slightly better results in terms of postoperative metabolic complications and improvement in quality of life.

Laparoscopic adjustable pyloric band with fundoplication in bariatric surgery: technique and preliminary results

BACKGROUND

Laparoscopic biliopancreatic diversion according to Scopinaro is an extremely effective operation for weight loss, but carries significant morbidity in terms of metabolic deficiencies.

METHODS

A study was conducted as to the feasibility, safety and efficiency of a novel procedure, accomplishing a 'reversible Scopinaro BPD', performed in two stages: first the placement of an adjustable band in a juxtapyloric position, aiming at maintaining postprandial satiety, and second, the construction of a transmesocolic Roux-en-Y gastro-enterostomy with a 2.5-m long distal jejunal limb, reanastomosed 50 cm proximal to the ileocecal valve.

RESULTS

15 patients, mean BMI 38.9, 8 males and 7 females, underwent the first stage of pyloric adjustable banding. All benefited at the same time from a Nissen fundoplication, to avoid gastroesophageal reflux. 1 patient was withdrawn from the study at this stage because of peritonitis of unknown cause and removal of the band. 3 patients benefited from the second stage of the operation because of insufficient weight loss, and/or symptoms of gastric stasis. 1 patient developed diarrhea and was treated by peroral cholestyramine. Weight loss was similar to the regular BPD figures.

CONCLUSION

The placement of an adjustable gastric band in a juxtapyloric position, combined with a Nissen fundoplication, appears to be a safe and efficient satiety-inducing operation. In case of insufficient weight loss, and/or exaggerated gastric stasis, a Scopinaro BPD construction can be added to the otherwise unharmed stomach, hereby constituting an instantly reversible malabsorptive component.

Laparoscopic biliopancreatic diversion with duodenal switch

Preliminary results demonstrate the feasibility and safety of laparoscopic biliopancreatic diversion with duodenal switch, knowing that the superobese patient carries a higher risk than the normal population or the regular obese patient. Future studies with larger numbers of patients should be able to demonstrate the effectiveness this procedure in reducing weight and comorbidities such as hyperlipidemia, hypertension, sleep apnea, and diabetes mellitus, an effectiveness of that has been proven in an open approach. There is currently poor evidence regarding this effective due to small case series and early follow-up. Further research is needed to examine long-term efficacy, with a high priority given to randomized controlled trials.

Biliopancreatic diversion in the surgical treatment of morbid obesity

Biliopancreatic diversion is a malabsorptive technique of bariatric surgery that has gained wide acceptance in the Western world. It is performed in one of two ways: In its classic form it consists of partial gastrectomy with a Roux-en-Y gastroenterostomy; in its duodenal switch form a vertical sleeve gastrectomy is combined with a duodenoenterostomy. Both techniques realize diversion of biliopancreatic juice, thereby creating a mild form of malabsorption. Weight loss has been approximately 70% of initial excess weight, exceeding that obtained with most other bariatric procedures. Iron, calcium, and vitamin deficiencies may occur, especially with classic biliopancreatic diversion, and must be prevented with adequate supplements during vigorous follow-up. Weight loss is followed by a substantial reduction in the co-morbidities that are present in many morbidly obese patients. Biliopancreatic diversion should be included in each obesity clinic program and be proposed for morbidly obese patients who are having difficulty with the prospect of continuous restraint of food intake or problems due to failed gastric restrictive interventions. The postoperative results in such patients have been good and have substantially improved quality of life and self-esteem in this category of morbidly obese patients.