Biliopancreatic Diversion

Biliopancreatic bypass is performed either laparoscopically or through a midline incision. A subtotal gastrectomy is performed, leaving a proximal gastric remnant of 200 to 500 ml. The ileum is transected 250 cm proximal to the ileocecal valve. The distal ileal limb is brought through a retrocolic opening in the transverse mesocolon and anastomosed to the gastric pouch. The biliopancreatic or proximal limb is anastomosed end-to-side to the distal ileum, 50 cm proximal to the ileocecal valve. This results in a 50 cm common channel between the two limbs (Figure 7.3). A modification of this technique is the biliopancreatic bypass with a duodenal switch (BPD-DS).51,52 The greater curvature of the stomach is resected to create a lesser curvature gastric sleeve (sleeve gastrectomy). This reduces the gastric volume to 200 ml to 500 ml, equivalent to a subtotal gastrectomy, and maintains the integrity of the vagus nerves. The duodenum is transected 5 cm distal to the pylorus. The ileum is transected 250 cm proximal to the ileocecal valve, and the distal ileal limb is anastomosed end-to-end to the proximal duodenum. The biliopancreatic limb is anastomosed end-to-side to the distal ileum, 100 cm proximal to the ileocecal valve, resulting in a 100 cm common channel between the two limbs.

There are significant reports of the outcomes after BPD and BPD-DSs from Italy and Canada, but fewer have been reported in the U.S. Scopinaro and colleagues53 at the University of Genoa, Italy, published results for 1356 patients undergoing

FIGURE 7.3 Biliopancreatic bypass with a duodenal switch. The greater curvature of the stomach is resected to create a sleeve gastrectomy. After dividing the duodenum 5 cm distal to the pylorus, the distal alimentary (Roux) limb, created by dividing the ileum 250 cm proximal to the ileocecal valve, is anastomosed end-to-end to the proximal duodenum. The biliopancreatic limb is anastomosed end-to-side to the distal ileum 100 cm proximal to the ileocecal valve, leaving a 100-cm common channel between the biliopancreatic and the distal alimentary limb.

FIGURE 7.3 Biliopancreatic bypass with a duodenal switch. The greater curvature of the stomach is resected to create a sleeve gastrectomy. After dividing the duodenum 5 cm distal to the pylorus, the distal alimentary (Roux) limb, created by dividing the ileum 250 cm proximal to the ileocecal valve, is anastomosed end-to-end to the proximal duodenum. The biliopancreatic limb is anastomosed end-to-side to the distal ileum 100 cm proximal to the ileocecal valve, leaving a 100-cm common channel between the biliopancreatic and the distal alimentary limb.

BPD. Short- and long-term weight loss and weight maintenance has been excellent. Loss of excess body weight has been 74 percent and 78 percent at 2 and 14 years, respectively. Other beneficial effects include significant improvement of the hypoventilation and obstructive sleep apnea syndromes, hypertension, venous stasis disease, hypercholesterolemia, glucose intolerance, and adult-onset diabetes mellitus following the procedure. Marceau and associates51 in Canada reported results in 465 patients undergoing BPD-DS. Mean percentage excess weight loss at 51 months follow-up was 73 percent, or an average of 101.2 pounds per patient. Only 4 percent of patients with diabetes mellitus, 42 percent with hypertension, and 49 percent with obstructive sleep apnea or hypoventilation syndromes still required medical treatment for these obesity-related conditions. When Marceau51 compared the 457 patients undergoing BPD-DS to 233 previous patients undergoing BPD, revision rates were lower and calcium and iron homeostasis improved in the BPD-DS group. However, there was no significant difference in weight loss between the two groups.

Gagne and colleagues have reported a comparison between open and laparoscopic BPD-DS. In their report, 54 patients, 26 laparoscopic and 28 open procedures, were retrospectively reviewed. The laparoscopic approach had improved operative time, blood loss, and hospital stay; however, none reached statistical significance. Complication rates were slightly higher in the laparoscopic group (23 percent versus 17 percent), and death rate was higher in the laparoscopic group (7.6 percent versus 3.5 percent), but again, the levels did not reach statistical significance.54

Short-term complications from BPD vary, but include abdomical abscess (1.9 percent), anastomotic leak (1.9 percent), wound infection (5.6 percent), wound dehiscence (1.9 percent), respiratory failure (1.9 percent), and pancreatitis (1.9 percent). Late complications can include marginal ulceration (12 percent), bone demineralization (6 percent) secondary to calcium and vitamin D deficiencies, protein malnutrition (15.1 percent) characterized by hypoalbuminemia, anemia, edema, asthenia, and alopecia, and vitamin B12, iron, and folate deficiencies (5 percent).53 In summary, BPD with or without a duodenal switch has demonstrated superb weight-loss results. However, its complication rate is significant. There is a high rate of protein malnutrition, and the degree to which medications are malabsorbed is still unknown.

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