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Globally, obesity is the fifth leading factor for mortality. It is a complex condition affecting multiple organs and predisposes to numerous chronic diseases such as diabetes, hypertension, heart diseases, etc. A BMI index of more than 50kg/m2 negatively influences the overall health and longevity which warrants an adequate surgical interventionthat could be restrictive, malabsorptive, or a combination of both. Biliopancreatic diversion, with duodenal switch (BPD/DS) is a type of combination procedure which was first described by Scopinaro in 1979.The modification of duodenal switch was proposed by Douglas Hess and Picard Marceau to reduce the complications associated with the primary procedure. The restrictive part of the surgery is performed first wherein the distal part of the stomach is resected and the duodenal stump is closed. During the malabsorptive procedure, a gastrointestinal anastomosis is created which causes temporary decrease in appetite and consequent reduction in food intake. BPD/DS produces significant improvement in obesity related co-morbidities and results in potentially positive metabolic effects. Despite its effectiveness and best results BPD/DS shows minimal diffusion in the world which is probably be due to its complexity that entails a thorough pathophysiological understanding. On the contrary recent data have procured that the complexities associated with BPD/DS are more apparent than real and the perceived operative risks lower than other bariatric operations such as sleeve gastrectomy.
Routine preoperative laboratory investigations:
If your body mass index (BMI) is more than 50kg/m2 and other methods of weight loss are not working for you, then you can consult your doctor regarding surgical methods for weight management. Patients with co-existing co-morbidities who are at health risks can opt for BPD/DS which helps them manage weight issues simultaneously treating the chronic conditions. Superobese patients need to make their doctor aware of their expectations from the procedure and should be prepared to promote a healthy lifestyle postoperatively.
Only selective cases with respiratory co-morbidities may be referred to the Intensive Care Unit (ICU). The antithrombotic prophylaxis which was started preoperatively is continued postoperatively for up to 30 days. An upper gastro-intestinal radiology might be done. On the first post-operative day the naso-gastric tube is removed and on the third post-operative day the drain is removed. Patient is placed on liquid dietinitially and if tolerated, the diet is the progressed to soft diet first and, on the fifth or sixth postoperative day, to a free diet.
Patients undergoing BPD/DS must be made aware that they will absorb little fat, starch and protein for the rest of their life. Postoperatively a protein requirement of about 80mg/day orally should be maintained. Food types to be avoided are: milk, simple and refined sugars, large meal portions of fruits and vegetables. After the body weight has been stabilized, and then variations can be made according to individual weight adjustments. It might take approximately a year for the appetite and the eating capacity to be fully restored and the average self-reported food intake reaches one and half times the preoperative value. Beginning from the day of discharge, the patient is put on multivitamin supplementation orally and after a month when the patient regains his/her appetite then calcium and iron is added to the supplements. This helps to prevent the occurrence of metabolic bone diseases and diseases of vitamin deficiency. These biochemical tests are to be performed at yearly intervals and are to be continued even the weight has settled.
The weight is maintained via the intestinal energy transport threshold and stabilized partly by the changes in body composition subsequent to the operation. An analytical study showed more than 70% of initial excess weight loss in the first year post surgery and 80% during next 20 years. A long term relief from diabetic complications lasting for up to 20 years has been observed.
The cost of BPD/DS varies depending on the surgeon and hospital. As it is a complex procedure with a propensity towards complications thus an experienced surgeon charges higher fees. The surgical procedure is extensive and requires hospital admission for about 3-5 days which may incur additional charges. The surgical procedure may cost approximately $50000 in US while in India it can be performed at slashed prices of $15000-20000 owing to its popularity.
Biliopancreatic diversion, with duodenal switch (BPD/DS) causes one of the best results when properly executed. Owing to this reason it is imperative to acknowledge and master the surgical procedure and management of its complications. With MedcureIndia you can be sure of being in good hands. Our team of committed bariatric surgeons provides you with an operational procedure tailored to best suit your health. We employ advanced diagnostic technologies that aids in prompt diagnosis and customized treatment options.
• What are the contraindications for Biliopancreatic Diversion with Duodenal Switch (BPD/DS)?
Absolute contraindications include chronic diarrhea, chronic renal failure, alcoholism, severe liver cirrhosis, inflammatory bowel disease, uncontrolled psychiatric illnesses, and endogenous protein loss as seen in protein losing enteropathy andnephrotic syndrome. Other relative contraindications for the procedure lack of financial means to afford supplements and inability orunwillingness to undergo lifelong chronic follow-up.
• How thin will I become?
It is obligatory for the surgeon and patient to discuss openly any false expectations and set realistic goals. On an average a postoperative excess weight loss of 70% is achieved through BPD/DS. A weight reduction more than is associated with more problems. Ahigher degree of weight loss is likely to be met with complications.On an average a subject loses 20-30% of their total body weight during the first two years postoperatively. The patient should be educated that the main aim of BPD/DS is weight maintenance and not weight loss. The surgery has different effects on different people as some lose more weight than others and some lose weight faster than others.
• Can I continue my previous diet plan?
Dietary habits need to be modified post BPD/DS surgery in order to achieve and sustain the results and further to minimize complications. Food types to be avoided are: milk, simple and refined sugars, large meal portions of fruits and vegetables. This helps to minimize the chances of any regain in weight and also brings about a reduction in flatulence. Number of stools is also consequently minimized which is confortable change for the patient. Patient is advised to take a protein rich diet in small meals at frequent intervals distributed throughout the day.
• What changes can I expect after BPD/DS surgery?
Patients undergoing BPD/DS must be made aware that they will absorb little fat, starch and protein for the rest of their life. Bowel movements tend to increasewith increase in frequency of stools in the most of patients. All the patients develop a reduced appetite and early satiation. Occasionally epigastric pain and vomiting may develop which can be discomforting. The symptoms are more intense and last longer in cases where the gastric volume is made much smaller. With intestinal adaptation these symptoms subsequently subside. The patient may experience two-four bowel movements in a day and stools might be foul smelling. You may experience hair loss or thinning for about 3-6 months postoperatively, which will subside once your body recovers.
• Will I regain the weight later?
Diet modification is mandatory to maintain the weight and reduce side-effects. This diet has to be strictly followed for the rest of the life. Sweet-eaters and nibblers tend to gain weight fast. To avoid gaining weight in the long term you need to develop healthy behaviors such as following a healthy diet and exercising regularly. Do not miss any of the follow-up appointments.
• When do I need to visit the doctor after surgery?
The first follow-up visit is scheduled 30-45 days post an uncomplicated surgeryand later on at four and twelve months post-operatively. At each general visitblood and biochemical analyses are done and any abnormality is duly noted. Any unexplained and unremitting abdominal pain, vomiting and other complications are to be immediately reported and promptly managed.
• Will I require additional operations later?
Revision of BPD/DS might be required to correct an excess effect of the original operation, if the patient experiences recurrent episodes of protein malnutrition, excess weight gain despite following a normal food intake, the stools are exceedingly foul swelling associated with severe flatulence and diarrhea, intractable extreme bone mineralization, co-existence of diseases whose effects are detrimental to proper absorption and in subjects with intolerance of the operation.
• How does BPD/DS make me lose weight?
Following BPD/DS you lose weight as it makes your stomach small thus you eat less as you are satiated early. Whatever you eat and drink bypasses most part of the small bowel reducing the absorption of fat, protein and carbohydrates in the intestines. The surgical procedure also alters the hormonal levels of the body that affect metabolism, hunger and appetite.
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