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Biliopancreatic Diversion with Duodenal Switch (BPD/DS): The modern way of fat assassination

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

What is Biliopancreatic Diversion with Duodenal Switch (BPD/DS)?

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

Indications forBiliopancreatic Diversion with Duodenal Switch (BPD/DS)

  • Superobese patients: Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is considered in patients who have a body mass index (BMI) more than 50kg/m2 and suffering from co-existing co-morbidities. In such patients weight management by other means such as exercising has not produced significant effects and the additional weight gain could be detrimental for the patients’ well-being. Pre-operative weight loss is advised which is probably difficult to achieve in practice. A two-step approach wherein an intragastric balloon is placed prior to the BPD/DS surgery can be offered in these patients. 
  • Severe metabolic syndrome especially uncontrolled T2DM: BPD/DS is a powerful and effective surgical option in patients suffering from highly compromising metabolic diseases. If properly executed and adequately management, BPD/DS leads to resolution of type 2 diabetes mellitus.
  • As a surgical option for revision of failed other bariatric operations: Such patients present with comorbidities more severe than normal bariatric patients. A multidisciplinary approach has to be followed in these patients such as pulmonary and respiratory function analyses, arterial blood gases assessment, cardiologic evaluation and sleep apnea studies. Any of the coexisting co-morbidities have to be managed first in order to reduce perioperative morbidity.

Diagonstic tests for Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

Routine preoperative laboratory investigations: 

  • It helps to have a baseline value upon which to compare the subsequent follow-up values. Vitamin A, D and E values and parathyroid hormone (PTH) determinations are done. 
  • Pregnancy and chronic liver or renal disease need to be ruled out either by biochemical tests or ultrasound. 
  • Any abnormal levels in platelet count, or albumin, or creatinine or any abnormality detected in the ultrasound necessitates putting the patient on hold for further evaluation. 
  • Upper gastrointestinal assessment and endoscopy is advised in revision cases. 

Types of Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

  • Laparoscopic approach: In this method, 4-5 keyhole abdominal incisions are made, through which the laparoscopic armamentarium is inserted into the body cavity. It is a minimally invasive surgical technique.
  • Open approach: This involves a larger incision in the abdomen along the midline that provides open visibility of the abdominal cavity. This approach may leave a bigger scar.

Treatment Procedure of Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

  • Preoperative management: Following admission in the hospital, routine antithrombotic prophylaxiswith 4000 to 6000 units of low-molecular weight heparin is initiated. To prepare the bowel the patient is instructed to maintain a liquid diet for twenty four hours prior to the surgery. An ultra-short acting antibiotic prophylaxis with a second generation cephalosporin is given approximately half an hour before the surgical intervention. A urinary catheter is placed and maintained for twenty four hours.  
  • Positioning the patient: The weight of the patient poses greater risk of ischemic, venous, and nervous injuries which need proper surveillance. If the surgery is performed via a laparoscopic approach, the patient is placed on the operating table with legs apart so as to make place for the surgeon to stand in the region between the patients legs, as this position provides proper visualization of the gastrointestinal region. The assistants are positioned on the right and left of the patient while the monitor is set adjacent to the head of the operating table on the right. Carbon dioxide is used to inflate the abdominal region that provided adequate space for instrumentation and proper visualization of the anatomy.  
  • Placing incisions: Approximately 5-6 small incisions each 5-12 mm in size are made that allow the placement of trocars and the optical system used for laparoscopic procedure. These incisions are placed in the supraumbilical, hypondriac, xiphoid and subcostal regions i.e. in and around the umbilicus and along the midline of the body. 
  • Restrictive phase- Cholecystectomy and gastric resection: The gall bladder is resected and left over the liver which is to be removed from the abdominal cavity at the end of the surgery. Gastrectomy is carried out next and the fundus part of the stomach is dissected followed by closure via staples. 
  • Enteroenterostomy: The operating table is rotated 15 degrees to the right and the surgeon is now placed at the patients’ left flank. The intestinal loops in the small bowel are completely measured backwards from the cecum and marked at 50cm. The loop is divided at 250-300 cm mark from the iliocecal valve using endoscopic forceps. Enteroanastomosis is performed by bringing the biliopancreatic limb next to the 50cm mark from the iliocecal valve. 
  • Gastroenterostomy and liver biopsy: The surgeon returns to his/her primary position. A small opening is created in the transverse mesocolon and the gastric stump is pulled into the submesocolic space. The alimentary limb is arranged on the patient’s right side and the biliopancreatic limb on the left side to avoid twisting. A methylene blue test is performed in the end. Liver biopsy is performed as a baseline analysis for the assessment of liver condition. 
  • Closure: The dissected stomach stump and gallbladder are extracted through the supraumbilical incision and a closed suction drain is placed over the duodenal stump. Incisions are closed by interrupted slowly absorbable sutures. 
  • Open approach: Following a mid-abdominal incision, the intestinal organs are explored and measured accordingly. Stitches are placed at 50 and 300cm of the small intestine. A distal gastrectomy is performed and the duodenal stump is closed followed by the removal of gallbladder. Liver biopsy is performed at this stage. Lastly gastroenterostomy is done and a final intestinal check is done. Incision is closed via continuous sutures and drains are placed similar to the laparoscopic technique. 

Complications/Risk factors associated with Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

  • Anemia: It is an unavoidable complication that manifests due to the dissection of the alimentary tract that hampers the iron absorption sites. It presents with symptoms such as excessive bleeding during menstruation and/or hemorrhoids and stomach ulcer. Anemia has a general incidence of 40% among the BPD/DS patients nevertheless it can be reduced to less than 15% with chronic supplementation with iron or folate or both.
  • Stomach ulcer: BPD/DS is a potentially ulcerogenic technique and these stomach ulcers have been reported to significantly affect men than women. During the initial years the incidence of stomach ulcer was rather high but with advancements in the surgical technique wherein most of the gastrolienal ligament is preserved, has led to a reduction in the number of stomach ulcer cases. With the addition of postoperative oral prophylaxis using H2 blockers, the incidence of stomach ulcer has reduced further to 3.3%. Stomach ulcers have reported to respond positively to drug therapy using proton pump inhibitors showing complete remission and no recurrences. 
  • Bone demineralization: Intestinal dissection can hamper with the calcium absorption sites leading to malabsorption of calcium. Similar to proteins when calcium intake is increased it results in increased absorption as well; hence the patient is advised to maintain an oral supplementation of 2g/day of calcium. 
  • Protein malnutrition: It is one of the severe complications of BPD/DS. If it occurs during the first postoperative year it is known as early episodic and occurs due to non-compliance of the patient to follow the alimentary rules. Protein malnutrition occurring during later stages is termed as late recurrent, and it occurs due to inadequate protein intake or intestinal malabsorption. It has been reported that in subjects with severe reduction in gastric volume and lower weight stabilization, were more predisposed to the risk of protein malnutrition.

Am I a Good Candidate for Biliopancreatic Diversion with Duodenal Switch (BPD/DS)surgery? 

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.

Recovery time

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.

Aftercare

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. 

Success Rate of Biliopancreatic Diversion with Duodenal Switch (BPD/DS):

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.

Benefits of Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

  • Biliopancreatic diversion, with duodenal switch (BPD/DS) has a wide range of therapeutic interval due to the variable length of the intestinal limbs which can create selective absorption of nutrients thereby customizing the procedure according to individual patient requirement.
  • Best possible results in weight loss with minimal complications and risks. 
  • Weight reduction leads to decrease in insulin resistance, thus treating type 2 diabetes mellitus in almost 100% of the diabetic patients who were previously morbidly obese.
  • A decrease in serum cholesterol levels in about 30% of the patients with prior levels of cholesterol within normal range and in approximately 45% of hypercholesterolemic patients. Reduced levels of low density lipoprotein (LDL), very lowdensity lipoprotein (VLDL) and cholesterol was observed with significant increase in high density lipoprotein (HDL). 

Cost of Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

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. 

Why Choose MedcureIndia? 

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. 

FAQ

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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