Biliopancreatic Diversion and Duodenal Switch

Biliary-Pancreatic Diversion with Duodenal Switch

The Biliary Pancreatic Diversion with Duodenal Switch (BPD with DS, BPD, Duodenal Switch, Biliopancreatic Diversion with DS) is a well established weight loss surgical procedure that provides excellent weight loss and long term resolution of comorbid conditions.  Due to its complexity most surgeons and centers do not offer the BPD with DS.  Drs. Gachassin and Eschete are  proud to offer ALL approved procedures laparoscopically.  The primary mechanism of weight loss with the BPD with DS is malabsorption.  The operation is usually  but not always reserved for super obese patients (BMI > 50).  The special benefit of the DS to the super obese is that they may expect to lose 85% of their excess weight allowing them to achieve a truly health weight.

While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and bypass the majority of the normal digestive process. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine.

Since food bypasses the duodenum, all the risk considerations discussed in the gastric bypass section regarding the malabsorption of some minerals and vitamins also apply to these techniques, only to a greater degree.

Biliopancreatic Diversion (BPD)

BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an “alimentary limb.” All the food moves through this segment, however, not much is absorbed. The bile and pancreatic juices move through the “biliopancreatic limb,” which is connected to the side of the intestine close to the end. This supplies digestive juice in the section of the intestine now called the “common limb.” The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.

Biliopancreatic Diversion with “Duodenal Switch”

This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the “alimentary limb” is then attached to the beginning of the duodenum, while the “common limb” is created in the same way as described above.

Advantages

  • These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
  • These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
  • In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
  • Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.

Risks

  • For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
  • Abdominal bloating and malodorous stool or gas may occur.
  • Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
  • Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
  • Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.

Procedure

Trocars are inserted into the abdominal wall to allow access to the abdominal organs. A Vertical Sleeve Gastrectomy is performed removing 80% of the stomach. The duodenum is then divided preserving the pyloric valve with the remaining stomach. The small bowel is divided and the distal end is connected to the duodenum creating the “Alimentary” limb 8 feet long (food is blue in the video). The proximal end of the small bowed is the “Biliopancreatic” limb (biliopancreatic juices are yellow in the video) and it is connected to the Alimentary limb 3 feet from the colon. This creates a “Common Channel” out of the last 3 feet of the alimentary limb (green is the mixture of the food and biliopancreatic juices). The common channel is where calories and nutrition is absorbed into the body.

Recovery

Although this is a larger operation than other weight loss surgical procedures, most patients only have a 2-3 day hospital stay. The surgery is performed laparoscopically and requires about 2-3 hours of operating time depending on the patient’s history and BMI. The post operative dietary phases and schedule are the same as with the Gastric Bypass. Patients can return to office style work in two weeks and have unrestricted activity at one month. Even though the percetage of excess weight loss with other procedures decreases as the BMI increases, patients with BMI’s > 50 can expect excess weight loss of 85%! Because of the outstanding results with the BPD with DS it is used as a primary operation for patients with a BMI > 50 and as a salvage operation for patients with failed Gastric Bypass, Vertical Sleeve Gastrectomy and Laparoscopic Adjustably Gastric Bindings. Patients must be prepared to follow the prescribed diet or they may suffer from diarrhea and flatulence.

Most centers do not offer the BPD. If you would like to learn more about this exceptional option, please call Drs. Gachassin and Eschete at the Acadiana Weight Loss Surgery for a free informational seminar and a consultation.


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