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Laparoscopic BPD-DS

Outcome from laparoscopic BPD-DS – a single centre study

Biliopancreatic diversion (Credit: Chelsea and Westminster Hospital NHS Foundation Trust)
Excess weight loss was 81±14% at 12 months, 88±13% at 24 months and 83±14 % at 36 months
Major complications occurred in 3% of the patients and reoperation was required in 1.9% of the patients
Before surgery, 38% of the population had an Haemoglobin A1C (HbA1C) above 6%, after surgery 1.4% had an HbA1C above 6% (p<0.005)

Researchers from the Department of Bariatric Surgery, Québec Heart and Lung Institute, Laval University, Québec, Canada, have reported that laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) is, for the experienced surgeon, only slightly more technically difficult than other bariatric procedures. Furthermore, the procedure has a similar low rate of major peri-operative complications (3%), offers some of the best weight loss and cure-rate of obesity related diseases and allows a better eating experience, by preserving the pyloric valve and avoiding dumping syndrome. Although these long-term benefits come at the cost of certain gastrointestinal side effects, they recommend long-term compliance with vitamin supplementation.

The paper’ ‘Current Outcomes of Laparoscopic Duodenal Switch‘, published in the Annals of Surgical Innovation and Research, reported the current outcomes of laparoscopic BPD-DS at the Québec Heart and Lung Institute from 566 patients. All the patients who had a laparoscopic BPD-DS using a hand-sewn anastomosis at the Quebec Heart and Lung Institute, were included in this study.

Open BPD-DS has been performed since 1989 and laparoscopic BPD-DS was introduced in November 2006. I addition, the researchers first used a mechanical stapler for the duodenal anastomosis (21-mm circular stapled anastomosis). However, this technique was associated with a higher rate of complication (including stenosis, leak, bleeding) and they moved to hand-sewn anastomosis, which has been their standard operative technique since 2011. Therefore, all patients who were operated using this technique were included in this study (up to February 2015).

Surgical procedure

The authors write that during the procedure, a 15mm Hg pneumo-peritoneum first created and the greater curvature of the stomach is mobilised using ultrasonic shears (Ace Ultrasonic, Ethicon EndoSurgery). A 34-44Fr Bougie is used for the calibration of the sleeve and the stomach is then transected along that Bougie using an articulating linear stapler-cutter (Echelon-Flex long 60, Ethicon EndoSurgery), starting 7–8 cm from the pylorus, to create a gastric reservoir, with an estimated volume of 250cc.

The duodenum is then transected 3-4 cm from the pylorus, using a blue cartridge. The ileo-caecal valve is then identified and the small bowel is transected 250cm proximal, using a white cartridge. The duodeno-ileal anastomosis is then created and a hand-sewn anastomosis, using two posterior layers and one anterior layer of absorbable sutures (3-0 V-lock suture). The mesenteric window is closed using a 2-0 Prolene suture. A routine cholecystectomy is also performed.

All patients were followed at the clinics at four, eight, 12, 18 and 24 months and yearly thereafter. Blood analyses were performed at these times, including a complete blood count, electrolytes, urea and creatinine, calcium, parathormone levels, vitamin D, vitamin A, serum iron, total iron binding capacity and ferritin. Post-operative supplements were adjusted over time according to these analyses using standardised supplementation protocols.

Outcomes

The pre-operative BMI for the 566 patients was 49±6.1. All patients underwent a laparoscopic BPD-DS (by four different surgeons), although one patient required conversion to open surgery because of difficulties getting good exposure and was kept in the series in an intention-to-treat process.

Major complications occurred in 3% of the patients and reoperation was required in 1.9% of the patients. A leak occurred at the duodenal anastomosis in 0.7% of the patients (n=4) and at the gastric level in 0.2% (n=1). There was no short- or medium-term mortality, during a mean 21 ± 12 months follow-up. During that period, readmission for a medical problem related to the surgery was required in 3.5% of the population, and a reoperation was required in 0.5% (including two patients who required a surgical revision for malnutrition). 

Excess weight loss was 81±14% at 12 months, 88±13% at 24 months and 83±14 % at 36 months. Total body weight loss (kg) was 57±13 at 12 months, 63±14 at 24 months and 61±17 at 36 months (Figure 1).

Figure 1: Percentage of excess weight loss over time. Data are reported as the Mean ± standard deviation. Numbers above the curve represents the number of available data at each interval

At three years, one patient (1.7%) had a BMI above 35, three patients (5%) had a BMI between 30-35 and 14 (23%) had a BMI between 25-30.

Before surgery, 38% of the population had an Haemoglobin A1C (HbA1C) above 6%. After surgery, only 1.4% had an HbA1C above 6% (p<0.005). There was also a significant drop in total cholesterol, low density lipoproteins and triglycerides. There was a significant improvement in ferritin level, vitamin D-25-OH and vitamin B12. However, albumin, haemoglobin and vitamin A dropped significantly. Even though the mean albumin level dropped significantly, values were below normal (35gr/l) in only two patients at two years (2/182, 1.1%) and one patient at three years (1/70 or 1.4%).

“The excellent long-term weight loss and correction of obesity-related diseases after BPD-DS have never been really challenged,” the authors write. “In a meta-analysis of the bariatric literature, Buchwald et al reported that BPD is the surgery offering the best long-term EWL (70.1 %) and improvement in type 2 diabetes (98 %). However, BPD has also been associated in the past, with some of the highest mortality rate (1.1 % compared with 0.28 % for all procedures)…Indeed, we observed a mortality rate of 0.1 % in a series of 1,000 BPD-DS which included our initial cases of laparoscopic BPD-DS and a significant portion of open DS Perioperative complications in a consecutive series of 1000 duodenal switches. In this series, we did not experience any mortality in a consecutive series of 566 patients.”

They note that the risk of leak using a circular-stapled anastomosis was 2.6 %, compared to the use of a hand-sewn technique allowed to reduce that risk 0.4 %, which they claim, is consistent with the leak rate reported in recent series of gastric bypasses (Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass). They add that the use of a hand-sewn technique has virtually eliminated the risk of anastomotic stenosis, which occurred in an average of 10% of patients who had a circular-stapled anastomosis.

To access this paper, please click here

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