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BPD/DS vs RYGB

BPD/DS betters RYGB in super obese patients

BPD/DS results more adverse events and GI symptoms, but with similar quality of life (QoL), compared to patients operated with RYGB.

Super obese patients have superior weight reduction and a better effect on diabetes with biliopancreatic diversion with duodenal switch (BPD/DS) compared to Roux-en-Y gastric bypass (RYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS), according to researchers from the Uppsala University, Uppsala, Sweden. However, BPD/DS results more adverse events and GI symptoms, but with similar quality of life (QoL), compared to patients operated with RYGB.

The study, ‘Duodenal Switch Is Superior to Gastric Bypass in Patients with Super Obesity when Evaluated with the Bariatric Analysis and Reporting Outcome System (BAROS)’, published in the journal Obesity Surgery, sought to compare results after RYGB and BPD/DS in patients with super obesity using BAROS, as well as investigate possible differences of gastrointestinal symptoms after the two operations.

Eligible patients were invited to participate in the study and were asked to complete the BAROS quality of life questionnaire (MAQ) and a local questionnaire about additional surgery, rehospitalization, comorbidities, gastrointestinal symptoms (GI symptoms), current weight and general perception of outcome after surgery. Baseline data of the patients’ preoperative BMI and comorbidities, as well as information about possible adverse events, were collected from medical records.

Comorbidities analysed were diabetes, hypertension, cardiovascular disease, sleep apnoea and dyslipidaemia. Major complications, defined in BAROS as reoperation or a complication with prolonged hospital stay/rehospitalization ≥7 days, deducted one point from the final score, while minor complications, i.e., complication with prolonged hospital stay/rehospitalisation <7 days, deducted 0.2 points. A BAROS score was calculated for each patient, which classified the result as failure (<1 point), fair (>1 to 3 points), good (>3 to 5 points), very good (>5 to 7 points), or excellent (>7 to 9 points). In patients not suffering from any obesity-related comorbidity preoperatively, the modified scoring key, excluding changes in comorbidities (failure ≤ 0, fair > 0–1.5, good > 1.5–3, very good > 3–4.5, and excellent > 4.5–6), was used.

Outcomes

In total, the final analysis included 211 patients (98 RYGB and 113 BPD/DS), RYGB was performed as laparoscopic surgery in 11 patients; otherwise, all procedures were open surgery. Mean follow-up time was four years for both groups (4.0±1.1, range 2.2 to 6.5 years for RYGB, vs. 4.0±1.0 years, range 2.1 to 7.3 for BPD/DS). Groups were similar concerning gender distribution, age, and comorbidities, but preoperative BMI was lower in the RYGB group.

The %excess BMI loss was 62 ± 23% for the RYGB group, while the BPD/DS group lost 79 ± 17% of their excessive BMI, which resulted in a significant lower postoperative BMI in the BPD/DS group (31 vs. 36 kg/m2, p < 0.01). There were 48 patients (49%) in the RYGB group and 27 patients (24%) in the BPD/DS group who were severely obese (BMI > 35 kg/m2) even after weight loss.

In 61 patients (62%) in the RYGB group and in 66 patients (58%) in the BPD/DS group, obesity-related comorbidities were noted in the medical records preoperatively. Both groups had a significant reduction in diabetes and sleep apnoea (all p < 0.05). The BPD/DS group also had a significant reduction in dyslipidaemia (p < 0.01), while the reduction in dyslipidaemia after RYGB and the reduction in hypertension for both groups failed to reach statistical significance. The effect on diabetes was superior after BPD/DS, while changes in the other comorbidities were similar between groups. No positive change of cardiovascular disease was seen; another two patients in the RYGB group and one patient in the BPD/DS group had congestive heart failure at follow-up. No differences in comorbidities were seen between groups postoperatively. Fourteen patients (14%) had one or more complications in the RYGB group and 31 patients (27%) in the BPD/DS group.

In the first category (weight loss), the RYGB group scored lower than the BPD/DS group, while scores were similar in the second category (comorbidities). If patients without comorbidities (38% of RYGB and 42% of BPD/DS) were excluded, the average score was 1.6 for RYGB and 1.9 for BPD/DS (p=0.15). The third category (QoL) was also similar between the groups. A subgroup analysis of patients who had suffered an adverse event showed that these patients’ score on the MAQ did not differ significantly compared to those without an adverse event (RYGB group 0.9 vs. 1.2, p=0.52, and BPD/DS group 1.0 vs. 1.3, p = 0.47). The RYGB group had less score deduction for complications (p<0.05). Overall, the BPD/DS group had a higher BAROS score (Table 1).

Table 1: BAROS score of BPD/DS and RYGB

There were more patients in the BPD/DS group with “excellent” (27 vs. 13%) as outcome, and fewer patients categorized as “failure” (4 vs. 8%) or “fair” (8 vs. 17%) compared to the RYGB group (Figure 1).

Figure 1: The percentage distribution of patients in the five categories. RYGB Roux-en-Y gastric bypass, BPD/DS duodenal switch

Symptoms of rapid gastric emptying (dumping) were more common after RYGB (p < 0.01), 13% had symptoms weekly or more often. Gastroesophageal reflux, diarrhoea, faecal incontinence and problems with malodorous flatus were more common after BPD/DS (all p<0.05). The most prominent GI symptoms after BPD/DS were diarrhoea and malodorous flatus (59 and 80% daily or weekly, vs. 20 and 41% after RYGB). Frequency of nausea/vomiting and abdominal pain was similar (Figure 2).

Figure 2: Percentage of patients with GI symptoms weekly or more often. RYGB Roux-en-Y gastric bypass, BPD/DS duodenal switch

On the question where patients were asked to rate their overall perception of the outcome after surgery, 58% in the RYGB group and 62% in the BPD/DS group said they were “satisfied” or “very satisfied.” In both groups, 90% of the patients would recommend bariatric surgery to other patients suffering from severe obesity.

“The main reason for better BAROS score after BPD/DS was a significant better result on weight loss compared to RYGB,” they write. “Almost half (49%) of the patients in the RYGB group were still severely obese (BMI>35) at follow-up.”

In concluding that the benefits of BPD/DS comes with a cost of more adverse events and GI symptoms, the authors stress the importance of a well-informed patient: “We therefore believe that the choice of bariatric procedure must be made in close agreement between the surgeon and a well-informed patient.”

To access this paper, please click here

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