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BOLD outcomes

Biliopancreatic diversion/ duodenal beats bypass

biliopancreatic diversion/duodenal has lower rates of failure compred with bypass
Study reports biliopancreatic diversion/duodenal switch improves comorbidities, compared with bypass
Biliopancreatic diversion/duodenal switch results in higher earlier reoperation rates

Biliopancreatic diversion/duodenal switch results in greater weight loss in super-obese patients (BMI>50) compared with gastric bypass and control of co-existing illnesses, a study published in the Archives of Surgery has reported.

However, Dr Daniel W Nelson and colleagues from the Madigan Army Medical Center, Fort Lewis, Washington, also reported that the biliopancreatic diversion/duodenal switch procedure may be associated with higher early risks compared with gastric bypass.

"Although the duodenal switch carries a higher relative risk profile than gastric bypass, the absolute risk is low,” the authors report. “Among morbidly obese patients, the duodenal switch results in superior sustained weight reduction and improved comorbidity control compared with gastric bypass, which may outweigh early perioperative risk. The benefits of the duodenal switch, including a significant decrease in the bariatric failure rates, appear to be greatest in the super-obese population.”

Despite the Roux-en-Y gastric bypass being widely acknowledged as the gold standard bariatric procedure, the authors note that there is some evidence that weight loss failure and weight regain following a bypass procedure may be more prevalent than first thought, especially among the super-obese.

Therefore, they decided to compare the outcomes of a large cohort undergoing biliopancreatic diversion/duodenal switch against those undergoing gastric bypass, using data from the Bariatric Outcomes Longitudinal Database (BOLD).

They compared 1,545 patients who underwent biliopancreatic diversion/duodenal switch (average preoperative BMI 52), with 77,406 patients who underwent gastric bypass (average preoperative BMI 48) between 2007 and 2010. The average age of the patients was 45 years and 78% of the patients were female.

The main outcome measures were weight loss; control of comorbidities including diabetes mellitus, hypertension and sleep apnoea; and failure to achieve at least 50% excess body weight loss.

Results

The outcomes revealed that biliopancreatic diversion/duodenal switch was associated with longer operative times (191 vs. 114 minutes), greater estimated blood loss and longer hospital stays (2.4 vs. 4.4 days), compared with bypass (all p<0.05). Early reoperation rates were also higher in the biliopancreatic diversion/duodenal switch group (3.3% vs. 1.5%).

However, the percentage of change in BMI was significantly greater in the biliopancreatic diversion/duodenal switch group at all follow-up intervals (p<0.05). In the super-obese population, biliopancreatic diversion/duodenal was also associated with a significantly greater percentage of excess body weight loss at two years, compared with bypass (79% vs. 67%, p<0.01).

In addition, comorbidity control of diabetes, hypertension, and sleep apnoea were all superior in biliopancreatic diversion/duodenal switch patients (all p<0.05).

The results also indicate that nearly 20% of bypass patients failed to lose at least 50% of their excess BMI by both the one- and two-year follow-ups, compared with weight loss failure rates of 9% and 6% for biliopancreatic diversion/duodenal patients.

“In regard to postoperative comorbidity control, the biliopancreatic diversion/duodenal switch group saw significantly greater resolution or improvement in most of the well-recognised obesity-related comorbidities, including diabetes, hypertension, hyperlipidemia and obstructive sleep apnoea,” the authors reported.

Although the researchers note a relative increase in the use of the biliopancreatic diversion/duodenal switch in the US, gastric bypass is more commonly performed.

They suggest that is likely due to several factors, including the technical difficulty of the procedure, the higher reported rates of short-term complications and concerns about the longer-term nutritional consequences of a primarily malabsorptive procedure.

"Further studies of this procedure to determine the optimal patient selection, operative technique and longer-term risks vs. outcomes are warranted," the authors concluded.

Commenting in an invited critique, ”Time for a Change in Gastric Bypass?”, Dr Alec C Beekley, Thomas Jefferson University Hospitals, Philadelphia, wrote: "Their findings and conclusions challenge the notion that gastric bypass is the optimal operation for the majority of patients. As more surgeons familiarise themselves with the operative techniques and follow-up requirements for biliopancreatic diversion/duodenal switch patients, it may be used more frequently in the super-obese population.”

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