Biliopancreatic Diversion with Biliopancreatic Diversion with Duodenal SwitchDuodenal Switch

Alfons Pomp, MD FACSAlfons Pomp, MD FACS

Weill Medical College of Cornell University Weill Medical College of Cornell University

New York Presbyterian HospitalNew York Presbyterian Hospital

DisclosureDisclosure

Consultant/speaker bureau

Covidien

Ethicon Endo Surgery

W.L.Gore Associates

apomp@med.cornell.edu

Surgical Procedures:Surgical Procedures: Biliopancreatic Diversion (BPD)Biliopancreatic Diversion (BPD)

Nicola Scopinaro, Genoa, Italy 1976

Large gastric pouch Alimentary limb

– 250 cm Biliopancreatic limb Common channel

– 50-75 cm Mechanism:

– mildly restrictive – malabsorptive

Surgical Procedures:Surgical Procedures: Biliopancreatic Diversion (BPD)Biliopancreatic Diversion (BPD)

Problems:– Marginal ulcer– Diarrhea– Excessive flatus– Malnutrition

This has not stopped surgeons from using it!

6

Surgical Procedures:Surgical Procedures: BPD with Duodenal Switch (BPD/DS)BPD with Duodenal Switch (BPD/DS)

Doug Hess, 1988 Picard Marceau “Sleeve” gastric pouch Alimentary limb

– 40% of bowel (250-300 cm) Common channel

– 50-100 cm (arbitrary) Benefits over BPD:

– no dumping – decreased marginal ulcer– better tolerated

– Reroute the intestinal tract into long alimentary and bilio-pancreatic limbs

– Weight loss is generally secondary to mal-absorption of nutrients (better to say metabolic effects!) rather than gastric restriction

– The length of the common channel appears proportional to the risk of nutritional deficiencies

– Greater weight loss but higher operative risk and more long term sequelae than the gastric “bypass” procedures (Ca, fat soluble vitamins, protein deficiencies, etc)

Lap Biliopancreatic Diversion Lap Biliopancreatic Diversion with Duodenal Switchwith Duodenal Switch

TechniqueTechnique

Sleeve gastrectomyDuodenal transectionIdentification of ileocecal valve (vs

ligament of Treitz)Duodenal – ileal anastomosis

Sleeve GastrectomySleeve Gastrectomy

Surgical Procedures:Surgical Procedures: Laparoscopic BPD/DS: TechniqueLaparoscopic BPD/DS: Technique

Technique of duodeno-ileostomy

Transgastric (duodenal) EEA anvil Transabdominal Linear stapler Hand sewn

DS – Anvil TechniqueDS – Anvil Technique

DS – Hand SewnDS – Hand Sewn

Weight Change SOS so Weight Change SOS so notnot EBWL EBWL

The Super ObeseThe Super Obese

MacLean et al.,MacLean et al., Ann Surg, Ann Surg, April 2000 April 2000

Super-obeseSuper-obese BPD-DS delivers superior weight loss outcomes in superobese

compared to RYGB*

*Prachand et al. Ann Surg 2006

BMI< 60 BMI >60

Number of patients 107 31

Major morbidity 13% 23%

Conversion 0 1

Mortality 0 6.5%

DS Complications and BMI

BPD-DS for Super-Super Morbidly BPD-DS for Super-Super Morbidly Obese PatientsObese Patients

0.0

5.0

10.0

15.0

20.0

25.0

One-StageLBPD-DS

(n=31)

Open BPD (n=28)

Morbidity

Mortality

23%

6.5%

17%

3.5%

Two-Stage LBPD-DSWeight Change based on BMI

0

10

20

30

40

50

60

70

80

Stage I 3 wkBMI

3 mosBMI

6 mosBMI

Stage II 3 wkBMI

3 mosBMI

6 mosBMI

BM

I (k

g/m

2)

Second StageFirst Stage

Normal Range

Sleeve gastrectomy Sleeve gastrectomy RYGBRYGB

8 / 73 patientsGERD = 3; Weight regain = 5Interval 33 months36F bougieAll patients had resolution of GERD1 postoperative leak; treated with stent

Langer FB, et al; Obes Surg; Online April 15, 2010

Sleeve gastrectomy Sleeve gastrectomy RYGBRYGBMean weight reduction = 15 + 8kg (range = 6-25kg)

Langer FB, et al; Obes Surg; Online April 15, 2010

British Journal of Surgery 2010;97(2):160-166

Results Results Peri-operative results (<30 days) No mortality Mean (SD) operative time:

– LRYGB: 91 (33) min– LDS: 206 (47) min ….. (p<0.001)

Conversion rates: 1 LDS procedure, 0 LRYGB Complications:

– LRYGB n=4– LDS n=7 .…. (p=0.327)

Median (range) LOS– LRYGB 2 (2-15) days– LDS 4 (2-43) days .…. (p<0.001)

ResultsResults

Weight loss:

ConclusionConclusion

Large difference in BMI at 1 year (6 kg/m2 lower in LDS group), and stability of weight loss after DS shown by other groups, suggest

that LDS is better at promoting short- and long-term weight loss in super-obese patients

Biertho et al, SOARD 2010;6(5):508-514

AimAim

To determine safety & efficacy of DS as a primary weight loss procedure in patients with BMI < 50 kg/m2

Usually reserved for super-obese (BMI >50) because of increased risk of nutritional complications

ResultsResults 810 consecutive patients (1992-2005): BMI< 50

– 637 women (78.6%)– Mean age: 41.1 years – Mean preop BMI: 44.2 kg/m2 (Range 33-49)– Comorbidities:

DM 28% (n=227) Hypertension 37% Sleep apnea 25%

– Mean follow-up: 103 months (Range 36-201)– Mean hospital stay: 6.9±5.4 days

ResultsResults

Complications: Intra-op: 0.7% (n=7)

– Liver laceration (1)– Splenic injuries (6)

Major post-op: 4.9% (n=40)– 5 operative deaths (<30 days)

Minor complications: 8% (n=66)– Wound infections– Respiratory infections– Intestinal disturbance

*

**

*

ResultsResults Long-term outcomesWeight loss: – At mean of 8.6 years:

EWL 76% ± 22.3%Only 11% had EWL <50%BMI was <35 in 92%, and < 30 in 71%

ResultsResults Comorbidity status postoperatively:

– DM: 92.5% ‘cured’ (requiring no medications)– Hypertension: 60% no longer requiring anti-hypertensives– Sleep apnea: Only 2% still require an apparatus

Patient satisfaction

63% very satisfied with weight loss; 91% very satisfied overall outcome

Results Results

Long-term complications– Rehospitalization required in 15.8% (n=127)

Normal Inadequacy Deficiencyn range % % range %

Vitamin A mmol/l 325 >1.2 91.4 7.7 <0.7 0.9

Vitamin D nmol/l 307 >50 72.3 21.0 <30 6.5

Calcium mmol/l 367 >2.10 85 12.0 <2 .00 3

Iron mmol/l 363 >8 84.3 12 <4 3.8

Ferritine Ug/l 348 >9 83.6 13.8 <4 2.6

Hgb g/l 365 >120 83.6 10.4 <110 6

PTH pmol/l 338 <90 79.2 16.5 >150 4

Deficiencies are infrequent and correctable (25 years gives no sign of latent damage)

10 years post duodenal switch

Henry Buchwald JAMA 2004Henry Buchwald JAMA 2004

Meta-analysis Buckwald JAMA 2004

GB GBP BPD

Improved diabetes % 47.9 83.7 98.9

FBS (mmol/l) -3.1 -3.4 -5.8

Insulin (pmol/l) -49.5 -153.7 -115.3

Cholest tot (mmol/l) -0.3 -0.96 -1.97

LDL (mmol/l) -0.11 -0.89 -1.36

Trig decreased 77% 91% 100%

HTA resolved 43.2% 67.5% 83.4%

Risk/benefit ratioRisk/benefit ratiocomparison between procedurescomparison between procedures

GB GBP BPD

Operative mortality % 0.1 0.3 1

Operative complication % 9 15 15

Success rate % 50 60 90

Reoperation rate % 20 10%+ 2

Bacterial overgrowthBacterial overgrowth

Current Surgery 2003; 60: 274-277

Manageable side effects

% Treatment

Mild (bloating discomfort) 20 dietary counselling

probiotics

Moderate (proctitis, nocturnal diarrhea, abdominal distension)

2metronidazole

Severe (bypass enteritis) 0.4 reversal

Mechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DS

The exclusion of the duodenal The exclusion of the duodenal nutrient passage may offset an nutrient passage may offset an abnormality of gastrointestinal abnormality of gastrointestinal physiology responsible for physiology responsible for insulin resistance and type 2 insulin resistance and type 2 diabetesdiabetes

The exclusion of the duodenal The exclusion of the duodenal nutrient passage may offset an nutrient passage may offset an abnormality of gastrointestinal abnormality of gastrointestinal physiology responsible for physiology responsible for insulin resistance and type 2 insulin resistance and type 2 diabetesdiabetes

« Proximal mechanism » « Proximal mechanism » « Proximal mechanism » « Proximal mechanism » 

Mechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DSMechanisms of diabetes control after BPD/DS

Nutrients reach the distal ileumNutrients reach the distal ileum within minutes of the ingestion of foodwithin minutes of the ingestion of foodand this stimulates the secretion of and this stimulates the secretion of GLP-1 by L-cells located in this area GLP-1 by L-cells located in this area

Nutrients reach the distal ileumNutrients reach the distal ileum within minutes of the ingestion of foodwithin minutes of the ingestion of foodand this stimulates the secretion of and this stimulates the secretion of GLP-1 by L-cells located in this area GLP-1 by L-cells located in this area

« Distal  mechanism »« Distal  mechanism » « Distal  mechanism »« Distal  mechanism »

Summary - BPDSummary - BPD

Excellent long-term weight loss (65% + )

Resolution of most co-morbidities

100% DM (ok its really 98%), 80% HTN

Potential malnutrition or mineral/vitamin deficiency requires intense life-long monitoring

Laparoscopic approach can be done safely

Super Obese (>50 or >60 BMI)Super Obese (>50 or >60 BMI)

Band is not be the best option DS results are superior to GBP

long term data does not support sustained weight loss BMI <35 in this group

High risk group

Staged procedure may be best option

“lower” risk procedure, evaluate patient

Surgical Options- PompSurgical Options- Pomp Laparoscopic Adjustable Gastric Banding

+ low surgical morbidity/complexity - vomiting, high maintenance, port/device problems, less weight loss (especially with high BMI) Roux-en-Y Gastric Bypass/Sleeve Gastrectomy + low maintenance, excellent weight loss - ulcer/stricture rate, leak management (sleeve) - significant weight regain (esp. super obese) Biliopancreatic Diversion/Duodenal Switch) + sustained weight loss; all BMI categories - surgical complication rate, post-op maintenance

Information-Knowledge-Information-Knowledge-WisdomWisdom

This operation is not for every patient (nor for every surgeon)

“TRIFECTA”

-motivated, intelligent patient

-financial resources ($1000-1500/year)

-compulsive (12-15 supplements/5 doses)

Surgery for ObesitySurgery for Obesity

How does it work?– Restriction– Malabsorption/metabolic

4 operations– Lap band– Sleeve gastrectomy– Gastric bypass– Duodenal switch

Thank you Thank you apomp@med.cornell.eduapomp@med.cornell.edu