Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 180 Consecutive Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is used by many as a surgical treatment for morbid obesity. The authors present their results in 180 consecutive cases. Method: Between June 1995 and May 1998, the authors performed BPD by Scopinaro's method on 180 patients (36 men) with morbid obesity, mean age 35.8 years (range 18-58 years), mean body mass index (BMI) 48.8 kg/m² (range 35-66 kg/m²). Results: In all cases, a gradual decrease in weight was obtained: the mean BMI at 1 month was 40.3 kg/m², at 6 months 34 kg/m², at 1 years 32 kg/m², at 18 months 30.2 kg/m², and at 36 months 28.8 kg/m². At the same time a significant improvement in the pathologic conditions associated with morbid obesity was observed. Postoperative complications were two duodenum blowout syndromes requiring prolonged intensive care, and an 18% rate of incisional hernias. Conversion to normal small bowel continuity was necessary in three cases. Protein malnutrition developed in 2 patients (1.1%), in 1 patient coinciding with addiction to cocaine. One patient could not psychologically accept the physical changes and requested conversion. Anastomotic ulceration was seen in 11% of the patients. Operation for late obstruction occurred in 2 patients. There was no mortality. Conclusions: Although BPD by Scopinaro's method is technically complex, it is safe and effective.     

Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 50 Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. Methods: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m² (range 37.01-81.56 kg/m²). Results: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m², at 6 months (31 patients): 35.09 kg/m², at 1 year (23 patients): 31.36 kg/m², at 18 months (14 patients): 29.89 kg/m² and at 2 years (5 patients): 29.27 kg/m²]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). Conclusions: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.     

Modifications of Intestinal Permeability Test Induced by Biliopancreatic Diversion: Preliminary Results

Background: Biliopancreatic Diversion (BPD), excluding the jejunum and part of the ileum from the transit of the food, reduces the absorptive intestinal area available to 250 cm of the distal ileum. The Intestinal Permeability Test (IPT) with Lactulose/Mannitol is performed to assess the intestinal mucosa function. The aim of this study was to investigate the effect of intestinal anatomical modifications induced by BPD on IPT in a group of severely obese patients. Methods: Group A: 18 severely obese subjects who underwent BPD; the IPT was performed before (T_o) and 8.2 ± 0.9 days after BPD (T₁). Group B: nine subjects of Group A; IPT was repeated 96.1 ± 12.7 days (T₂) and 180.4 ± 19.7 days (T₃) after BPD, respectively. IPT was expressed as the %Lactulose/%Mannitol ratio in the urine collected during 5 h after oral administration (normal %L/%M < 0.04). Results: Data from Group A (paired Student's t-test) exhibited significantly higher values in T₁ with respect to T₀ for %L/%M (p < 0.05) and for %L (p < 0.05), and significantly lower values in T₁ with respect to T₀ (p < 0.001) for %M. In the Group B analysis of Variance from T₀-T₁-T₂-T₃ resulted statistically significant (p < 0.05) for %L/%M and %M. Conclusions: The reduction of intestinal absorption surface induced by BPD causes a significative increase of the Lactulose/Mannitol IPT values, showing an intestinal mucosa function impairment. The IPT values improve progressively at 3 and 6 months after this surgical procedure.     

Why the Operation I Prefer is Biliopancreatic Diversion (BPD)

The author discusses why his operation of choice is biliopancreatic diversion (BPD). BPD is the most effective in obtaining long-term weight loss and permits unchanged eating habits. Although BPD is technically demanding, revisions for protein malnutrition or stomal ulcer have not been difficult and have become infrequent. However, lifelong follow-up must be guaranteed.     

Biliopancreatic Diversion: 170 patients in a 7-year follow-up

During the past 7 years, 170 morbidly obese patients have been subjected to a biliopancreatic diversion. Mean weight loss achieved over 2 years was greater than 70% of excess weight and was maintained. Early complications were rare. The most common side-effects are discussed. The re-operation rate because of these side-effects was 7%. Eating normal meals, together with a stable weight loss, has provided these patients with a better quality of life.     

Biliopancreatic Diversion with Transitory Gastroplasty Preserving Duodenal Bulb: 3 Years Experience

Background: The authors have performed 521 bariatric surgery operations (319 restrictive procedures and 202 malabsorptive procedures). Methods: During the last few years we have introduced an evolution of biliopancreatic diversion (BPD): BPD with transitory gastroplasty, preserving the duodenal bulb (53 cases). From a technical point of view, the operation consists of a BPD, coupled with a gastroplasty which is transitory due to the use of a polydioxanone (PDS) band. In the last few cases, instead of a VBG (with PDS band) in order to make the operation completely reversible without any suture on the stomach, we made a gastric pouch by banding with PDS calibrated with the same tube as for the Lap-band (20 cc). We maintained completely the duodenal bulb (5 cm from the pylorus), making an end-to-side duodeno-ileal isoperistaltic anastomosis. Results: With this anastomosis, only 2% of patients developed an anastomotic ulcer. With this new procedure, results have been good in terms of weight loss (similar to that of BPD-AHS) and in nutritional complications. No patient has had hypoalbuminemia, diarrhea or halitosis. Conclusion: BPD with temporary gastric restriction has provided satisfactory results.     

Late Perforation of the Distal Roux-en-Y Anastomosis in a Patient with Biliopancreatic Diversion

A 38-year-old female with a history of biliopancreatic diversion for morbid obesity developed a perforation at the distal Roux-en-Y anastomosis 13 months after the original surgery. The etiology of this complication was not determined. Perforation of a Roux-en-Y anastomosis occurring this late in the postoperative period has not been described previously.     

Laparoscopy-Assisted ERCP after Biliopancreatic Diversion

Therapeutic biliary endoscopy after biliopancreatic diversion (BPD) for morbid obesity is not possible through the anatomical route. In the case of a long excluded afferent limb, the possibility to reach endoscopically the papilla through a surgical gastrostomy or jejunostomy has been reported. A case of laparoscopy-assisted ERCP performed 4 years after laparoscopic BPD with distal gastrectomy, is reported. Access to the papilla was obtained laparoscopically by enterotomy, insertion of a trocar into a jejunal loop 40 cm distal to the ligament of Treitz and passage of the duodenoscope through the trocar to the papilla. A guidewire was laparoscopically advanced into the cystic duct, and bile duct cannulation was achieved using the rendez-vous technique; endoscopic sphincterotomy and extraction of stones were successful. Laparoscopic cholecystectomy was performed and the enterotomy was sutured. The clinical course was uneventful.     

Biliopancreatic Diversion: early complications

The experience and early complications in 66 morbidly obese patients who underwent biliopancreatic diversion are presented. There was one death, due to a pulmonary embolus (PE) at home on the 15th postoperative day. Postoperative complications occurred in nine patients, consisting of gastric hemorrhage (2), gastric outlet obstruction (2), non-lethal PE (1), deep vein thrombosis (1), wound dehiscence (1), and asymptomatic gastric leak (1). In addition, there were 12 superficial wound infections. Four patients required urgent reoperation for gastric hemorrhage (2), gastric outlet obstruction (1), and wound dehiscence (1). The high complication rate is believed to represent the early part of the learning curve. Some reports of the early complications following other bariatric operations are discussed.     

Emergency Surgical Conditions after Biliopancreatic Diversion

BACKGROUND: Urgent late complications of biliopancreatic diversion (BPD) are rare and often require the experience of a bariatric surgery team for their immediate resolution. METHODS: The present work analyzes the incidence of emergency surgical conditions in a group of 138 patients who had undergone classical BPD, with a mean follow-up of 60 months (24-96) after BPD. RESULTS: Urgent surgical intervention was necessary in 9 patients out of 138 (6.5%): 7 (5%) were for intestinal obstruction (4 of the biliopancreatic limb and 3 of the alimentary tract); 2 (1.4%) were for stomal ulcer with complications (1 massive hemorrhage and 1 perforation). CONCLUSIONS:These complications of BPD are common to all GI operations, and thus are not specific to the type of surgery. We emphasize the importance of early diagnosis and treatment, particularly in regard to intestinal obstruction, because delay could have dramatic consequences.     

Biliopancreatic Diversion Preserving the Stomach and Pylorus in the Treatment of Hypercholesterolemia and Diabetes Type II: Results in the First 10 cases

Background: Besides weight loss Scopinaro's operation produces correction of hypercholesterolemia and noninsulin dependent diabetes mellitus in all patients who suffer from these conditions. These results encouraged us to perform biliopancreatic diversion (BPD) without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolemia associated with diabetes type II and hypertriglyceridemia. Methods: Between March 1996 and July 1997 we performed BPD without gastric resection on 10 moderately overweight patients [mean body mass index (BMI) = 33.2 kg/m²]. All patients had suffered from hypercholesterolemia and hypertriglyceridemia for more than 5 years. Ten patients suffered from diabetes type II; four of them had had insulin treatment or oral anti-diabetic agents; the other patients all had hyperglycaemia in the fasted state and diabetes confirmed by preoperative oral glucose tolerance test (OGTT). Five patients suffered from hypertension. Results: In all patients, cholesterol and triglyceride levels returned to normal within the first postoperative month. Glycemia also stabilized at normal values in nine patients within the early weeks after surgery. One patient who took 70 U of insulin reduced his daily intake to 35 U 2 months postoperatively. In all patients blood pressure returned to normal. Weight loss was predictably slight (10-15 kg). Conclusions: Our experience with the procedure found that this new method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of BPD. As expected, weight loss is only moderate, so that the modified BPD is not suitable for very obese patients.     

Biliopancreatic Diversion in a Renal Transplant Patient

Surgery is usually the only solution to modify the evolution of morbid obesity and resolve the associated co-morbidities. There is very little written regarding malabsorptive surgery and transplantation. A 48-yearold male with hypertension, hyperuricemia and obesity underwent renal transplantation in 1994 for renal amyloidosis. He was maintained on oral immunosuppressive cyclosporine. The patient developed uncontrollable hypertension, hyperlipemia, hyperglycemia and increasing weight to a BMI of 44. Thus, in December 2004, he underwent biliopancreatic diversion (BPD). After 18 months follow-up, he has lost 85% of his excess weight, and his hypertension, hyperglycemia and hyperlipemia are markedly improved. Renal function was not modified, nor were the levels of cyclosporine. He has had no complications derived from the BPD, and has a better quality of life.     

Biliopancreatic Diversion with a New Type of Gastrectomy: Some Previous Conclusions Revisited

Background: In 1990, we modified Scopinaro's biliopancreatic diversion (BPD); instead of a distal gastrectomy and gastroileal anastomosis, a parietal gastrectomy was performed with nutrients diverted through a duodenal switch. Also, the length of the common channel (50 cm) was doubled to 100 cm, while the nutrient limb remained 250 cm. In 1991, we reported initial results after 16 months: weight loss was as expected following BPD, but patients reported fewer side-effects and the prevalence of excessive malabsorption was less. This cohort of patients had their duodenum stapled shut to construct the duodenal switch. This staple-line failed insidiously in some patients, allowing the duodenum to recanalize partially or completely. This resulted in an incomplete BPD. Methods: Since 1992, the duodenal switch has been constructed with a complete transection of the duodenum to prevent recanalization. We report here on the first 61 patients who underwent this definitive procedure. Results: At 16 months, we observed a mean weight loss of 84% of initial excess weight, the number of daily stools at 2.9 ± 1.6 and the prevalence of diarrhea at 10%. Twenty per cent of patients experienced mild anaemia, hypocalcemia, or hypoalbuminemia, which required added supplements. Conclusions: BPD with parietal gastrectomy, duodenal switch and longer common channel improved weight loss and decreased gastrointestinal side-effects without an increased prevalence of excessive malabsorption. The parietal gastrectomy may contribute to weight loss by increasing satiety, and decreasing side-effects by regulating gastric emptying.     

Biliopancreatic Diversion with a Duodenal Switch

Background: This paper evaluates biliopancreatic diversion combined with the duodenal switch, forming a hybrid procedure which is a combination of restriction and malabsorption. Methods: The evaluation is of the first 440 patients undergoing this procedure who had had no previous bariatric surgery. The mean starting weight was 183 kg, with 41% of our patients considered super morbidly obese (BMI > 50). Results: There was an average maximum weight loss of 80% excess weight by 24 months postoperation; this continued at a 70% level for 8 years. Major complications were found in almost 9% of the cases. There were two perioperative deaths, one from pulmonary embolism and one from acute pulmonary obstruction. There were 36 type II diabetics, all of whom have discontinued medication following the surgery. Seventeen revisions were performed to correct excess weight loss and low protein levels. There have been no marginal ulcers, no cases of dumping syndrome, no foreign material used, and the procedure is a pyloric saving procedure which is functionally reversible. Conclusions: This operation has vastly improved the lives of seriously obese patients with many co-morbidities. All type II diabetics have essentially been cured of their disease. The procedure was tolerated well and patients are quite satisfied. There was minimal regain of weight with this method.     

Prompt Treatment of Intestinal Obstruction after Biliopancreatic Diversion can Save the Intestinal Loop

Bariatric surgery is becoming an accepted method for weight reduction. Biliopancreatic diversion is reserved for high initial BMI. With the increasing number of these procedures, the reports of complications become more important and prepare a wider range of specialties to deal with them. We report a 62-year-old woman who developed a volvulus of the biliopancreatic loop after a biliary diversion operation with a sleeve gastrectomy and antro-ileal anastomosis. Symptoms of biliopancreatic loop obstruction are rather vague, presenting with atypical abdominal pain, nausea, sometimes vomiting, preserved bowel motility, stool, and gas passage and normal upper GI X-ray. Due to the patient’s prompt reaction and straight referral to a bariatric surgeon, freeing of the loop was enough to maintain its viability. The patient’s further recovery and follow-up were uneventful. With this case, we stress the importance of an expert in such cases and a need to consider familiarizing doctors with these patients and with the peculiarities of their treatment.     

The Use of the Biliopancreatic Diversion as a Treatment for Failed Gastric Partitioning in the Morbidly Obese

The dilemma with which every bariatric surgeon is confronted is: What to do with the inevitable failures? In vertical gastric partitioning, revising the gastroplasty results in a high second failure rate. In an effort to improve the Success rate in failed gastroplasty patients who request revisionary surgery, the biliopancreatic bypass (classic Scopinaro procedure) was carried out on 57 patients. They have been followed for up to 10 years. The long-term weight loss has averaged 69.4 lb, which is 87% of the pregastroplasty excess weight. The price paid by these patients, in terms of complications, has been significant. Twenty-two Percent have developed hypoalbuminemia with its accompanying peripheral edema; 24% have required i.v. hyperalimintation because Of malnutrition. Sixteen percent of the patients developed a late post-op bowel obstruction, one resulting in death. Osteomalacia, spontaneous fractures have occurred. The biliopancreatic diversion procedure (BPD) is an effective weight-loss operation in the failed gastroplasty patients, but a significant price must be paid in terms of careful follow-up, nutritional deficiencies, and rehospitalizations.     

Phosphocalcic Metabolism after Biliopancreatic Diversion

Background Malabsorptive techniques to treat morbid obesity have been followed by alterations in phosphocalcic metabolism. Knowledge of the preoperative situation is important to assess the influence of these techniques on phosphocalcic metabolism and to consider treatments for these alterations. Methods 61 consecutive morbidly obese patients (50 women, 11 men, age 19 to 63 years) having had biliopancreatic diversion (BPD) were studied in a prospective manner. Preoperative and postoperative levels of calcium, phosphorus, 25-hydroxyvitamin D, tartrate resistant acid phosphate, plasma parathormone (PTH), tubular absorption of phosphate, and urinary calcium and pyridinolines were analyzed, as well as the potential risk factors for their alterations. Follow-up of all patients was a minimum of 4 years. Results Before BPD, 42.3% of patients presented an increase in PTH and 54% a decrease in the 25-OH vitamin D, but the values of calcium and plasma phosphorus maintained at normal level. 81.8% of the patients with an increase in the PTH maintained high levels after BPD, while 60% of those with a normal preoperative PTH also presented hyperparathyroidism 4 years after the intervention. A correlation between the levels of plasma PTH and body mass index was not found. Conclusion Morbid obesity is accompanied by a high percentage of hyperparathyroidism. BPD produces malabsorption of vitamin D during the first years, favoring the persistence or appearance of hyperparathyroidism. It is important to recognize and treat the secondary hyperparathyroidism.The postoperative period could necessitate more energetic interventions to get more efficient control of the phosphocalcic metabolism. Work supported, in part, by a grant from Fondo de Investigaciones Sanitarias to the Red Temática de Investigación Cooperativa G03/015.     

Biliopancreatic Diversion in Prader-Willi Syndrome Associated with Obesity

Background: Prader-Willi Syndrome (PrWS) is an uncommon neuroendocrine disorder of genetic origin, described in 1956 by Prader, Labhart and Willi. The main clinical manifestations in the adult are mental retardation, hyperphagia with gross obesity, hypogonadismcriptorhismus and short stature. The life expectancy of the affected individual ranges between 20 and 30 years - rarely beyond - due to complications related to excessive obesity. Sustained dieting combined with behavior modification programs, as well as gastric restrictive surgery for obesity, proved to have a high failure rate in PrWS, due to the patients' inability to cooperate in changing their eating habits. Methods: Billiopancreatic Diversion (BPD), which does not require the patient's cooperation in changing eating habits after surgery, was performed in two PrWS patients (13- and 22-years-old), both with excessive obesity, severe respiratory distress, day sleepiness and limited mobility. Results: Two years after surgery, the 13-year-old had lost 80% of her overweight, while the 22-year-old, after 1 year, had lost 34%. Recent laboratory tests showed normal data in both patients. Their respiratory distress had subsided completely, their mobility improved dramatically, and their self-image and alertness enhanced. Conclusion: BPD resulted in an improved quality of life in these patients.     

Bowel-Associated Dermatosis-Arthritis Syndrome after Biliopancreatic Diversion

The bowel-associated dermatosis-arthritis syndrome (BADAS), originally called the bowel bypass syndrome, and described after jejuno-ileal bypass, has subsequently been reported in association with inflammatory bowel disease and after gastric resection. BADAS has not been reported after biliopancreatic diversion (BPD). This case report describes a 47-year-old female who presented with recurrent skin rashes and arthralgia after a BPD, consistent with a clinical diagnosis of BADAS which was confirmed by skin biopsy. To date, she has been managed with cyclical courses of antibiotics without reversal of her surgery.This syndrome may be under-diagnosed and is a condition with which bariatric surgeons should be familiar.