Short-Term Changes in Serum Leptin Concentration Following Biliopancreatic Diversion

Background: The influence of the new anatomicofunctional structure created by biliopancreatic diversion (BPD) in the postoperative fall of serum leptin concentration was evaluated. Methods: Serum leptin concentration was determined in obese women before and immediately after BPD, before the usual postoperative intestinal rest. The measurements were repeated at the second postoperative month, when oral intake had nearly totally resumed and the patients had lost the first amount of weight. Results: 5 days following BPD, a sharp reduction of serum leptin concentration was observed. At the second postoperative month the values remained nearly unchanged and were indistinguishable from those observed in a group of obese non-operated patients with a closely similar body weight. Conclusions: Changes in the upper gastrointestinal tract due to BPD appear to have no influence in the postoperative reduction of serum leptin concentration, which appears to be substantially related only to the patient's adiposity.     

Wernicke-Korsakoff Encephalopathy Following Biliopancreatic Diversion

Wernicke-Korsakoff disease with sensory-motor neuropathy was diagnosed in three out of a series of 1663 patients (0.18%), with onset 2, 3 and 5 months after biliopancreatic diversion. Precipitating factors were vomiting, minimal food intake, anorexia, rapid weight loss, and glucose-containing intravenous feeding. Recovery was partial in two and complete in one of the patients. In the early postop, prophylactic thiamine should be given to the patients with excessively limited eating capacity. Larger doses of thiamine should be instituted parenterally either in the case of suspected Wernicke-Korsakoff encephalopathy or before starting feeding for protein malnutrition.     

Changes In Lipid Profile after Biliopancreatic Diversion

Background: Bariatric operations have varying degrees of effectiveness and different mechanisms of action. Our objective was to evaluate the efficacy of the biliopancreatic diversion (BPD) in reduction of weight and serum lipids. Methods: A prospective study was conducted with follow-up from 12 to 72 months (average 39.4 months) of 58 patients with morbid obesity (10 men, 48 women, mean BMI 49.4 kg/m²). Their lipid levels were generally normal or slightly high. All the patients were subjected to subtotal gastrectomy and BPD with jejunoileostomy 50 cm proximal to the ileocecal valve, and they were instructed to maintain the same hypocaloric diet as before BPD. Serum lipoproteins and apolipoproteins B and A1 were measured before BPD and every 6 months during follow-up. Results: Early and very significant reduction (P<0.001) of total cholesterol (32.8%), LDL (46.3%), total cholesterol / HDL ratio (29.7%) and apolipoprotein B (37%), with more moderate decrease of triglycerides (21.3%, P=0.004), were observed. This lipid decrease was maximum at 1 year after BPD. Important and persistent weight reduction that did not correlate with changes in lipids was observed. The youngest patients and those with high basal lipid levels proved to benefit most from BPD. There were no important side-effects. Conclusion: BPD, with careful selection of patients, is a well tolerated procedure that offers excellent results in the short- and mid-term in reduction in weight and blood levels of most atherogenic lipoproteins.     

Magnetic Resonance Spectroscopy Facilitates Assessment of Intramyocellular Lipid Changes: a Preliminary Short-Term Study Following Biliopancreatic Diversion

Background: Intramyocellular content of lipid (IMCL) appears to be important in the pathogenesis of insulin resistance, and the improvement of insulin activity observed following biliopancreatic diversion (BPD) for obesity has to be related to reduction of IMCL. This study evaluates the possibility of detecting changes after BPD in IMCL by means of H¹ magnetic resonance spectroscopy. Methods: The investigation was carried out in obese patients undergoing BPD prior to and at 1 month following the operation. Insulin sensitivity was assessed according to the homeostatic model of assessment (HOMA), and IMCL was determined by the spectroscopy of the tibialis anterior muscle. Results: At 1 month following BPD, an improvement in insulin action was observed in all subjects, and in nearly all cases the IMCL signal decreased. Conclusion: The data from this study indicate that magnetic resonance spectroscopy can detect IMCL changes following BPD and is fully suitable for longitudinal studies on muscle metabolic status.     

Dietary Habits and Body Weight at Long-Term Following Biliopancreatic Diversion

Aim  

This study aims to evaluate the role of simple carbohydrates and alcohol intake in determining weight of stabilization at long-term following malabsorptive bariatric surgery.     

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.     

Biliopancreatic Diversion as a Novel Approach to the HAIR-AN Syndrome

Background. The HAIR-AN syndrome is a rare multisystem disorder in women, that consists of hyperandrogenism (HA), insulin resistance (IR) and acanthosis nigricans (AN). The IR is likely due to a primary defect of the insulin receptor. Methods: We report the case of a 42-year-old Caucasian woman with HAIR-AN syndrome, impaired glucose tolerance (IGT), mild hyperlipemia, and hypertension, who underwent biliopancreatic diversion (BPD). Results: Within 24 months follow-up after BPD, impaired glucose tolerance, mild hyperlipemia, and hypertension completely reversed. Although insulin sensitivity, estimated by the euglycemic hyperinsulinemic clamp, did not improve, signs and symptoms of hyperandrogenism and acanthosis nigricans resolved fully. Conclusion: In HAIR-AN syndrome, malabsorptive bariatric surgery is effective in improving hyperandrogenism and acanthosis nigricans, with noteworthy esthetic consequences. BPD was followed by disappearance of co-morbidities of the syndrome, such as IGT, hypertension and hyperlipemia.     

Chronic Increase of Bone Turnover Markers After Biliopancreatic Diversion is Related to Secondary Hyperparathyroidism and Weight Loss. Relation with Bone Mineral Density

Background  

Biliopancreatic diversion (BPD) is the most effective bariatric procedure. Around 70% of these patients have secondary hyperparathyroidism (SH) in the long term as a consequence of calcium and vitamin D malabsorption. This work was aimed to study the influence of SH on bone turnover and its relationship with bone mineral density (BMD).     

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.     

Pregnancy in Formerly Type 2 Diabetes Obese Women Following Biliopancreatic Diversion for Obesity

BACKGROUND: This study describes the pregnancy of previously obese women with type 2 diabetic who reduced body weight and normalized serum glucose level following biliopancreatic diversion (BPD) for obesity. METHODS: A subset of ten women who had type 2 diabetes prior to BPD and who developed pregnancy after the operation was retrospectively identified. RESULTS: All pregnancies were completely normal, and serum glucose levels remained within the physiological range throughout all the pregnancy. These post-diabetic women delivered 13 infants in good health with a normal birth weight and no case of macrosomia. CONCLUSIONS: These data are a clinical confirmation of the post-BPD improvement of beta-cell response to increased functional demand in obese patients with preoperative type 2 diabetes.     

Biliopancreatic Diversion with a New Type of Gastrectomy

In an attempt to improve the results of biliopancreatic diversion in the treatment of morbid obesity, two aspects of the procedure performed at Laval Hospital were modified to reduce adverse physiological consequences. The distal gastrectomy was replaced by a parietal gastrectomy which preserves vagal continuity along with the lesser curvature, and leaves intact the antro-pyloro-duodenal pump. The duodenum was stapled shut and nutrients were diverted through a duodeno-ileal anastomosis. The biliopancreatic diverting intestinal limb was anastomosed to the nutrient ileal limb 100 cm proximal to the ileocaecal valve instead of 50 cm proximal to it, thus doubling the length of the common ileal absorptive segment. Weight loss after either operation was greater than 70% of initial excess weight. Following the new operation, there was a lesser prevalence of side-effects, especially loose stools and malodorous gas, a lesser degree of hypocalcemia and no hypoalbuminemia. The duodenum recanalized at the staple line in 20% of the patients who had the new operation. When data from these patients were excluded, weight loss following the new operation was greater than that seen after the old one. The prevalence of side-effects and the degree of calcium and protein malabsorption remained significantly lower. Weight loss remained satisfactory with a common limb measuring 100 cm. The parietal gastrectomy was not restrictive as shown by the failure to lose further weight when the duodenal stapled diversion failed. Weight loss was thus mainly a function of biliopancreatic diversion, but increased weight loss in the new procedure despite a doubling of the common ileal limb suggests that parietal gastrectomy contributed to weight loss. Because duodenal recanalization can be corrected surgically and now prevented, the modified biliopancreatic bypass is preferred.     

Gastro-ileal Stenosis and Gastroparesis after a Biliopancreatic Diversion

Biliopancreatic diversion (BPD) is a very effective bariatric operation particularly for super-obese patients (BMI ≥50 kg/m²). We present the development of a stricture at the gastro-ileal anastomotic site, with subsequent dilatation and aperistalsis of the stomach in a female patient who had undergone a standard open Scopinaro BPD. The patient remained symptomatic and persisted in losing weight, despite endoscopic balloon dilatations of the stricture and surgical revision of the anastomosis. She finally underwent conversion to a standard Roux-en-Y proximal gastric bypass. We describe the development of the stricture after the use of the stapling gun, subsequent gastric dilatation and dysmotility.     

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.     

Five-year Changes in Health-Related Quality of Life after Biliopancreatic Diversion with Duodenal Switch

Background

Long-term data of health-related quality of life (HRQL) after biliopancreatic diversion with duodenal switch (BPDDS) procedure are lacking. The aim of this study was to evaluate changes in HRQL from baseline to 5 years after BPDDS.

Methods

Fifty morbidly obese patients were followed for 5 years after BPDDS procedure. The sample consisted of 27 women and 23 men, the mean age was 37.8 years, and the mean body mass index (BMI) was 51.7 units. HRQL was measured with the Short Form 36 questionnaire (SF-36). Anxiety and depression were measured with the Hospital Anxiety and Depression Scale (HADS). Linear mixed model was used to investigate the change scores. The SF-36 scores and HADS scores of the sample were also compared with a Norwegian population norm, adjusted for age, gender, and BMI.

Results

Mental summary scores (MCS) and physical summary scores (PCS) were very low preoperatively but significantly improved (P?<?0.05) 5 years after surgery. The PCS was comparable to the population norm, while MCS was lower. Depression improved significantly from baseline to the 5-year follow-up (P?=?0.004), but anxiety did not (P?=?0.595).

Conclusions

This study demonstrates a sustained weight loss and improved, although somewhat fading, HRQL scores 5 years after BPDDS. The study also shows that BPDDS is associated with a sustained reduction in depression symptoms but not in anxiety symptoms.     

Conversion of Failed Vertical Banded Gastroplasty to Biliopancreatic Diversion, a Wise Option

Background  

Reoperations due to failures constitute an essential but challenging part of bariatric surgery practice today. The aim of this study was to evaluate the perioperative safety, efficacy, and postoperative quality of life in patients with biliopancreatic diversion (BPD), after failed vertical banded gastroplasty (VBG).     

Carcinoid Syndrome Misdiagnosed as a Malabsorptive Syndrome after Biliopancreatic Diversion

A case is reported of a woman who developed untreatable diarrhea after a prior biliopancreatic diversion (BPD), attributed to the malabsorptive component. Abdominal ultrasound incidentally found focal liver lesions. On fine needle aspiration biopsy, atypia was found, and these hepatic lesions were resected with free margins. The specimen showed liver metastases of an aggressive malignant neuroendocrine neoplasm. The primary site was subsequently identified to be in the pancreas. The physician and surgeon must realize that non-related diseases can develop after bariatric surgery, as in the general population.     

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.     

A Technique for Converting the Roux-en-Y Gastric Bypass to a Modified Biliopancreatic Diversion

Our group has performed the Roux-en-Y gastric bypass (RYGB) in 1450 patients since 1983: 805 patients had primary operations, and 645 were converted from previous gastroplasty procedures, i.e. horizontal gastroplasty, vertical banded gastroplasty, and gastrogastrostomy. Within the last 2 years, 38 patients who failed the RYGB were converted to a modified biliopancreatic diversion (BPD) using a technique that did not require dismantling a major portion of the original gastric exclusion. A 24-month follow-up has demonstrated a significant and sustained weight loss in all patients. In addition, the modified BPD completely eliminated the problem of reflux bile gastritis in those patients with a short Roux-en-Y jejunal limb.     

Delayed Rupture of a Splenic Artery Pseudoaneurysm After Biliopancreatic Diversion

Splenic artery pseudoaneurysm (SAP) is a known but rare complication of pancreatitis and blunt abdominal trauma. SAP caused by operative trauma has been rarely reported. We present a patient who presented with massive upper gastrointestinal (GI) bleed in shock. On exploratory laparotomy, a SAP was diagnosed. He must have sustained injury to his splenic artery while undergoing reinforcement of sleeve gastrectomy during an open biliary pancreatic diversion procedure 2 years back. Alternatively, the prolene suture might have eroded into the splenic artery to cause the SAP. Literature on iatrogenic SAP is reviewed. SAP should be considered in patients with history of foregut surgery with GI bleed and equivocal endoscopic findings.