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.     

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.     

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.     

Postoperative Morbidity of Biliopancreatic Diversion Depending on Common Limb Length

Background Laparoscopic gastric bypass, currently the most popular surgical method for bariatric therapy, have proved to be effective in weight loss, but some matters regarding its long-term efficacy for super-obese patients (BMI >50 kg/m²) have arisen. Biliopancreatic diversion (BPD) is a complex technique that has shown good results in the treatment of the super-obese patient. We analyze our >5 years results, evaluating weight loss, morbidity and mortality of this operation, depending on the length of the common and alimentary limbs. Methods We studied two series of patients: 150 patients with BPD of Scopinaro (50–200 cm) and 70 patients with modified BPD (75–225 cm). The results have been analyzed in terms of weight loss, co-morbidity improvement, and postoperative morbidity using BAROS. Results Range of follow-up is 1–12 years. Weight loss was slightly higher for the Scopinaro group than for the Modified group but with no significant difference. There was more prevalence of malnutrition and of iron deficiency in the Scopinaro group (16% and 60%) than in the modified group (2% and 40%), with similar postoperative morbidities. Conclusion The modified BPD method (75–225 cm) shows long-term effectiveness in weight loss and comorbidity improvement for super-obesity. Proteins, vitamins and oligoelement deficits appear distant in time, and thus it is necessary to maintain strict followup of these patients and supplement against deficiencies for the rest of their lives.     

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.     

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.     

Complications of Biliopancreatic Diversion Surgery as Proposed by Scopinaro in the Treatment of Morbid Obesity

Background. This study concerns 33 patients treated for morbid obesity with the procedure proposed by Scopinaro. Results are reviewed retrospectively in terms of complication rates. Methods. The group consisted of ten men and 23 women with a mean age of 34 years (range 20-51 years), and a mean BMI of 49.5 kg m⁻² (range 37-77). Adequate attempts at medical management had failed repeatedly. The operative procedure involved a 2/3 partial gastrectomy and biliopancreatic diversion by Roux-en-Y reconstruction 50 cm before the ileocecal valve. In one patient, a cholecystectomy was added. Results. The mean weight loss after 6 months was 18.9% of the initial weight, with mean BMI 41 kg m⁻² (range 29-60). Early complications included four wound infections (15%), while two patients complained of an early dumping syndrome (6%), treated by dietary measures. There were no respiratory infections and no pulmonary embolism, likely as a result of the thoracic epidural anesthesia and high doses of prophylactic heparin used. There was no mortality. As to late complications, nine patients complained of diarrhoea due to bacterial overgrowth (27%) and were treated with antibiotic therapy. There were five incisional hernias (15%). Five patients had a peptic ulcer (15%) and required medical treatment. Two patients had acute cholecystitis (6%). One patient had an afferent loop obstruction (3%), requiring reoperation. Conclusions. Overall, this series of intestinal diversion procedures by the method of Scopinaro had a larger complication rate than generally reported.     

Outcome of Pregnancies after Biliopancreatic Diversion

Background: Severe obesity has deleterious effects on fertility and pregnancy outcomes. Although surgery is the best long-term treatment for severe obesity, there is a risk of gestational undernutrition in operated mothers because bariatric surgery reduces nutrient availability. This is a follow-up report of our initial findings regarding pregnancy and neonatal outcomes in biliopancreatic diversion (BPD) patients, with addition of a new cohort of children born to mothers after BPD. Methods: All women (n = 916) who had successfully undergone BPD in our hospital were mailed a questionnaire containing multiple-choice and essay questions concerning gynecologic and obstetric history, and pregnancy and neonatal outcomes in both preoperative and postoperative pregnancies. Patients operated between 1984 and 1995 (n = 568) were mailed an additional questionnaire regarding children's weight and height progress, and school performance. Perinatal records from our patients' obstetric clinics were also reviewed. Results: The questionnaire was completed by 783 women (85.5%). 251 postoperative pregnancies in 132 women resulted in 166 infants by 109 mothers. 47.0% of patients who were unable to become pregnant preoperatively were successful postoperatively. 90 out of 109 women (82.6%) reported an appropriate weight gain (9.1 ± 5.9 kg) during postoperative pregnancies. The incidence of fetal macrosomia decreased from 34.8 to 7.7%, with a concomitant increase in normalweight babies from 62.1 to 82.7%. The elevated miscarriage rate (26.0%) in these obese women persisted after surgery. Conclusion: Major weight loss following BPD improves the reproductive function of severely obese women. BPD provides major beneficial effects for both mother and child, including normalization of gestational weight changes, reduction of fetal macrosomia, and normalization of the infant's birth-weight. Our results speak in favor of delaying pregnancy in obese women until after the substantial surgical weight loss has occurred.     

Biliopancreatic Diversion: Clinical Experience

Background: Biliopancreatic diversion (BPD), by ad hoc stomach resection (AHS-BPD) has been accepted as an effective surgical treatment for morbid obesity. Methods: Between 1.1.1992 and 31.7.1996, 59 patients (54 females, five males, mean age 40.3 years, range 23-61 years) underwent AHS-BPD. Mean preoperative body-weight was 121.2 kg (range 94-160), with a mean body mass index of 48.6 (range 35-64). Three of these patients were converted from a previous vertical banded gastroplasty to AHS-BPD (one patient with stomach preservation). After at least 36 months follow-up, seven patients underwent abdominal dermolipectomy (five with associated incisional hernia repair, one with thigh dermolipectomy). Results: Mean post-operative hospital stay was 13 days (range 10-30 days). Follow-up is currently in progress in all patients. Excess body weight-loss was 78% in 33 patients with 24 months follow-up, with excellent long-term weight loss maintenance. Protein deficiency was the main specific complication, encountered in two patients (3.4%). Mortality was one patient (1.7%), due to pulmonary embolus. Conclusions: This clinical experience supports the effectiveness and safety of AHS-BPD, despite some criticism. This procedure appears to be suitable for patients with clinically severe obesity who will poorly tolerate food intake restriction but will accept long-term follow-up. Careful preoperative clinical assessment and selection of patients who will be reliable in long-term follow-up are the keys to success with AHS-BPD, both in terms of weight loss and reduction of specific metabolic complications.     

Orally Administered Ranitidine Plasma Concentrations before and after Biliopancreatic Diversion in Morbidly Obese Patients

Background: Patients undergoing biliopancreatic diversion (BPD) may develop gastric ulcers, particularly within the first postoperative year. The prophylactic use of antisecretory compounds at the usual therapeutic doses, mainly conventional H₂-receptor antagonists such as ranitidine, may reduce the incidence of this complication, which occurs in ∼5% of patients after BPD. Methods: The authors measured the plasma concentrations of ranitidine (300 mg orally) in obese patients, before and 8 months after BPD, and in control subjects of normal weight. The study included 11 obese patients undergoing BPD (age 45 ± 14 years; preoperative and postoperative weights 124 ± 21 and 92 ± 11 kg) and 10 normal-weight subjects (age 37 ± 13 years, weight 67 ± 9 kg). Results: Postoperative ranitidine plasma concentrations showed only minor differences from preoperative levels, with slightly higher maximum concentrations occurring sooner. The mean area under the curve was on the average 30% higher than preoperatively. All parameters, however, were similar to those in control subjects. Conclusions: BPD per se does not greatly affect the pharmacokinetic behavior of ranitidine, and therefore a conventional dosage regimen appears adequate for the prophylaxis and therapy of gastric ulcers associated with this operation.     

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.     

Orally-administered Serum Ranitidine Concentration after Biliopancreatic Diversion for Obesity

Stomal ulcer occurs in about 5% of patients after biliopancreatic diversion (BPD). Seven females were given 150 or 300 mg of ranitidine orally. Blood samples found a pharmacologically effective concentration from 0.5 to 8 h after both doses. Intestinal absorption of ranitidine is maintained after BPD.     

Short-, Mid- and Long-Term Results of Larrad Biliopancreatic Diversion

Background In an effort to reduce the complications of Scopinaro’s biliopancreatic diversion (BPD), in 1989 we introduced the modification of lengthening the alimentary channel preserving most of the jejunum-ileum, by creating a short biliopancreatic limb (50 cm) and maintaining 50 cm of common limb (Larrad 50–50 BPD). Methods Of 343 patients who consecutively underwent Larrad 50–50 BPD surgery, 325, 194 and 65 patients were evaluated at 2, 5 and 10years after surgery, respectively, in terms of surgical morbidity, mortality, metabolic sequelae and weight. Mean age was 41.2years (range 17–62), mean initial weight 151.2 kg (range 97–260), and BMI was 52.2 kg/m2. Maximum follow- up was 120months. Results Mortality was 0.87% and surgical morbidity 7.6%. There were no cases of suture dehiscence, peritonitis or stomal stenosis. Percent excess weight loss (%EWL) stabilized 2years after surgery and at 10years was 77.8±11.2% for morbidly obese patients and 63.2±11.8% for super-obese patients. The main complications were 43.8% clinical incisional hernia, 2.5% severe diarrhea, 10.8% mild diarrhea and 9.2% constipation. 30% experienced anemia and/or iron deficiency, and 3% required iron parenterally or lifelong zinc supplements. 28% showed preoperative PTH elevation and 30% vitamin D deficiency; these values postoperatively increased to 45% and 43% respectively. Both these alterations were resolved using supplements, although 12% needed increased doses of vitamin D. The incidence of severe hypoproteinemia was 0.29%. No patient required surgical reversal. When independently evaluated, failure rates in terms of insufficient weight loss were 9% at 5years and 11.3% at 10 years for morbidly obese, and 12.2% and 14% for super-obese patients respectively. According to the BAROS questionnaire, 75% of surgery outcomes were excellent or very good, 18% good, 5% fair and 2% failures. Conclusions After 2, 5 and 10years, Larrad’s BPD has offered excellent results in terms of weight loss and quality of life, a low rate of metabolic sequelae, including a hypoproteinemia rate <0.5%, and a revision surgery rate 0%.     

Prospective Evaluation and 7-Year Follow-up of Swedish Adjustable Gastric Banding in Adults with Extreme Obesity

Background Swedish adjustable gastric banding (SAGB) is a widespread laparoscopic procedure in bariatric surgery. Few long-term data is available. Aim To determine long-term outcome after SAGB in 196 patients studied prospectively. Patients and Methods 196 patients, 40 men, and 156 women have been operated from 1996 to 2005. Age was 38 ± 1 (mean ± sem) years. Mean follow-up was 63 ± 2 months. Results Hospital morbidity was 3% (0.5% early reoperation); mortality was 0. Late complications were band migration (1%), leakage (5%), slipping (4%), or pouch dilatation (8%). Minor reoperations (tube replacement, port-related, and hernias) were needed in 7.5%. Cumulative major reoperation rate reached 32%. Eighteen percent had a band replacement; 14% had removal of band anatomy. Late mortality was 0.5%. Exactly 7 years after SAGB, BMI decreased from 45 ± 1 kg/m² to 33 ± 1 kg/m², and excess weight loss (EWL) was 61 ± 4%. Sixty-eight percent of the patients reached ≥50% EWL. Conclusion In 14% of the patients, the band anatomy had to be removed. Seven years of intact band anatomy leads to a successful EWL of 61 ± 4% and to EWL of ≥50% in 68%. However, cumulative major reoperation rate of 32% in 7 years makes it mandatory to offer and discuss other bariatric procedures to the respective patients. Presented at the 48th Annual Meeting of the Society for Surgery of the Alimentary Tract, Washington, DC, from May 19 to 23, 2007 and published as an abstract in Gastroenterology 2007;132:A-837.     

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: 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.     

Survey of Vitamin and Mineral Supplementation after Gastric Bypass and Biliopancreatic Diversion for Morbid Obesity

Background: The authors investigated whether practice patterns of bariatric surgeons correlate with published data regarding metabolic deficiencies after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD). Methods: 109 surgeons completed a questionnaire to determine use of supplements and frequency of lab tests. Results: Regarding supplements routinely prescribed after RYGB, 96% of surgeons gave multivitamins, 63% gave iron, and 49% gave vitamin B₁₂. After BPD, 96% of surgeons gave multivitamins, 67% gave iron, 42% gave vitamin B₁₂, 97% gave calcium, 63% gave fat-soluble vitamins, and 21% gave protein supplements. Regarding laboratory tests obtained routinely after RYGB, 95% of surgeons do complete blood counts, 56% do iron determinations, 66% do vitamin B₁₂ determinations, 58% do folate determinations, 76% do electrolyte determinations, and 8% test for proteins. After BPD, 96% of surgeons do complete blood counts, 80% do iron determinations, 67% do vitamin B₁₂ determinations, 71% do folate determinations, 88% do electrolyte determinations, 84% do protein determinations, and 46% test for fat-soluble vitamins. Regarding frequency of blood tests, after RYGB, 22% of surgeons obtain them after 3 months, 33% after 6 months, and 41% after 12 months; 4% do not routinely obtain postoperative laboratory tests. After BPD, 46% of surgeons obtain them after 3 months, 33% after 6 months, and 16% after 12 months; one does not obtain laboratory tests. Surgeons estimated these deficiencies after RYGB: 16% iron, 12% vitamin B₁₂, 14% anemia, 5% protein, and 3% calcium. They estimated these deficiencies after BPD: 26% iron, 11% vitamin B₁₂, 21% anemia, 18% protein, 16% calcium, and 6% fat-soluble vitamins. The estimated incidence of deficiencies after RYGB was considerably lower than the published incidence. Unnecessary tests were commonly performed (electrolytes after RYGB). Conclusion: Despite wide variations in the performance of laboratory tests and the use of supplements, the practice patterns of most surgeons protect patients from developing severe metabolic deficiencies after RYGB and BPD.     

Biliopancreatic Diversion,with Distal Gastrectomy, 250 cm and 50 cm Limbs: Long-term Results

Background: Since 1984, biliopancreatic diversion (BPD) has been our procedure of choice in the treatment of morbid obesity. Better understanding of long-term outcome following BPD is needed. Methods: We report the results of our first consecutive 92 patients who underwent BPD more than 5 years ago. Of these 92, only 82 were available for a recent formal evaluation after a mean of 79 months. Results: Weight loss was maintained over the years at 62% of initial excess weight; the success rate for losing more than 50% of initial excess weight was 72%. The gastrointestinal side-effects decreased with time, but diarrhea was still present in 13%. The average number of daily stools was 3 ± 1.0. Of the patients, 76% were free from any gastrointestinal side-effects, taking normal diet and having normal stools. Malabsorption, however, was still present. A third of patients had laboratory values slightly below normal levels for haemoglobin, albumin and calcium. These values were mostly without clinical manifestation and were well tolerated by the patients. Regarding associated diseases, 75% were cured or improved following BPD. In 14 patients, reoperation was required to improve diarrhea or serum albumin. In these patients, the common channel was lengthened from 50 to 100 cm. The revision was successful in 11 and did not cause significant weight gain. Conclusion: BPD, as proposed by Scopinaro, was an efficient surgical treatment of morbid obesity that allowed normal eating habits and despite malabsorption was well tolerated by the great majority of patients.     

Resolution of Diabetes Mellitus and Metabolic Syndrome following Roux-en-Y Gastric Bypass and a Variant of Biliopancreatic Diversion in Patients with Morbid Obesity

Background Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. Methods The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1±2.9 kg/m²) and 111 BPD-RYGBP (BMI 59.7±10.6 kg/m²). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39±21.17 months. Results Excess weight loss was ∼70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose <110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. Conclusions RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP.We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.