Biliopancreatic Diversion / Duodenal Switch

Biliopancreatic Diversion (BPD) is an obesity surgery which had proved its efficacy and safety in more than 40 years. BPD was first developed and performed by Italian surgeon Dr. Nicholas Scopinaro in 1979. The most known obesity operation until such years were Jejuno-Ileal Bypass (JIB).  However, patients who have undergone Jejuno-Ileal Bypass (JIB) had organ damages progressing to fatal liver failure and severe nutritional disorders, and the operation has been left in 1970s.   Dr. Scopinaro has performed many operations on animals for a few years for an operation which will preserve positive effects of this strong operation and remove negative nutritional disorders and fatal organ damages.  Since the first Biliopancreatic Diversion (BPD) operation performed on 1979, more than 5000 patients had the BPD procedure.

Effect of Biliopancreatic Diversion (BPD) operation significantly depends on malabsorption.

Biliopancreatic Diversion (BPD)            Biliopancreatic Diversion with

Duodenal Switch (BPD/DS)

The classical Scopinaro operation, the Biliopancreatic Diversion (BPD), removes the 2/3^rd of distal stomach just like in ulcer surgeries. And the new route is constructed with distal ileum in a Roux-n-Y fashion. Remaining gastric volume may be up to 300 to 500 cc. A larger stomach is left when compared with Roux-N-Y Gastric Bypass.  So, when Biliopancreatic Diversion (BPD) is performed, a very satisfactory amount of  meal may be consumed.  The operation shows its effect by malabsorption of foods.

What Is Malabsorption?

Malabsorption means decreased nutritional absorption. This means caloric restriction of fat and carbohydrates. In this way, weight loss takes place. The absorption of fats and carbohydrates need some process of degradation with biliary acids and pancreatic enzymes. The biliopancreatic juice is vital for these processes. The diversion of biliopancreatic juice, inhibits fat absorption. BPD and/or its Duodenal Switch version, forms up to 65 % fat malabsorption. So that patients may be free to have animal derived fat in their diets.

What is Duodenal Switch?

Pylorus is a muscle that is present at the gastroduodenal junction which is responsible for controlled transfer of gastric content in to the small bowels. Pylorus muscle also prevents reflux of fluids assisting digestion from bile duct and pancreas duct into the stomach.  If the pylorus functions are not sufficient, than an alkaline reflux may occur.

Pylorus muscle is sacrified technically Biliopancreatic Diversion (BPD). Therefore Dumping syndrome may be frequent and severe.  Furthermore, ulcer development in gastroileal anastomosis is more frequent in absence of pylorus muscle.

Duodenal Switch is another type of Biliopancreatic Diversion (BPD) operation where stomach is not divided horizontally and the pylorus muscle is preserved. Duodenal Switch is a combination of a Vertical Sleeve Gastrectomy with a postpyloric duodenal transection which preserves the pylrous muscle. The distal ileum is anastomosed to the postpyloric duodenal segment in a roux-n-y fashion.

What is the Difference of Biliopancreatic Diversion/Duodenal Switch (BPD/DS)?

The stomach is transected vertically in Biliopancreatic Diversion/Duodenal Switch (BPD/DS).  A gastric tube is created just like Laparoscopic Sleeve Gastrectomy.  However, the gastric tube created for Duedonal Switch is wider than gastric tube created in sleeve operation.  Furthermore, small intestines carrying bile flow is connected on the last 100 cm instead of last 50 cm.  So, a comparable stomach and  equivalent malabsorption are applied with  Biliopancreatic Diversion (BPD).

The stomach volume left with DS is around 150-200 cc and up to 4-5 folds when compared to RYGB which has a tiny gastric pouch of 40-50 cc. Patients eat comfortably as a standard BPD operation.

The most important difference of Duodenal Switch operation is that pylorus muscle is preserved.  Dumping Syndrome is very less because pylorus muscle is preserved.  Less Dumping Syndrome increases postoperative quality of life.  However, majority of RYGB surgeons, do not perceive Dumping Syndrome as a problem.  Because, RYGB patients avoid high calorie and fatty meals because of Dumping Syndrome.  So, weight loss is better and they may preserve this better. But as the gastric pouch and anastomoses enlarges, RYGB patients may easily be prone to severe weight regain. DS is nor a volume restrictive surgery, but leans on an efficient malabsorption which leads to long term control of weight loss and associated comorbidities such as diabetes, sleep apnea, dyslipidemia and high blood pressure with almost full free nutrition for life time.

There is another benefit of preservation of pylorus muscle.  Small intestine is directly connected to the stomach in a standart BPD operation.  Therefore, ulcers are more common.  In fact, pylorus is preserved in Duodenal Switch operation with a duodenum segment of about 2 to 3 cm.  The ileum end is connected to this duodenal part. Since duodenum is resistant against acid coming from the stomach and bile from liver due to its natural structure, marginal ulceration is extremely rare in DS.

Some surgeons believe that iron and calcium absorption is better after Biliopancreatic Diversion – Duedonal Switch (BPD-DS) operation because of this short (2 to 3 cm) duodenum preserved.  However, this hypothesis has not been proven yet.

Very good results have been reported by many centers for both operations.  BPD and BPD/DS operations have a power to create more weight loss than all other bypass and volume restricting operations.   However, both of these operations frequently cause severe nutritional disorders which are not frequently observed in any other operation.  Very severe nutritional disorders and fatal diseases due to these may be observed in patients who are not regularly followed-up.

Biliopancreatic Diversion – Duodenal Switch (BPD-DS) operation is especially suggested for individuals who are super obese (BMI over 50 kg/m²).  It has been shown in very experienced centers that, it may be applied in a single session on patients with a BMI value over 60 kg/m².  However, two-stage procedures on super obese patients had become a preferable method lately because of short anesthesia duration and reduction of risks created by additional diseases. Sleeve procedure which is a part of Duodenal Switch operation is applied rapidly during the first session on these patients. Duodenal Switch is applied as a second step after the patient becomes thinner more after 1 year and a permanent effect is obtained.

Biliopancreatic Diversion/Duodenal Switch (BPD/DS):  Advantages

• Greater portions than Roux-N-Y Gastric Bypass, Sleeve or Gastric band.
• Nausea-vomiting is very less after meal.
• Weight loss and relief of obesity related co-morbidities are preserved for long duration.
• Faster and more significant weight loss than other operations.
• The patient looses 74% of her/his current excess weight within the first year.   Excess weight loss after 5 years reaches up to 84%.  In fact, it is possible to regain 35% of weights lost within first 5 years after Gastric Bypass.
• It protects its effect for many years.  However, regular doctor visits are important to maintain this.

Biliopancreatic Diversion/Duodenal Switch (BPD/DS):  Risks and Disadvantages

Diarrhea: Frequent and watery defecation is seen after all malabsorptive operations within first year.  These effects decrease greatly when small intestine structure starts to differentiate in time.  However, although this type of diarrhea decreases, it may continue for lifetime.

Stinky Flatus: Stinky flatus complaint may appear significantly after fatty meals because fat absorption is restricted in particular.

Lifetime Vit’s & Min.’s Supps: Vitamin and mineral support is necessary regularly for lifetime depending on absorption disorder.  Therefore, it is very important to be under doctor control.  It is especially important for iron and vitamin B12 deficiency, anemia.  We care about our patients to take Vitamin D and calcium after the surgery. Osteoporosis and fractures due to this may be detected in calcium deficiency.

Gallbladder Stones: It is believed that small intestine hormones which change after Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation cause this.  Normally, cholecystokinin which is secreted from duodenum and stimulated when foods enter into duodenum provides contraction of gallbladder and discharge of bile inside into duodenum.  Duodenum is separated from food passage in Biliopancreatic Diversion/Duodenal Switch (BPD/DS).  It functions as a transmission channel of bile which comes from liver.  Secretion of cholecystokinin decrease because no food enters into duodenum.  Because gallbladder can not contract regularly and sufficiently, the bile inside is deposited like olive oil and precipitation occurs.  These precipitates are called bile mud. These bile mud appear as gallbladder stone in time. Like many centers, we suggest to remove gallbladder for our DS candidate patients.   

Protein Deficiency:  Carbohydrate and fat originated calorie absorption are restricted with Biliopancreatic Diversion-Duodenal Switch (BPD-DS). That’s why especially when carbs are consumed much, some patients may feel bloating and gag reflex. This is sometimes may be similar to dumping syndrome of RYGB.  In fact, Dumping Syndrome is an expected and desired outcome for RYGB.  Because the RYGB operation strengthens its effect by this aspect. When carbs are taken in RYGB,  these food types cause abdominal pain, severe vomiting, gag reflex, hypotension, dizziness and syncope in patients because they draw water much into the small intestine if they are taken much.  What happens in DS when carbs are taken is different than Dumping Syndrome. However, if you reduce to eat meat and meat products to avoid these effects, you become weak and exhausted.  Because our body needs protein.

Fat and carbohydrate sourced energy of your body decreases and your body starts to use proteins in your muscles as energy source.  It starts to use proteins in muscles by converting them into glucose (simple sugar). If you stay deficient for protein intake, your muscle mass gradually decreases.  Exhaustion and over tiredness appear.  In case of severe nutritional deficiency, you need to be hospitalized and treated with intravenous serum and nutritional fluids.

Biliopancreatic Diversion/Duodenal Switch (BPD/DS):  Surgery-Induced Risks

Leakages: Leak from gastrointestinal anastomosis is the main risk that may appear in all digestive system surgeries.  These risks exist on long incision line and two connection points along the stomach in Duodenal Switch surgery.  The incision line in my technique is closed by a second suture line on itself.  We perform this connection by handsown two layer anastomosis. We do perform an additional impermeability test during the operation.  Leakages from lower anastomosis where small intestine are connected to each other are very rare.  Because the intestinal anastomosis is always larger than 4-5 cm and there is no narrowing. We do fashion this anastomosis with 60 mm of staplers. Leakages are minimized by this way.

Intraabdominal Abscesses:  It is generally seen because of small leakages which are not noticed.  Most of them are treated comfortably without any surgery.  You should take intravenous antibiotics in this case.  Therefore, you are hospitalized.

Pulmonary Embolism and Deep Vein Thrombosis: It appears because of clog moving from your leg veins into your lungs.  The clinical presentation may vary from mild dyspnea to fatal lung crisis.  It is a problem which may appear in all patients with morbid obesity in any kind of surgery.  Anti-coagulant injections are done to prevent this problem before and after Biliopancreatic Diversion-Duodenal Switch (BPD-DS) operation.  You start to walk just on the next day from the surgery.  Starting to move early after surgery, prevents clog formation in your tibial veins.  Risk of pulmonary embolism can not be prevented 100 % against all precautions taken.

Intestinal Obstruction: Intestinal Obstruction may occur after weeks from the surgery in Biliopancreatic Diversion – Duodenal Switch (BPD-DS) operation.  Nausea, vomiting and bloating appears.  Abdominal pain accompanies.  Exhaustion and syncope may appear.  Some small intestine parts may be squeezed from opening created after cutting the small intestine and taken up.  This intestinal squeezing is called internal herniation.  These holes are closed by sutures during operation.  We prevent almost all internal herniations and intestinal obstruction.

Wound Infections

Pulmonary Infections

Temporary Kidney Diseases: If you go dehydrated after the surgery, your kidneys get tired.  It can not produce sufficient urine.  This makes you exhausted and tired.  In this case, you need to be treated with intravenous serum.  This condition recovers within one to two days in general.  In very rare cases, your blood need to be filtered temporarily.  This procedure is called hemodialysis.  It is applied to make kidneys rest for a while when temporary kidney failure appears.

BPD-DS For Whom and When?

Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation provides an excellent weight loss and long term control.  This power of action appears significantly on obesity-induced additional diseases.  Obesity –induced additional diseases include Type 2 Diabetes, Hypertension, Hyperlipidemia (elevation in bad cholesterol), Sleep-Apnea Syndrome.  It is an accepted fact that this and many similar diseases may appear due to obesity only.  We define all these diseases developed by obesity as "Metabolic Syndrome".

Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation provides excellent results in patients with metabolic Syndrome.  It provides weight loss by 85% of current body weight when applied for patients with BMI of 50 kg/m2 in one session.  Symptoms and findings of metabolic syndrome recover rapidly due to this huge weight loss.

Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation has been started to be applied by many centers worldwide with small modifications to treat diabetes for patients who have lower BMI, even do not have morbid obesity with a BMI below 40 kg/m2.  The operation controls diabetes of these patients very strongly and may eliminate symptoms completely in majority of patients.

It is preferred for permanent treatment and long term control for patients who have Gastric Band or Roux-N-Y Gastric Bypass operation due to obesity (fatness requiring treatment) but can not obtain sufficient weight loss or start to regain weight.  Frequent consumption of calorific foods reduce success of gastric band and sleeve gastrectomy much.  Restriction of absorption of excessive calories are required for these patients.  Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation provides some restriction on gastric volume and discharge of fatty foods and carbohydrates without absorbtion.  So, excellent results are achieved even for patients who start to regain weight after other operations.

Diet After Biliopancreatic Diversion/Duodenal Switch (BPD/DS):

Biliopancreatic Diversion-Duedonal Switch (BPD-DS) operation reduces the quantity of meal that yıu eat and provides not to take excessive calories.  Both effects provide not to gain weight.

Things That You Need To Know For Correct Eating Habit

• Eat in small amounts.  Your stomach will be full with food less than a half bowl after the operation.  To try to eat more may cause bloating, abdominal pain, nausea and vomiting.  Your eating capacity will increase as much as a small portion in time.
• Stop eating when you get full.
• Note what you eat during the day.  You will need to eat 5 to 6 times a day during first days.  Because meat and meat products that you may eat once do not meet protein amount required for a day.  Your stomach capacity will increase in time and you will eat less frequently.
• Get used to eat slowly.  Possibility of nausea and vomiting increases if you eat fast.  Remember that Duodenal Switch operation makes your stomach into a narrowed tube.  If you fill it fast, discharge of air on the lower part is prevented and foods come to your mouth.  The air compressed on lower part of the stomach bloats your stomach and cause severe abdominal pain.  Take small bites and chew a lot to prevent this.
• Eat at least 100 grams of protein during the day: There is not any restriction for protein intake. In contrast, you will feel less tired and exhausted when you eat meat and meat products much.  You may need to eat ready-to-eat formulas including high protein during early period after the operation.  Your own intake will increase sufficiently in time.
• Avoid fatty foods: When you have duedonal switch, your body can not digest fats like used to be.  Your defecation becomes frequent after fatty meals, diarrhea and starts to smell bad.  Furthermore, fatty nutrition may decelerate weight loss.   
• Avoid bakery products, deserts and floury foods: Avoid ready-to eat deserts made of sugar and white flour.  To consume this kind of carbohydrates may trigger nausea and vomiting.  It may cause abdominal pain and bloating.  Furthermore, it stops weight loss.  You may eat vegetables and fruits containing fiber.  If you will eat bread, prefer natural bread rich in fiber.
• Do not drink water with meals:  Do not try to drink water with solid food.  Do not drink water following your bites to make swallowing easier.  A sudden pressure increase appears in your stomach.  Pain and nausea progressing to vomiting appear.  You may drink water half an hour before and after the meals. Drink water or all drinks slowly.  Soups are included in these.  Do not take drinks including high calories.
• Best drink is water.
• Do not drink carbonated drinks.

These principles will be those that you will follow for lifetime.  It may differ among individuals.  It is useful to share these with your dietician and physician.

You may drink clear drinks without grains for first week after the surgery.  Then, denser drinks will be tried slowly. Freshly squeezed fruit juices, fat-free milks may be included in these.  Mashed foods start to be tolerated well after one month.  Well-cooked vegetable meals with mince will be ideal in these days.

Your protein need until this period will be met by mashed cheese, soft boiled egg, fat-free milk.  However, you will need to take with formulas including high protein ingredient or ready to use protein powders  such as CUBITAN® or PROTIFAR® during first months.

Well coked white meat (chicken or fish) is added into the meals after the first month.  You will start to eat any kind of food providing to be fresh and cooked well after two months.

Your diet will be planned on daily basis and will be given to you in written by your dietician.

Duodenal Switch and Vitamin-Mineral Support

All patients whom Biliopancreatic Diversion-Dudenal Switch (BPD-DS) surgery are planned are absolutely assessed for nutritional parameters before the surgery.  Preoperative status of basic vitamin and mineral levels is detected.  We start some basic drugs before the surgery even you do not have any vitamin or mineral deficiency.

Preoperative Preparation:

Dodex 1000 mcg vial: It includes Vitamin B12.  It is administrated intramuscularly before the surgery.  It is continued to be injected every three months during first year.

Venofer Vial: It is administrated intravenously for iron supplementation.  It is started 10 days before the surgery.  Three vials in total are administrated for three days.

Vitamin supplement after the surgery:

You will need to take your vitamins for lifetime.  You can not swallow tablets during first days.  Take a small and clean mortar for you and make powder of all your vitamins.

• SUPRADYN® drage 4 / day
• APİKOBAL® tablet 2 /day
• Calcium Citrate 8/day
• IRON tablet 2/day

A printed list including taking form and time of your drugs and vitamins will be provided after the surgery.  To use your drugs regularly and accurately after the surgery will provide ultimate benefit from Biliopancreatic Diversion-Duodenal Switch (BPD-DS) operation.