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Laparoscopic Bilio-Pancreatic Diversion with Duodenal Switch (Lap BPD-DS)

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LAPAROSCOPIC BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH(BPD – DS, DUODENAL SWITCH, SLEEVE GASTRECTOMY WITH DUODENOILEAL)

This is the most effective bariatric surgery since hormonal changes are very high. But risk of mal-absorption is also very high because of bypassing extensive length of small bowel. Because of high risk of mal-absorption, this is reserved for super obese and super super obese individuals. It is also used as a back up revisional operation when other bariatric surgeries fail.

How BPD – DS surgery is performed?

Abdominal cavity is entered through small holes. Upto 80 percent of left side of the stomach is removed and stomach tube (gastric sleeve) of 60 to 200 ml is fashioned over a calibration tube using high quality linear cutter staplers. First part of small bowel (duodenum) is divided 3 to 4 cm below stomach using linear cutter stapler. Lower part of small bowel (Ileum) is divided 250 cm above junction of small bowel and large bowel (ileocaecal junction) and is joined to the divided first part of duodenum (duodenoileal anastomosis). Upper divided end of the terminal ileum is joined to the side of small bowel 100 cm above ileocaecal junction to restore continuity of bowel. All the mesenteric gaps are closed. Most of the small bowel is bypassed (Remaining duodenum, jejunum, most of the ileum) and doesn’t come in contact with food (biliopancreatic limb). In this operation, after leaving gastric sleeve, food passes through the 150 cm of ileum (ailementary limb) to reach the common channel where it mixes with bile and pancreatic juices.

Laparoscopic Bilio-Pancreatic Diversion with Duodenal Switch (Lap BPD-DS)  (Drawn by Dr. V. Amar)

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Why there is long term/ permanent weight loss (fat loss) after BPD – DS surgery?

Weight loss after BPD – DS is not because of food restriction or mal-absorption but because of hormonal and genetic changes. After this operation Ghrelin hormone levels come down as fundus of the stomach is removed. GLP 1, Peptide YY hormone levels increase as food directly enters lower small bowel (terminal ileum). Food doesn’t enter the remaining duodenum, jejunum and most of ileum. So levels of anti incretin hormones come down. Removal of body of stomach alters several genes involved in energy balance. These hormonal and genetic changes reduce appetite, increase energy expenditure and reset the ‘set point for fat storage’ to a lower level, resulting in long term/ permanent effective weight loss. These changes are very high in BPD – DS, Sleeve Gastrectomy with Duodenoileal Interposition (SG – DII), Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy (SADI – S), compared to any other metabolic/ bariatric surgery.

Please click the following link for more information on how bariatric surgery works – ‘Bariatric surgery’

How type II diabetes is resolved after BPD – DS surgery?

Same hormonal changes are responsible for resolution of type II diabetes. Ghrelin and Anti incretins act against insulin. As levels of these hormones come down, insulin acts well. GLP 1 increases insulin production and reduces insulin resistance. Since GLP 1 is increased, insulin production increases and insulin resistance comes down. These changes result in resolution/ remission of diabetes. Hormonal changes are very high in BPD – DS, SG – DII, SADI – S compared to any other metabolic/ bariatric surgery. So resolution/ remission of diabetes is better.

Please click the following link for more information on how type II diabetes is resolved – ‘Metabolic surgery’

Which is better? BPD – DS or RYGB

In terms of weight loss and resolution of type II diabetes, BPD – DS is always better than RYGB. In roux-en-y gastric bypass (RYGB), excluded stomach is still present, so if any ulcer or cancer develops in future, in that remnant stomach, it cannot be detected by upper GI endoscopy. Since total duodenum is excluded and doesn’t come in contact with food, risk of calcium and iron deficiency is very high inspite of giving these supplements. There is no valve controlling the food passage from stomach pouch into intestine, so risk of dumping syndrome is high. These risks are either low or absent after BPD – DS. After BPD – DS, upper GI endoscopy can be done, there is no ‘at risk’ stomach remnant, calcium and iron deficiency risk is low since first 4 cm of duodenum is not bypassed and risk of dumping syndrome is less because of intact pylorus controlling food out put into first part of duodenum. But extensive length of small bowel is bypassed in BPD – DS, so mal-absorption is very high.

Is BPD – DS surgery risky?

This is a very safe and highly effective operation when performed on suitable candidates after assessing fitness. Major complications like bleeding, leak from the staple line or anastomoses are very rare because of using high end technology such as full HD camera, advanced vessel sealing systems (Harmonic scalpel, Force Triad) and high quality staplers. Minor problems like hair loss, weak look due to rapid weight loss and skin wrinkling can occur but these are temporary. There is vitamin and mineral deficiency risk. But these deficiencies can be rectified by giving vitamin and mineral supplements. Calcium and iron deficiencies are less after BPD – DS since first 4 cm of the duodenum is not bypassed. But mal-absorption is very severe after BPD – DS. Patients develop foul smelling sticky stools after this as fat is not absorbed. Incidence of protein energy malnutrition is also very high after BPD – DS. There is risk of formation of renal and gall bladder stones.

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