Effects of biliopancreatic diversion with or without duodenal switch

J.G. Kral et al. / Surgery for Obesity and Related Diseases 1 (2005) 35– 63 [13] de la Torre RA, Scott JS. Laparoscopic Roux-en-Y gastric bypass: a totally intraabdominal approach—technique and preliminary report. Obes Surg 1999;9:492– 8. [14] Matthews BD, Sing RF, DeLegge MH, Ponsky JL, Heniford BT. Initial results with a stapled gastrojejunostomy for the laparoscopic isolated Roux-en-Y gastric bypass. Am J Surg 2000;179:476 – 81.

doi:10.1016/j.soard.2004.12.015

Effects of biliopancreatic diversion with or without duodenal switch Michel Gagner, M.D., F.R.C.S.C., F.A.C.S., Professor of Surgery, Weill Medical College of Cornell University, New York, New York Biliopancreatic diversion (BPD), first described by Scopinaro et al in 1979, remains one of the most effective surgical procedures for the treatment of morbid obesity. It allows satisfactory weight loss with a low rate of long-term nutritional complications. Further modifications by Hess and Marceau, consisting of a longitudinal sleeve gastrectomy and duodenal switch (BPD/DS), have significantly diminished the more severe complications of BPD, including dumping syndrome, ulcerogenicity, hypoproteinemia, and hypocalcemia. The antrum, pylorus, first part of the duodenum, lesser curvature of the stomach, and vagus nerve are all spared, allowing the patient to eat more normally. Buchwald et al conducted a recent systematic review and meta-analysis of published reports (publication years 1996 – 2002) on the impact of bariatric surgery on weight loss, operative mortality, and comorbidities. A total of 4035 patients with BPD or BPD/DS from 17 studies and 20 treatment groups were analyzed. This represents an important cohort of patients, almost equal to that of gastric bypass patients, equal to gastric banding patients, and four times greater than gastroplasty patients. The mean percent of excess weight loss (%EWL) in the BPD and/or BPD/DS group was the highest, at 70% (range, 66%–74%). This group also had the largest mean absolute weight loss (46 kg) and body mass index (BMI) reduction (18 kg/m2). The operative mortality rate was 1.1% (on 3030 patients). The efficacy for improvement in diabetes-related outcomes was extremely successful, with a 99% resolution rate reported. Dramatic rates of improvement were seen for other comorbidities as well, including hyperlipidemia (99% improvement), hypercholesterolemia (87% improvement), and hypertrygliceridemia (100% improvement). Resolution rates for hypertension and sleep apnea were 83% and 92%, respectively. With regard to comparative evidence-based studies on open malabsorptive procedures, there has been no randomized controlled trial comparing either BPD or BPD/DS to other bariatric operations. Four cohort studies, two casecontrol studies, and 10 case series showed excellent weight

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loss after BPD (level of evidence 2A, grade B). One casecontrol study and three case series reported weight loss after BPD/DS (level of evidence 3B, grade B). Concerning laparoscopic BPD and BPD/DS, only five case series were reported for laparoscopic BPD/DS and four case series for laparoscopic BPD. For open BPD, Scopinaro reported the most impressive longitudinal assessment of 2,241 patients followed for more than 20 years. The short-term mortality was 0.5% and the 75% EWL was sustained and permanent. Resolution of comorbidities was between 90% and 100%, depending on the type. Morbidity, primarily protein-calorie malnutrition, was seen in 5% of patients. The increased long-term survival has not been assessed in a comparative study with controls; however, it appears to be similar to that for gastric bypass patients. A recent analysis on the quality of life after BPD during a 15-year follow-up showed excellent results using the BAROS scale, with a score of 2.2 for weight loss and 2.1 for medical comorbidity improvement; 85% of patients had good, very good, or excellent results. Physicians from the University of Southern California recently reported a cohort of 701 patients with an average BMI of 52.8 undergoing open BPD/DS. They reported a perioperative mortality rate of 1.4% and major morbidity rate of 2.9%. At 5 years postsurgery, the %EWL was 66%. At 3 years, 98% of patients had a normal albumin serum level and, although 71% were normocalcemic, none had evidence of clinical hypocalcemia. Hess demonstrated similar results in 440 patients with an initial mean weight of 183 kg: 70% EWL at 8 years, perioperative mortality of 0.5%, and cure of diabetes. Marceau et al reported a large cohort (1200 patients) who underwent open DS and demonstrated a reduction in mean BMI from 48 to 31 on mean follow-up of 8 years. The importance of this study lies in the fact that the RAMQ (Regie de L’Assurance Medicale du Quebec) is the sole payer for medical services, thus enabling 100% patient follow-up. The most recent analysis of 1907 consecutive patients at 20 years of follow-up reported a perioperative mortality of 1% with a very low reoperation and revision rate. In terms of a positive affect on comorbidities, 96% of the patients achieved cure of diabetes; 58% of patients treated for hypertension were able to cease their medicating, 79% of patients improved their asthma, and 86% were able to discontinue the use of nasal continuous positive airway pressure for sleep apnea. Laparoscopic BPD/DS was introduced in 1999 by Gagner. A recent analysis of five combined case series totaling 467 patients operated on laparoscopically showed a mean age of 39 years with a preponderance of female patients (63.5%) and preoperative mean BMI of 47.3 kg/m2 [10 – 19]. Two of these five studies reported a high percentage of associated comorbidities, including hypertension, diabetes mellitus, degenerative joint disease, and sleep apnea. The conversion rate to open surgery varied with a mean conver-

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sion rate of 6.1% reported. Postoperatively, an average %EWL of 72% was seen during a mean follow-up of approximately 12 months. Rabkin et al reported a follow-up of 24 months with a mean %EWL of 91%. This report had very low early complication (6%) and reoperation (4.8%) rates for these high-risk patients. A length of hospital stay of 3.3 days using the laparoscopic approach compared favorably to 5 days in a larger series of 701 patients using the open procedure. The overall mortality was reported by two groups to be 1.5%. These results are very similar to those found in the systematic review and meta-analysis of Buchwald et al in open BPD and open BPD/DS [20]. It can be concluded that there is evidence demonstrating the effectiveness of BPD or BPD/DS in the treatment of morbid obesity. Although there are no randomized controlled trials assessing this operation, the available clinical data encompasses a large number of patients with significant follow-up. To date, BPD or BPD/DS has been shown to produce a substantial weight loss and comorbidity improvement even after 10 years. Surgical complications and shortterm mortality is low and comparable to that of gastric bypass. Although the feasibility of laparoscopic BPD/DS and standard BPD has been proven, efficacy results are still only available from relatively small reports with short-term follow-up. Preliminary data shows similar results to the open operation [1–21].

References [1] Scopinaro N, Gianetta E, Civalleri D, et al. Biliopancreatic bypass for obesity (I and II). Br J Surg 1979;66:616 – 620. [2] Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg 1998;22:936 –946. [3] Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996;19:261–268. [4] Marinari GM, Murelli F, Camerini G, et al. A 15-year evaluation of biliopancreatic diversion according to the bariatric analysis reporting outcome system (BAROS). Obes Surg 2004;14:325–328. [5] Van Hee R. Biliopancreatic diversion in the surgical treatment of morbid obesity. World J Surg 2004;28:435– 444. [6] Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch.World J Surg 1998;22:947–954. [7] Anthone GJ, Lord RVN, DeMeester TR, et al. The duodenal switch for the treatment of morbid obesity. Ann Surg 2003;238:618 – 628. [8] Biron S, Hould FS, Lebel S, et al. Twenty years of biliopancreatic diversion: what is the goal of surgery? Obes Surg 2004;14:160 –164. [9] Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998;8:267–282 [10] Scopinaro N, Marinari GM, Camerini G. Laparoscopic standard biliopancreatic diversion: technique and preliminary results.Obes Surg 2002;12:362–365. [11] Resa JJ, Solano J, Fatas, JA, et al. Laparoscopic biliopancreatic diversion with distal gastric preservation: technique and three-year follow-up. J Laparoendosc Adv Surg Tech 2004;14:131–134. [12] Paiva D, Bernardes L, Suretti L. Laparoscopic biliopancreatic diversion: technique and initial results. Obes Surg 2002;12:358 –361. [13] Feng JJ, Gagner M. Laparoscopic biliopancreatic diversion with duodenal switch. Semin Laparosc Surg 2002;9:125–129.

[14] Gagner M, Matteoti R. Laparoscopic biliopancreatic diversion with duodenal switch. Surg Clin N Am 2004, in press. [15] Baltasar A, Bouz R, Miro J, et al. Laparoscopic biliopancreatic diversion with duodenal switch: technique and initial experience. Obes Surg 2002;12:245–248. [16] Kim WW, Gagner M, Kini S, et al. Laparoscopic vs open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg 2003;7:552–557. [17] Rabkin RA, Rabkin JM, Metcalf B, et al. Laparoscopic technique for performing duodenal switch with gastric reduction. Obes Surg 2003; 13:263–268. [18] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514 –523. [19] Weiner RA, Blanco-Engert R, Weiner S, et al. Laparoscopic biliopancreatic diversion with duodenal switch: three different duodenoileal anastomotic techniques and initial experience. Obes Surg 2004; 14:334 –340. [20] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review of the literature and meta-analysis. JAMA 2004; 292:1724 –57. [21] Gentileschi P, Kini S, Catarci M, et al. Evidence-based medicine: open and laparoscopic bariatric surgery. Surg Endosc 2002;16:736 – 744 doi:10.1016/j.soard.2004.12.016

Open vertical banded gastroplasty and laparoscopic adjustable gastric banding Christine Ren, M.D., Assistant Professor of Surgery, New York University School of Medicine, New York, New York Restrictive operations limit the amount of food intake by the patients, with no component of malabsorption. Vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) fall into this category. Vertical banded gastroplasty VBG involves compartmentalizing the stomach to a smaller size through the use of a vertical row of staples with a nonadjustable banded outlet. It is most commonly performed by open laparotomy. A meta-analysis by Buchwald et al [1] has shown VBG to be safe, with a 0.1% mortality, and a mean percent excess weight loss (%EWL) of 68.2%. However, a prospective randomized trial of VBG versus Roux-en-Y gastric bypass (RYGB) by Sugerman et al [2] showed RYGB to be superior to VBG in terms of weight loss at 3 years (%EWL of 64% vs 37%), but potentially nutritionally safer. VBG also results in resolution or improvement in 89.5% of patients with diabetes mellitus, 80.6% of those with hypertensives, and 89.3% of those with sleep apneic. However, long-term maintenance of weight loss after VBG has been inconsistent. Balsinger et al [3] found that after 10 years, only 26% of 71 patients undergoing VBG lost and maintained more than 50% EWL. A 3-year randomized trial in Adelaide, Australia unequivocally demonstrated superior weight loss with RYGB and