Overview of Biliopancreatic Diversion With Duodenal Switch
The concept of surgery for weight loss came about from doctors noticing patients losing weight after having parts of their stomach or small intestine removed. The first such weight loss procedure, called a jejunoileal bypass, was developed in 1954. However, due to its severe side effects, it was abandoned and weight loss surgeries were not seen favourably.
Public opinion of weight loss surgeries, also known as bariatric surgeries, started changing after a few key events:
- In 1992, The National Institutes of Health supported “vertical gastric banding” as a safe and effective weight loss surgery.
- Research published in 1995 demonstrated that bariatric surgery had positive long-term effects on managing diabetes.
- Improvements in bariatric surgery equipment led to fewer complications after surgery.
In 1994, the first laparoscopic gastric bypass surgery was carried out. As doctors became more skilled with this technique, laparoscopic surgeries began to show better results than traditional open surgery. These advantages included fewer wound complications, smaller chances of developing hernias, shorter hospital stays, and a decrease in overall patient death rates.
Weight loss surgeries have proven to be an efficient way to achieve and maintain weight loss while also reducing health conditions associated with obesity. These health conditions include type 2 diabetes, heart disease, high blood pressure, sleep apnea, and certain issues related to the skeletal system.
Current common weight-loss surgical procedures include sleeve gastrectomy, Roux en-Y gastric bypass, and the biliopancreatic diversion with duodenal switch. The last procedure was originally described by Scorpinaro in 1979 and included a combination of steps involving parts of the stomach and small intestine. However, early patients experienced side effects such as bile gastritis, leading to modifications that evolved it into what we know today as the modern biliopancreatic diversion with duodenal switch procedure. This modern method includes performing a sleeve gastrectomy and making surgical changes to the small intestine.
Anatomy and Physiology of Biliopancreatic Diversion With Duodenal Switch
The duodenal switch surgery closely relates to the stomach, its nearby structures, and the veins and arteries which supply blood to them.
The stomach is a muscle just below the region where the food pipe and stomach meet. It stretches from this junction down to the first part of the small intestine, divided into 5 parts. The uppermost part called the cardia, the dome-shaped part is the fundus, the main body, followed by the antrum and the pylorus that connect to the small intestine. The long left border of the stomach stretching from the fundus to pylorus is called the greater curvature, connected to a fatty layer known as the greater omentum. The part under the liver is the lesser curvature, which has a significant point known as incisura angularis, the point at which the body and antrum of the stomach meet. Behind the stomach lies a space, known as the lesser sac, housing the pancreas.
There are also several ligaments that connect the stomach to nearby organs. The gastrophrenic ligament connects the fundus to the left-side diaphragm. The gastrohepatic ligament attaches the lesser curvature to the liver’s edge with gastric arteries running within it. The gastrosplenic ligament connects the greater curvature to the spleen and contains short gastric vessels. Lastly, the gastrocolic ligament links the lower part of the stomach to the colon and runs within the gastroepiploic vessels.
The blood supply to these regions comes from the celiac artery that has 3 main branches, namely left gastric, common hepatic, and the splenic arteries. The combination of the left and right gastric arteries is found on the upper lesser curvature. The gastroduodenal artery branches off the common hepatic artery and is located behind the first part of the small intestine. The left gastroepiploic artery branches off from the splenic artery, while the short gastric arteries are found in the gastrosplenic ligament.
Bariatric surgery has a direct impact on several hormones that have a significant effect on weight loss. Ghrelin hormone controls our energy use and is usually increased when we are fasting, with a decrease after eating. Surgeries like Roux encode Y Gastric Bypass and sleeve gastrectomy have been seen to suppress or reduce Ghrelin levels, which has resulted in more weight loss.
Leptin hormone produced by fat cells helps control hunger and store fat. These levels usually increase with more fat in the body. However, after weight loss surgeries, Leptin sensitivity increases and hence reduces the resistance to this hormone. This control in resistance is directly proportional to the amount of lost body fat.
Insulin, a peptide hormone, is essential for metabolism, absorbing glucose from the blood, glycogen metabolism in the liver, and skeletal muscles. All types of bariatric surgeries have been shown to increase insulin sensitivity, thus helping reduce diabetes and obesity.
Several hormones like incretins, insulin and leptin that facilitate digestion, control appetite, and manage weight, are regulated during such surgeries. This process, along with the physical changes to the digestive system, supports weight loss and improves overall health.
Why do People Need Biliopancreatic Diversion With Duodenal Switch
The main reason someone would undergo a procedure called a biliopancreatic diversion, which alters the pathway of food through the digestive system, is usually for weight loss surgery (also known as bariatric surgery), with a few exceptions for other medical conditions. There are a few conditions that need to be met before patients are considered for this procedure:
1. The patient’s Body Mass Index (BMI), a measure of body fat based on weight and height, is 40 or more. Alternatively, if the BMI is 35 or more and the patient also suffers from a condition caused by obesity, such as diabetes, sleep apnea, high blood pressure, or severe issues with their bones and muscles.
2. The patient hasn’t been able to lose enough weight through non-surgical means like diet and exercise.
3. The patient has been evaluated by a mental health professional and is considered mentally prepared for surgery.
4. The patient has no other medical conditions that would make surgery dangerous.
5. Extraordinarily obese patients with a BMI over 50 should think about having a biliopancreatic diversion combined with another procedure called a duodenal switch.
Also, for patients who’ve had two other types of weight-loss surgery (a Roux-en-Y bypass or a gastric sleeve) without losing enough weight, a biliopancreatic diversion with a duodenal switch might be an alternative to consider.
When a Person Should Avoid Biliopancreatic Diversion With Duodenal Switch
There are certain situations where a specific weight loss surgery, known as biliopancreatic diversion with a duodenal switch, cannot be performed. These situations are mainly in relation to weight loss surgeries, known as bariatric procedures.
The following are the absolute no-go situations for weight loss surgery:
1. Pregnancy: It’s not safe for a pregnant woman to undergo this type of surgery.
2. Severe psychiatric illness: If a person is dealing with a serious mental health issue, they may not be able to cope with the demands of the surgery and recovery process.
3. Eating disorders: If a person has an eating disorder, weight loss surgery may not resolve their issues with food and may even exacerbate the disorder.
4. Patient-related contraindications to undergo surgery: If there’s a high risk of heart issues or complications with anesthesia due to the person’s overall health conditions, surgery may not be possible.
5. Substance misuse (alcoholism): If a person is struggling with substance abuse, particularly alcohol, this can complicate the surgery and recovery process.
6. Severe coagulopathies: This refers to conditions that negatively affect the blood’s ability to clot. If a person has such a disorder, surgery can be too risky due to potential difficulties in controlling bleeding.
Equipment used for Biliopancreatic Diversion With Duodenal Switch
Biliopancreatic diversion with a duodenal switch is a type of weight loss surgery. This complex operation can be done in two ways: ‘open surgery’ where a large cut is made, or ‘laparoscopy’, which uses smaller cuts and a camera to guide the surgeon. In this context, we’ll focus on the laparoscopic method.
To perform this laparoscopic method, the doctor will need specialized medical tools. These will include a machine to inflate your belly with harmless CO2 gas to make room for the tools, clean drapes to maintain a sterile environment, high-quality screens to display the video footage from the surgery, various instruments made for laparoscopic use, devices to cut and seal blood vessels, and tube-like tools (trocars) to guide the other instruments into the body.
Because those going through a bariatric surgery tend to have thicker abdominal walls, longer trocars and instruments are generally necessary.
Other equipment includes:
- Three small trocars and 2 larger trocars
- A liver retractor (a tool to move the liver out of the way)
- A laparoscope with a 30-degree angle, about the same diameter as a drinking straw
- A smaller laparoscope
- An endoscopic stapler (a tool to staple tissues or blood vessels together)
- A long, tapered tube called a bougie to help guide the stapling of the stomach
- A flexible endoscope (a long, flexible instrument with a light and a camera)
- A laparoscopic energy device (a tool that uses energy to cut or seal tissue)
- Sutures (stitches) – both silk and vicryl (a type of suture that dissolves in your body over time)
Who is needed to perform Biliopancreatic Diversion With Duodenal Switch?
Bariatric surgery, often used for weight loss, usually involves a team of different medical professionals all working together to make sure you’re in the best health before, during, and after the surgery. This team might consist of a dietitian (a specialist in nutrition), a psychiatric specialist (a doctor who takes care of your mental health), an anesthetist (a doctor who helps you stay relaxed and pain-free during surgery), nursing staff, a surgical team, and your regular doctor. All the experts working together is a proven method to increase your chances of a successful surgery and recovery, while reducing the risk of serious issues afterwards.
Specially trained doctors and staff are needed for the actual surgery. This includes an anesthesiologist (the doctor who will keep you asleep during the surgery), a bariatric surgeon (the doctor who performs the weight loss surgery), a scrub nurse (a nurse who assists the surgeon), a surgical technician (a specialist assisting in the procedure), and a resident or first assistant (another person assisting the surgery). These professionals work together to ensure your safety and the success of your surgery.
Preparing for Biliopancreatic Diversion With Duodenal Switch
Before weight-loss surgery, several professionals, including dietitians, psychologists, hormone doctors, anesthesiologists, nurses, heart doctors, and the surgeon, all work together to ensure the patient is ready for the procedure.
Mental health check-ups are important before undergoing weight-loss surgery to avoid major issues after the surgery. The team checks for mental health disorders, such as depression, anxiety, and eating disorders. The team also assesses the support system the patient has, and if they have any problems with substance misuse, like alcohol or drugs. If the patient has a problem with alcohol, they’ll need to address this first. Similarly, if the patient smokes, they’ll be encouraged to quit before the surgery. This is because smoking can increase the chance of complications during and after the procedure.
Next comes the dietary assessment and planning. This step involves guiding the patient towards necessary dietary changes after the surgery. Typically, patients are recommended to follow a low-carb diet before the surgery to shrink the liver as much as possible. Losing weight before surgery can actually improve the results and reduce the likelihood of complications after the operation. During this evaluation, the importance of maintaining weight and controlling blood sugar levels in patients with diabetes is also discussed.
A medical check-up and clearance for surgery are also extremely important before the procedure. This involves a detailed review of the patient’s medical history, previous surgeries, and recent lab tests. Also, the patient’s physical ability to deal with the surgery is gauged, and if there are any concerns, a heart doctor may need to step in. It’s also crucial to evaluate patients with sleep apnea, a sleep disorder that can increase the risk of complications during surgery, with a sleep study and monitoring by a lung specialist.
Imaging tests are not always used before weight-loss surgery. Some studies have examined the use of ultrasounds to assess the liver and gallbladder, but these images didn’t appear to change patient outcomes and only added to the healthcare costs.
There’s also some debate on whether an upper gastrointestinal evaluation (EGD) should be done before weight-loss surgery, especially since it might increase the risk of acid reflux and other issues, but could also make future examinations difficult. The current advice is to decide on a case-by-case basis, focusing on patients with significant digestive symptoms.
How is Biliopancreatic Diversion With Duodenal Switch performed
Before starting the operation, the patient is placed under general anesthesia, meaning they will be completely asleep and feel no pain. The patient is also given antibiotics through an IV to avoid any infection. To stop the patient from moving during surgery, they are strapped and taped securely onto the surgical table. They are lying flat on their back with their legs slightly apart and their arms spread to each side. Special devices for applying intermittent pressure are put on the patient’s legs to enhance blood flow and prevent clotting. Lastly, the patient’s body is cleaned and covered in a safe, sterile manner for the surgery.
The first step of surgery involves creating a tunnel-like space within the belly filled with gas. This is done by inserting a special needle into a location just under the left ribcage. Next, a long, narrow viewing instrument (optical trocar) is placed into the patient’s upper abdomen for the surgeon to monitor the surgery. Additional ports are also added to the patient’s left and right sides, lower and upper left areas, this is to insert other surgical tools.
The stomach is then separated from the surrounding tissue with an ultrasound-powered scalpel. After this, the lower part of the stomach and the beginning part of the intestine after the stomach (duodenum) is freed from its surrounding structures. The duodenum is then carefully separated either at its lower border or from behind. After safely carrying out all these steps, the duodenum is divided using a special surgical stapler.
Once the first part of the intestine is ready, a procedure known as sleeve gastrectomy is performed. This involves making a cut in the stomach, about 6 inches from the pylorus (the lower part of the stomach that connects to the duodenum). A surgical stapler is used to remove the stomach section. Once removed, the part of the stomach that was cut is controlled for any bleeding points and the cut part (called the specimen) is placed in a bag and taken out through one of the ports.
After this, attention is turned to the lower part of the small intestine (ileum). The small bowel is measured and divided using a surgical stapler. Another joinery is made between the divided part of the small intestine and the prepared duodenum. Doctors ensure that this new meeting point of the gut is intact and there is no leaking from it.
Then, the divided part of the ileum is joined with the part of the ileum that is close to the large intestine. This new connection is also carefully checked to avoid any leaks.
Finally, after ensuring everything is in order, the trocars (those long, narrow viewing instruments) are removed. The deep tissue layers in the abdomen are closed at larger sites and the skin is sewed together with special threads that get absorbed into the body, negating the need for removal. The operation area is then covered with sterile dressing or a special glue-like substance for skin closure.
Possible Complications of Biliopancreatic Diversion With Duodenal Switch
Like most surgical procedures, biliopancreatic diversion with duodenal switch, a type of weight loss surgery, can lead to some complications. These complications can occur shortly after the surgery (early complications) or over time (late complications). The early complications commonly include a ‘leak’ in the surgical connections (anastomotic leak) and bleeding (hemorrhage). Late complications usually involve problems related to nutrition.
An anastomotic leak is when the connections made during surgery start leaking. It happens in about 1.14% of these surgeries, which is similar to the risk in another type of weight-loss surgery (Roux en-Y gastric bypass). Leaks most likely happen at the place where the surgeon connected the new pathway for food (the duodenum). Although leaks can happen from other places, these are quite rare. When a patient develops a leak, they often show symptoms like a fast heartbeat (tachycardia), rapid breathing, or fever. The best way to check for a leak is with a CT scan that uses a contrast dye. If the leak is fresh, the patient might need to go back into surgery.
Bleeding after surgery happens less than 1% of the time. Depending on where the bleeding occurs—inside or outside the new path for food—it will be treated differently. If the patient is feeling unwell and the bleeding doesn’t stop with standard treatments, surgery might be needed again.
This type of weight-loss surgery can also lead to nutritional problems, more so than other bariatric procedures. After surgery, many patients require supplements because they might not get enough nutrients from their food. They could become anemic (low iron), malnourished, develop calcium deficiencies, or lack certain vitamins like B1, B12, and folate. Having regular follow-ups and the necessary medical tests is essential to keep track of and manage these deficiencies.
What Else Should I Know About Biliopancreatic Diversion With Duodenal Switch?
Biliopancreatic diversion with duodenal switch is a type of weight loss surgery that is becoming more common in the United States. However, it’s not as popular yet as other procedures, such as the sleeve gastrectomy and the Roux en-Y gastric bypass.
Research has shown that the long-term results of this procedure are similar to those of the Roux en-Y gastric bypass and sleeve gastrectomy. But there are a few key differences. For instance, this procedure often produces better results for individuals who are extremely overweight, with a Body Mass Index (BMI) over 50 kg/m2. These patients are often able to lose more weight and keep it off better than those undergoing other types of weight loss surgeries.
The biliopancreatic diversion with duodenal switch has also been found to be more effective in treating diabetes and reducing excessive fats in the blood (hyperlipidemia)
However, it’s important to note that this procedure comes with a higher risk of nutritional deficiencies. Therefore, if you have this procedure, you’ll need to take part in a follow-up program to ensure that you’re getting the nutrients your body needs.