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The entire contents of this page are used with permission, and are copyright ©1998 by Douglas S. Hess, MD, FACS, et al, all rights reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission. Correspondence should be directed to Douglas S. Hess, M.D., 640 South Wintergarden Road, Bowling Green, Ohio 43402, USA. Telephone: 419-352-1452; Fax: 419-352-1244 Biliopancreatic Diversion with a Duodenal Switch Douglas S. Hess, MD, FACS; Douglas W. Hess, MD Background Background: This paper is an evaluation of the use of the biliopancreatic bypass combined with the duodenal switch procedure forming a new hybrid procedure which is a combination of restriction and malabsorption. Methods: Evaluation is of the first 440 patients with this operation who have had no previous bariatric surgery. The mean starting weight is 183 kg., with 41% of our patients considered super morbidly obese (BMI > 50). Results: There is an average maximum weight loss of 80% excess weight which occurs at 24 month post-operative and continues at a 70% level for eight years. Our major complications are listed and total near 9% of all cases. We have two perioperative deaths, one from pulmonary embolism and one with acute pulmonary obstruction. There are 36 type II diabetics all of whom are no longer taking medication since the surgery. Seventeen revisions were performed to correct excess weight loss and low protein. There are no marginal ulcers , no dumping syndrome, no foreign material used, and it is a pyloric saving procedure which is functionally reversible. Conclusions: This operation has vastly improved the lives of our seriously obese patients with many co-morbidities. All type II diabetics have essentially been cured of their disease. The procedure is tolerated well and the patients are all quite satisfied. There does not seem to be the late regain of weight in this method. In 1988 using a combination of Dr. Scopinaro's biliopancreatic bypass and Dr. DeMeester's duodenal switch procedures, we developed a hybrid which has the advantages of the biliopancreatic bypass without some of the associated problems. This operation is now used by us for all our bariatric patients, both in primary surgical procedures and reoperations. The difficulty of establishing an operation that has both long and short term success is well known. Bariatric surgery is either restrictive or malabsorptive in nature, each with its own advantages, disadvantages and complications. While trying to find a procedure that would produce better long term results and fewer failures i.e., regain of weight, we began to look at Dr. Scopinaro's biliopancreatic bypass1. First we considered it only for reoperations on failed restrictive procedures. Our first cases were reoperations with the standard Scopinaro biliopancreatic bypass, and a few without a distal gastrectomy. However, the dense adhesions found in the upper gastric area of previously stapled patients caused difficulty in placing the anastomosis and we were troubled with marginal ulcer formation. We considered a method to anastomose the ileum to the duodenum away from the site of the previous surgery. While searching the literature on the subject of duodenogastric reflux, we found Dr. DeMeester's article about the duodenal switch procedure2 and adapted it to our use. The first patient to have a biliopancreatic bypass with a duodenal switch procedure was a male patient who had had a transverse gastroplasty nine years earlier, in 1979. He was six feet, four inches tall, and at the time of his surgery in 1979 , he weighed 166 kg (365 lbs.). That surgery eventually failed due to staple disruption, and his weight had increased to 206 kg (454 lbs) by the time of his reoperation in March, 1988. He also had developed chronic heart failure, shortness of breath, and was no longer able to perform many daily activities. Presently, he is approximately nine and one half years post-operative (converted to a duodenal switch with a biliopancreatic bypass), weighs 125 kg (275 lbs.), and is free from problems associated with his obesity. Due to the success of our reoperations, we decided to use this procedure for our primary operation for both the morbidly and super morbidly obese patients. Our first duodenal switch primary procedure was performed on a morbidly obese male patient (BMI 46) in May, 1988. At his most recent weighing on October 29, 1997, his excess weight loss was 88%, BMI was 26, and his percent of ideal weight was 112. The first super morbidly obese patient (BMI 58.7) was a female operated in June, 1988. At her last weighing on June 10, 1997, her excess weight loss was 78%, BMI was 30, and her percent of ideal weight was 137. Both of these patients are more than nine years post-operative and are doing well. This operation is now our procedure of choice for surgical correction of morbid and super morbid obesity. This paper will be limited to our first 440 patients, primary procedures only. Reoperations are not included. Examining the experimental work on dogs of Dr. DeMeester et al. as described in the Figure 1, it is evident that a small segment of proximal duodenum protects against marginal ulceration. The surgical procedures for all groups are basically the same, except that the dogs in groups C and D had a short segment of proximal duodenum left in place before the jejunostomy. The dogs in groups A and B had a high incidence of ulcers, perforation and weight loss. Groups C and D had significantly fewer ulcers and almost no perforations, however, the weight loss did not change. Using this data and DeMeester's report of patient cases (i.e. "duodenal switch") we felt the combination of the biliopancreatic bypass and the duodenal switch to be a logical progression of this procedure. Figure 1. Results of four diversion procedures with their effect on ulcer incidence, perforation and weight loss. To achieve the gastric restriction required by Dr. Scopinaro's biliopancreatic bypass, a vertical gastrectomy is performed, which removes a large portion of the fundus and also reduces acid formation, helping to prevent marginal ulceration (Figure 2). Figure 2. Biliopancreatic diversion with duodenal switch procedure. PATIENT SELECTION AND PREOPERATIVE EVALUATION Patients selected for surgery in this cohort were between the ages of 16 and 62, the average age being 39 years. All patients were 45.5 kg (100 lbs.) or more above their ideal weight using the 1983 Metropolitan height and weight tables. The presence of co-morbidities is an additional indication for surgery. Patients with combinations of co-morbidities with a lower excess weight are occasionally candidates for surgery. However, most patients are more than twice their ideal weight at the time of surgery (Table 1). Table 1. Preoperative data: morbid obese patients
All patients view a video explaining the surgical procedure and possible complications. They are later seen by the physician for an extended interview and second explanation of the procedure, including expectations. They have the usual preoperative complete blood count, chemistry profiles, cardiac evaluation, and x-rays. They are then seen by an internist for a medical evaluation. The patients are encouraged to attend one of the monthly support meetings before surgery, which is also attended by a physician. The meetings allow the perspective patients to acquire additional information and talk to patients who have had this surgery. Under general and epidural anesthesia a midline incision is used in the upper abdomen from the xyphoid to the umbilicus. A Gomez retractor is put in place, and the abdomen is explored. We start with an appendectomy, and complete measurement of the small bowel along the antimesenteric border with a mild stretch between two Babcock clamps, from the cecum to the ligament of Treitz. A silk suture is placed in the margin of the bowel at the estimated proximal common channel and the proximal end of the alimentary limb. These measurements may be changed after complete measurement of the bowel. The length of the alimentary limb is calculated by multiplying the bowel length by 40% to determine the distance from the cecum to the ligament of Treitz. Using 25 cm. increments, the final length of the alimentary canal is the nearest to the 40% area. Generally, the alimentary canal will be 250 cm., 275 cm., or 300 cm. Occasionally 225 cm. or 325 cm. will be used in patients with an unusually short or long small bowel. Since the epidural anesthesia may cause spasm of the small bowel, it is not used until after the measurements are completed. The position of the table is changed to reverse trendelenberg as our attention is focused on the upper abdomen. The left triangler and Falciform ligaments of the liver are incised to allow retraction of the liver away from the stomach and is held with gauze and a liver retractor. We open into the lesser sack by transecting a couple of short gastrics at the mid greater curvature of the stomach. With a tripolar cautery (i.e., a bipolar cautery with a knife for cutting cauterized tissue) we transect all the short gastrics from the pylorus to the esophagus, freeing up the entire greater curvature portion of the stomach. Blood vessels are transected along the greater curvature side of the duodenum for about five centimeters distal to the pylorus, and a penrose drain is passed around the duodenum at this point. The Salem tube is removed and a 40 F dilator, to be used as a sizer, is passed into the stomach, along the lesser curvature, and through the pylorus into the first part of the duodenum. The greater curvature side of the stomach is held upward and to the left by an assistant, using Babcock clamps. We size the new stomach by placing the ILA-100 stapler along the dilator, starting from the distal stomach a few centimeters proximal to the pylorus, directed upward, separated from the dilator by a space of one to two finger breadths. This stapling is repeated three or four times as needed to remove the entire greater curvature side of the stomach. Bleeding points along the staple row are oversewn with figure-of-eight silk sutures. Then the staple row is inverted by a continuous suture using (U.S. Surgical O-Biosin) a serosal to serosal suture. The dilator is removed and the duodenum is transected as far distal to the pylorus as possible (generally 4 to 5 centimeters) with an ILA 52 and the Salem tube is reinserted. We measure the volume of the stomach in all cases at this time by filling the stomach with saline and methylene blue dye. With one hand we press against the esophagus to stop reflux of the saline, we do not dissect around the esophagus. After the stomach is distended we withdraw the saline and this amount is considered to be the volume of the stomach, as well as our check for possible leaks. A cholecystectomy is performed in all patients who still have a gallbladder in the routine manner. The small bowel which was previously marked for the alimentary limb is transected with an ILA 52, and the mesentery is divided with the tripolar cautery until the distal ileum can be mobilized up to the pyloric area. The distal ileum is taken retrocolic to the right of center up to the duodenum which is still attached to the pylorus and anastomosed to this duodenum with a Valtrac anastomosing ring end to end using 1.5 mm gap and a 25 mm diameter Valtrac. The mesentery is sutured to the post peritoneal wall to prevent any internal hernias. The proximal ileum is taken distally to the previously marked area on the distal ileum and an end to side anastomosis is performed with a Valtrac anastomosing ring (1.5 mm gap and 25 mm diameter) and the mesentery is closed with a running suture. The abdomen is closed in the usual way and we generally place a drain in the gallbladder bed area. There are several concurrent procedures performed with this surgery as illustrated in Table 2. Table 2. Concurrent procedures, by type and number performed
After resection of the greater curvature we would prefer to have the volume of the stomach to be somewhere around 150 cc (generally, no less than 100 cc or more than 175cc). We size the stomach with a #40 dilator along the lesser curvature and we stay 1 1/2 to 2 finger breaths away from the dilator towards the greater curvature side when we apply the ILA-100 stapler. In general, this will give us a stomach that will fall in that range. The serosa to serosa suture reduces the size of the stomach which is a factor in early weight loss as time passes this stomach volume will enlarge. We believe that the total length of the alimentary limb (from the cecum to the stomach) should be approximately 40% of the total length and that the common channel (the distal portion of the alimentary limb just beyond the anastomosis of the biliary limb ) should be somewhere around 10% of the total small bowel length. We make the common channel 50 cm, 75 cm or 100 cm, whichever seems the most proper. The length of our alimentary limb is always calculated in 25cm increments: 250 cm, 275cm, 300 cm, etc. Table 3 illustrates the common channel, the alimentary limb and approximately the number of cases we used in that group. Also, it indicates the average length of the bowel, patient's weight, and stomach volume, and this illustrates that in general, the measurements are close to 40% alimentary canal and 10% common channel. These are only guidelines and we evaluate every patient individually at the time of surgery as to their age, their weight, and to the number of co-morbidities in making our decision on the above sizes. The proper volume of the stomach, and the lengths of the roux-en-y limbs and bilio limbs have been debated. Table 3 is of the first 382 cases of primary BPD with a duodenal switch and it gives an impression of the variety of measurements in lengths with similar bowel lengths in percentages. We believe that the percentage should be considered when deciding how long the limbs should be, then as long as consistency is maintained, the method of measurement is insignificant. Table 3. Measurements of the first 382 primary BPD with duodenal switch patients
Table 4 illustrates that the difference in bowel length from one person to the other may be more than 100%. If the same lengths are used in all patients then some will be too short and some too long. The exact proper size is elusive and is yet to be discovered. Table 4. Total small bowel length
Figure 3 is a graph of weight loss according to the sizes used in Table 3. Figure 3. Percent excess weight loss with time. The information presented at the bariatric surgery meeting in June 19973 (and by personal contact ) in Chicago by Dr. Scopinaro indicated that by increasing the length of the alimentary limb the absorption of protein increases substantially, whereas increasing the size of the common channel alone does not necessarily increase the amount of protein absorption, but it does reduce fat malabsorption. It is his feeling that most of the digestive juices and bile are reabsorbed before they reach the common channel and that an increase in the alimentary canal would be a method of increasing protein absorption without reducing the selective malabsorption of fat and weight loss capabilities. However, as you increase the length of the alimentary limb you also increase the absorption of carbohydrates. We feel that this is probably correct and in general it supports our method of using 40% for the guideline of the length of the alimentary canal. It appears that the alimentary canal can be made longer, the common channel made relatively short, and a selective malabsorption of fat will occur while maintaining adequate absorption of protein. Time in any surgical procedure is of importance. In the first 114 cases that we performed our average operative time was 199 minutes. After we had performed 213 cases our average time was 187 minutes. In the last 115 operations our operative time was 158 minutes, which is our current average. These improvements on operative time are partially due to newer techniques. We now measure the small bowel at the beginning of the operation and remove the appendix. We use a tripolar cautery to take down all the short gastrics along the greater curvature of the stomach. We rarely tie any short gastrics. This has reduced our blood loss and operative time. We use this same method for dividing the mesentary in the small bowel. There are two anastomosis, both of which are made with the Valtrac ring anastomoser. This has significantly decreased our operative time and reduced possible complications. All of these factors, technical and mechanical improvements, have made this operation more efficient. Our blood loss has not been excessive and in most cases we have the patient donate an autologous unit of blood two weeks prior to surgery which we give back at the time of surgery. Generally no further blood is needed. We have given 342 units of autologous blood in our first 440 patients. There are some patients who were either not able to give autologous blood or required extra blood and we have used a total 26 units of banked blood of our 440 primary surgeries, excluding two patients who had interabdominal bleeding post-operatively and required surgery to control the bleeding. In most cases our blood loss is about 300 cc. In bariatric surgery, patient follow-up and weight loss results over several years are very important. Without this follow-up we would have little idea about the success or failure of the surgery we are performing. Most of our patients are on six month follow-up visits after the second year of surgery, therefore, we have a six month period in which our follow-up is current. In this series of 440 primary biliopancreatic diversions with the duodenal switch there are six patients that we have not been able to contact for follow-up. This gives us in this cohort a total percent of follow of 98.60% We feel this gives credence to the value of our statistical results. The results are shown in Figure 4 by weight loss (kg.), percent excess weight loss, and percent total body weight loss. This is a graph of the average of the first 440 primary duodenal switch patients. The maximum weight loss occurs around 24 months and at about 80% excess weight loss and continues at a satisfactory level out to eight years. Figure 4. Weight loss in 440 primary bariatric surgery patients. This cohort is over nine years old and Table 5 illustrates the number of cases which were performed each year from which this graph is taken. This graph shows the average weight loss but we also evaluate our success according to individual patients. Table 5. Primary bariatric patients with BPD and a duodenal switch
We calculate each patient individually. Table 6 consists of the grade determinants that are used for individual results and includes 361 patients. We did not include any of the patients whose last recorded weight was taken less than 9 months after surgery (these results are based on the last weight recorded, not an average). Table 6. Composite grade and results for 361 primary cases.
Good, 60% EWL; Fair, 40% EWL; Poor, 20% EWL; Failure <2% EWL. Satisfactory = excellent, good, fair; unsatisfactory = poor, failure. Table 6 illustrates the number of patients in the different categories and their results with follow-up to nine years. There are 335 patients in the "good" and "excellent" categories for a total of 93%. The other group falls into the "fair" category which is still satisfactory. Most of these are considered successful, as they have had a stable weight for a long time, but did not lose excess weight of more than 60%. In the "fair" group there are 25 patients whose excess weight loss is from 40.2 to 59.8 percent with an average of 50.2% excess weight loss. When comparing those to the determinates in Table 3, our total satisfactory results is 99% with 1% unsatisfactory. Table 7 illustrates the total patients counted in different years follow-up by number of patients, number of satisfactory cases, and number in good and excellent categories at that year. Of the long term results, there is a only small amount of regain and we have never had a patient regain weight up to their original weight. Our one patient in the "poor" category has a weight loss of 35% of excess weight. Table 7. Follow-up results of the BPD with duodenal switch patients, grouped according to time since surgery
Of the 440 patient cohort, 301 patients have a minimum of one year follow-up and some have a follow-up time to as much as nine years. The average maximum weight loss is at 23 months with an average maximum loss of 63.2 kg. and an average maximum excess weight loss of 85%. Table 1 gives the demographics on the group, total number of 440 patients with normal distribution of male/female and age. Our average weight is rising, and is now 137 kilograms with a body mass index of 50 and 222% excess weight. As illustrated in Table 5, the success of the BPD with the duodenal switch procedure has contributed to the increasing number of cases we perform. This method of surgery has been the most successful for patient weight loss that we have used so far to this date. By defining the super morbid obese patient to be 225% of ideal weight, or having a BMI of 50 or more, then 41% of our patients fall into that category4. Our average patient is now 138 kg (304 lbs) and the average starting weight has recently been rising. Figure 5 shows the weight loss curve of the super morbid obese patient (BMI>50), shows weight loss comparable to the morbid obese group (BMI<50) and it to continues to have weight loss in the 70% excess and maintains good weight loss throughout the eight year period. Figure 5. Weight loss shown by % EWL in morbid obese and super morbid obese patients. The statistical data of our 181 super morbidly obese patients is listed in Table 8, and the composite results of the super morbidly obese patients with at least nine months post-surgery follow-up are seen in Table 8. No unsatisfactory results were seen and 97.3% of the patients fell into the good and excellent categories. Table 8. Preoperative data: super morbid obese patients
The super morbid obese patient has a much more difficult time successfully losing weight. We feel that a restrictive procedure alone will probably not work for most super morbidly obese patients. The biliopancreatic bypass with a duodenal switch works quite satisfactorily and could be used for all super morbid obese patients in our hands. These are the patients who have the most serious co-morbidities, high degree of sleep apnea, cardiac problems, diabetics and so forth. These are the people whose lives are threatened daily by their severe obesity and if possible they need to have one successful operation that will bring them down to a near-normal weight. There are several complications that can occur in, but are not limited to, bariatric surgery. Table 9 list these complications in our group. In addition, there is the frequent problem of atalectasis (20%) in the obese post-operative patient. Table 9. Complications of BPD with duodenal switch
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