Weight loss surgery – Biliopancreatic diversion (BPD)

This is the least common form of all weight loss operations.  The original operation was described by an Italian surgeon Edwardo Scopinaro in the 1970’s.  It combines both restriction and malabsorption and produces good weight loss (85% of excess weight) but long term malnutrition and vitamin deficiencies are common and patients having this procedure need intensive follow up.

Apart from Scopinaro’s original operation which described a distal partial gastrectomy and a rearrangement of the small bowel to produce malabsorption, there are two more recent versions called the “Duodenal Switch” and “SADI” (see diagrams).  These have been designed to overcome some of the long-term problems of the Scopinaro, but have not been performed long enough to have accurate long term results.

Classic BPD (Scopinaro) Procedure

In this operation approximately ¾ of the stomach is removed to provide restriction of food intake.  The small intestine is then dissected 250cm from where it joins the colon.  The 250cm segment is then joined to the stomach to create the “alimentary limb”.  All the food moves through this segment, but not much is absorbed.  The bile and pancreatic juices move through the “bilio-pancreatic” limb which is connected to the alimentary limb, 50cm from its end.  This 50cm segment is now called the common limb and is where the bile and pancreatic juices meet the ingested food and absorption of nutrients takes place.  Digestion of fat is not affected by this procedure and it is therefore important to restrict fat intake, otherwise stools will be frequent and loose.

The absorption of fat soluble vitamins is also affected, particularly vitamin A (eyesight) and D (bone strength) and it is necessary to take lifelong supplements of both these vitamins.  It is possible to vary the length of the common limb, but the longer the common limb, the less the weight loss.

Another side effect of this procedure is the dumping syndrome.  This occurs because the valve that normally controls stomach emptying is removed as part of the partial gastrectomy.  As a result, food exits the stomach remnant rapidly, drawing fluid into the intestine and causing fainting, crampy pain and diarrhea in some patients.  To overcome this problem BPD with DS is performed. 

BPD with DS 

This operation is a variation of BPD in which stomach removed is restricted to the outer margin, leaving a sleeve and stomach with the outlet valve (pylorus) intact.  This results in normal gastric emptying and eliminates dumping syndrome.  The procedure is otherwise the same as the classic BPD operation. 

SADI

This is a single anastomosis version of the BPD.  As such, it is easier to perform laparoscopically.  All the potential short and long-term risks of BPD still apply however.

Advantages of BPD

The procedure results in a higher degree of weight loss ( >85%) than other bariatric procedures as has been demonstrated by the long term results of Prof Scopinaro. 

BPD with DS has the advantage of eliminating dumping syndrome as a long term complication.

Risks of BPD

• Operative risks include leaks from any of the bowel join ups (anastomoses) or sleeve staple lines.  This is the same as for Roux-Y bypass or sleeve gastrectomy.
• For all malabsorptive operations, bowel motions can be liquid and frequent and smelly especially if fat in the diet is maintained.  Over time this can reduce, especially if a low fat diet is maintained.
• Life-long follow up and monitoring of nutrients is required and must be agreed to before any surgery is performed.  Life-long vitamin supplements of vitamin A & D (fat soluble) are required and also a multivitamin supplement of water soluble vitamins.  If these are not followed serious nutritional illness that may result in life-long disability can occur.
• Changes to the intestinal “plumbing” arrangements can result in increased risk of gallstone formation and the need for gallbladder removal as a result.

Laparoscopic Surgery and BPD

BPD is the most difficult of all bariatric procedures to perform laparoscopically (ie with key-hole surgery).  A recent variation (SADI) can make the laparoscopic approach relatively simpler.

Either procedure is most frequently performed in the context of one or more previous obesity operations and this makes the possibility of laparoscopic surgery even more difficult.  Each case must be assessed individually, but often the final decision can only be made at the time of surgery.

BPD and other Bariatric Operations

 Although BPD can produce the best weight loss of all the bariatric operations, it also has the most potential for long-term nutritional complications and is least likely to be performed with laparoscopic (key-hole) surgery.  It should therefore be reserved for patients who are super obese (BMI >50) or on patients in whom other bariatric operations have failed.

This is a larger operation than most other bariatric procedures and requires a hospital stay of 3 days for laparoscopic procedures and 6-7 days for open procedures.

Patients can return to office style work in approximately 3 weeks and work in 6 weeks (often less for laparoscopic procedures)

A low fat diet and life-long vitamin supplements must be maintained.

Potential Complications of BPD

The general complications of surgery have previously been outlined.  Complications which are specific to BPD are as follows:

Peri operative (ie. during surgery and in the immediate post operative period)

• Anastomotic leak which can result in peritonitis and the need to re-operate.
• Staple line bleeding, requiring blood transfusion and possible re-operation.
• Gastric stricture
• Internal adhesions and bowel obstruction.

Long Term:

• Gastric stricture
• Internal adhesions and bowel obstruction
• Vitamin deficiencies (especially fat soluble, A, D & E)
• Protein malabsorption
• Osteoporosis
• Stomach ulcers
• Dumping syndrome (more common after classic Scopinaro)
• Diarrhea/fatty stools/abdominal bloating

In summary, BPD with DS is used as a last resort operation and although generally produces good weight loss this cannot be guaranteed and it has a potentially higher complication rate both short and long term than other obesity procedures.

All patients MUST be followed up by medical practitioners who have experience with BPD patients FOR LIFE

This document must be read in conjunction with the Royal Australasian College of Surgeons booklet on Weight Loss Surgery.   Although this operation is not discussed in that document, all the general discussion regarding weight loss surgery applies.  Special note should be taken of the section regarding symptoms developing post discharge from hospital.  Fi these symtpoms do occur post operatively, your surgeon should be contacted or go to the nearest Emergency Department.  Please note your surgeons after hours contact number.