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The goal of this article is to present an overview of selection criteria, surgical technique, and perioperative outcomes of biliopancreatic diversion with duodenal switch. The standard follow-up requirements, including vitamin supplementation, and long-term risks associated with metabolic surgery are also discussed. Most of the data reported here are based on the authors' experience with 4000 biliopancreatic diversions with duodenal switch performed in their institution since 1990., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) with a 100-cm common channel has been our treatment of choice for morbid obesity since the early 1990s. This procedure offers excellent long-term weight loss but can be associated with significant side effects., Objectives: To assess the effect on clinical and nutritional parameters of increasing the common channel to 200 cm., Settings: University-affiliated tertiary care center., Methods: Patients who underwent a BPD-DS with a 200-cm common channel (study group, n = 36) were matched 1:1 for age, sex, body mass index (BMI), and main co-morbidities with patients who underwent a BPD-DS with a 100-cm common channel (control group). The strict alimentary limb was 150 cm in both groups., Results: The mean age was 55±9 versus 53±7 years (P = .3), with 50% women and a BMI of 49±8 kg/m(2) versus 50±6 kg/m(2) (P = .9). Follow-up rate was 97%, with a minimum follow-up of 3 years. There were no significant differences in the remission rate of major co-morbidities between the 2 groups. At 3 years, the excess weight loss was 61±22% versus 68±18% (P = .18) and the total weight loss was 33±11% versus 38±9% (P = .055) in the study group versus control group, respectively. The study group had a lower incidence of severe protein deficiency (11% versus 19%, P = .3) and hyperparathyroidism (17.1% versus 35.3%, P = .17); required a lower amount of vitamins A and D (P<.05); and had a decreased number of daily bowel movements (2.0 versus 2.9, P = .03)., Conclusion: In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is one of the most effective surgical approaches for the treatment of severe obesity., Objective: The objective of this study is to compare perioperative complications and long-term results of open BPD-DS in elderly versus younger patients., Methods: All patients aged 60 years and above who underwent a primary open BPD-DS in our center were selected (n = 105). Patients were matched 1:1 for sex, BMI, the presence of type 2 diabetes (T2DM), and year of surgery with a group of younger patients (aged ≤55 years)., Results: The mean age of the patients was 62.3 ± 2.0 vs. 40.4 ± 7.0 years (p ≤ 0.0001). Initial BMI and prevalence of T2DM were similar in both groups, at 50.9 kg/m(2) and 57%, respectively. Mean operative time (178.6 ± 46.7 vs. 162.5 ± 39.9 min, p = 0.01), hospital stay (10.2 ± 8.3 vs. 6.3 ± 1.5 days, p = 0.0001), and blood loss (593 ± 484 vs. 474 ± 241 ml, p = 0.05) were significantly higher in elderly patients. No difference in 30-day mortality rate was observed (0.9% in each group). There was no significant difference in major complication rate (16.2 vs. 8.6%, p = 0.09). At a mean follow-up of 7.1 ± 4.1 years, excess weight loss (67.6 ± 19.2 vs. 72.7 ± 20.7%, p = 0.06) and BMI (32.2 ± 5.7 vs. 30.8 ± 6.6 kg/m(2), p = 0.15) were not significantly different. No significant difference was observed between the two groups for the resolution of T2DM (p = 0.53) and obstructive sleep apnea (p = 0.44)., Conclusions: Open BPD-DS is associated with similar long-term benefits in elderly and younger patients, in terms of weight loss and resolution or improvement of obesity-related comorbidities. Perioperative complications might be more frequent in the elderly population, but this was not associated with increased mortality.

Background: The choice of first-stage operation in bilio-pancreatic diversion with duodenal switch (BPD-DS) is controversial. There are no published long-term comparisons of one- and two-stage BPD-DS outcomes., Methods: During 2001-2009, among 1,762 patients scheduled for BPD-DS 48 had duodenal switch (DS) and 53 sleeve gastrectomy (SG) as first-stage procedures. We compared prospectively updated outcomes of 42 DS (100 % open) and 49 SG (88 % laparoscopic), 13 of whom completed their second stage, to a control group of 91 patients with open one-stage BPD-DS., Results: One-year mean percent excess weight loss (%EWL) was greater after SG than DS (47 ± 19 vs. 39 ± 13 SD; p = 0.01) with earlier nadir (16 ± 10 vs. 45 ± 30 months; p < 0.0001) but more rapid significant weight regain. After 5 years, %EWL was 12 ± 35 for 9 SG, 45 ± 19 for 30 DS (p < 0.0006), and 70 ± 18 for the first-stage BPD-DS (p < 0.0001). Weight loss was less after two- than one-stage procedures (p < 0.02). Comorbidities improved progressively between SG, DS and BPD-DS (p < 0.001 for trend). HbA1C decreased by 10, 19, and 31 %, respectively (p < 0.0001). Dyslipidemia was cured in 41, 82, and 100 %, respectively. Systolic and diastolic blood pressure decreased only after DS (12 %; p < 0.0002). Patient satisfaction was similar for SG and DS but greater after BPD-DS overall (p = 0.04)., Conclusions: SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.

Background: Sleeve gastrectomy (SG) was originally performed as the restrictive and acid-reducing part of a biliopancreatic diversion with duodenal switch (BPD-DS). It is now recognized as a stand-alone procedure, but direct comparison between the two procedures is still lacking. The goal of this study is to compare the outcomes of the two procedures and their respective impact on obesity-related comorbidities., Methods: All patients who had a laparoscopic SG (n = 378) or a laparoscopic BPD-DS (n = 422) before 10/2011 were included in this study (n = 800). Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation comparing SG with BPD-DS patients., Results: SG patients were older (48 ± 11 vs. 40 ± 10 years, p < 0.001) with a higher prevalence of comorbidities (type 2 diabetes mellitus in 51 vs. 37%; hypertension 62 vs. 49%; sleep apnea 63 vs. 51%; all p < 0.001). Initial BMI was 48 ± 9 vs. 48 ± 6 (p = 0.8). There was one 30-day mortality in the BPD-DS group, from a pulmonary embolism, for an overall mortality rate of 0.13%. Thirty-day complications occurred in 6 vs. 8% of patients (p = 0.2), including gastric leaks in 4 (1%) vs. 0 patients (p = 0.049). Mean follow-up was 29 ± 10 months. Excess weight loss was 45 ± 14 vs. 62 ± 15% at 6 months, 53 ± 18 vs. 81 ± 14% at 12 months, 53 ± 23 vs. 87 ± 15% at 18 months, 50 ± 19 vs. 86 ± 15% at 24 months and 51 ± 24 vs. 83 ± 16% at 36 months (p < 0.05 for all time points). The surgery induced the remission of type 2 diabetes mellitus in 56 vs. 90% of patients, hypertension in 54 vs. 76% and sleep apnea in 43 vs. 74% (all p < 0.05). In type 2 diabetic patients, fasting plasma glucose decreased by -1.9 mmol/l after SG vs. -2.9 mmol/l after BPD-DS (p < 0.05) and hemoglobin A1C by -1.1 vs. -1.9% (p < 0.05)., Conclusion: SG results in a significant 3-year weight loss and remission of comorbidities. BPD-DS provides further improvement of associated comorbidities and can be an option for the management of insufficient weight loss or residual comorbidities following SG.

Background: In the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center., Methods: A consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups., Results: The mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m(2) (47 ± 7 laparoscopy versus 52 ± 8 kg/m(2) open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS., Conclusion: The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Background: Severe or extreme obesity in children and adolescents is a progressive damaging disease, increasingly requiring surgical treatment. Timing and choice of operation are controversial., Method: In the last 16 years, we performed open biliopancreatic diversion with duodenal switch (DS) in 13 adolescents aged 15-17 years, who have been followed up for 2-16 years (mean, 10.6 years); three with Prader-Willi syndrome (PWS) are presented separately., Results: Among the ten non-PWS children (7 girls), no deaths or perioperative complications were reported, mean body mass index (BMI) decreased from 55.9 ± 14.0 to 28.8 ± 3.7 kg/m(2) (% excess weight loss (EWL) = 82.1 ± 10.5%), and none have regained weight. All comorbidities were cured except asthma, which improved in one patient. There were two reoperations: one for intestinal obstruction and one for post-anastomotic ulcer. Glucose and lipid metabolism improved, while vitamin and mineral deficiencies were mild and rare. Five of the seven girls gave birth to 11 children, aged 2-12 years, two of whom are overweight but not severely obese. Neurodevelopment is age-appropriate in all 11 individuals. PWS children, aged 15-16 years, had postoperative respiratory and infectious complications necessitating hospitalizations of 13-22 days (versus 5.1 ± 1.2 days in non-PWS). Weight loss and comorbidity improvement lasted approximately 5 years, providing improved quality of life for patient and family. One PWS patient died from complications after reoperation for weight regain after 4 years. One was reoperated after 6 years and the third is considering reoperation 14 years after primary DS., Conclusion: The beneficial effects of DS in adolescents exceed the risks, even in the presence of PWS.

Background: Biliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990 s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] ≥ 50 kg/m(2)). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m(2)., Methods: This was a retrospective study of all patients with a BMI <50 kg/m(2) who had undergone DS from June 1992 to May 2005. The data are reported as the mean ± standard deviation., Results: The data from 810 consecutive patients, with a mean initial BMI of 44.2 ± 3.6 kg/m(2), were reviewed. The mean follow-up was 103 ± 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% ± 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients "very satisfied" with the global result was 91%, and 37% would have preferred to lose more weight., Conclusion: These results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D., (Copyright © 2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This was a retrospective study, performed 10 years after surgery, to compare the results between biliopancreatic diversion (BPD) with distal gastrectomy (DG) versus BPD with duodenal switch (DS)., Methods: Complete follow-up data were available for 96% of patients, allowing a comparison of weight loss, revision, side effects, and complications at 10 years., Results: After BPD-DS, weight loss was 25% greater than after BPD-DG (46.8 +/- 21.7 kg versus 37.5 +/- 22 kg, respectively; P <.0001). The need for revision decreased from 18.5% to 2.7% (P <.0001), and the prevalence of vomiting during the previous month was 50% less (23.7-50.6%, P <.0001) after BPD-DS compared with after BPD-DG. Late complications were the same for both procedures. Blood analysis showed that, after BPD-DS, the levels of calcium, iron, and hemoglobin were significantly greater and the parathyroid hormone level was lower than after BPD-DG (71.3 +/- 44.2 versus 103.0 +/- 64.0 ng/L, respectively; P <.0001)., Conclusion: The DS greatly improved the BPD, as it was initially proposed. The use of the DS increased weight loss, decreased the need for revision, resulted in fewer side effects, and improved the absorption of nutrients.

Background: This is to introduce a new test "negative alliesthesia" for measuring satiation after bariatric surgery. It is a test that is well known by physiologists but has never been used clinically. It is based on the observation that repeated pleasant gustatory stimuli turn into unpleasantness in the process of satiation., Methods: We measured the time it took for a repeatedly ingested sweet stimulus to become first unpleasant (negative alliesthesia) and then intolerable (satiety). At the same time, we measured the degree of pleasure aroused by the sweet stimulus (hedonic rating). The test was given to 9 patients before and 3 and 6 months after the duodenal switch procedure and in 10 morbidly obese patients, three times, 3 months apart., Results: The test showed that negative alliesthesia and satiety were three times faster after surgery. The negative alliesthesia time decreased from 16.0 +/- 3.9 minutes to 5.7 +/- 1.4 minutes (P < 0.0004). The satiety time decreased from 26.7 +/- 5.0 minutes to 10.7 +/- 1.3 minutes (P <0.001). Finally, the hedonic rating for the sweet stimulus decreased from 78.8% +/- 15.7% to 49.9% +/- 13.0% at 3 months and 39.3% +/- 20.6% at 6 months after surgery, without, however, reaching statistical significance., Conclusion: The duodenal switch modified negative alliesthesia. It is too soon to say what place this test may have in bariatric surgery, but its simplicity and ingenuity are attractive.

This prospective study evaluated bone changes after biliopancreatic diversion (BPD) consisting of a distal gastrectomy, a 250 cm alimentary channel, and a 50 cm common channel. Thirty-three consecutive patients had clinical, biochemical, and bone mineral density analysis before surgery and 4 and 10 years after surgery. Iliac crest bone biopsies and special tests including parathyroid hormone (PTH), 25-hydroxyvitamin D (25-OH-D), 1,25-dihydroxyvitamin D (1,25-OH(2)-D), bone-specific alkaline phosphatase (BAP), and osteocalcin were obtained at surgery and 4 years postoperatively. Over the years, with close metabolic surveillance, additional calcium and vitamin D were given as indicated. After BPD, serum levels of calcium and vitamin D were decreased and serum levels of PTH, BAP, and osteocalcin were increased. Bone turnover and mineralization were both increased. Mean osteoid volume (P < 0.0007) and bone formation rate in relation to bone volume (P < 0.02) were increased. Static measures of bone were altered as follows: cortical thickness decreased (P < 0.01) and trabecular bone volume increased (P < 0.01). Ten years after surgery, overall bone mineral density was unchanged at the hip and was decreased by 4% at the lumbar spine. Overall fracture risk, based on the Z score, was unchanged. Preoperative factors predicting bone loss included menopause, smoking, and preexisting osteopenia. An elevated level of 1,25-OH(2)-D was also found to be a predictor of future bone loss (r = 0.40; P < 0.002). After surgery, a greater increase in bone markers and bone turnover was associated with an increased risk of bone loss. Although elevated osteocalcin levels were associated with overall bone loss (r = 0.52; P < 0.002), lower albumin levels were associated only with bone loss at hip level (r = 0.44; P < 0.02), whereas lower calcium levels were associated only with the loss at the lumbar spine (r = 0.39; P < 0.02). Ten years after surgery, bone loss at the hip continued to depend on albumin levels (r = 0.37; P < 0.03). We concluded that bone was relatively tolerant to the metabolic changes due to BPD. Provided that there is close surveillance for metabolic disturbances, the use of appropriate supplements, and the avoidance of malnutrition, the beneficial effects of surgery far outweigh the risk of postoperative bone disease., (Copyright 2002 The Society for Surgery of the Alimentary Tract, Inc.)

In 1990 Scopinaro's technique of biliopancreatic diversion with distal gastrectomy (DG) and gastroileostomy was modified. A sleeve gastrectomy with duodenal switch (DS) was used instead of the distal gastrectomy; and the length of the common channel was made 100 cm instead of 50 cm. A questionnaire and a prescription for blood work were sent to 252 patients who underwent DG a mean 8.3 years ago (range 6-13 years) and 465 patients who underwent DS 4.1 years ago (range 1.7-6.0 years). The questionnaire response rate was 93%, and laboratory work was completed for 65% of both groups. The mean weight loss after DG was 37 +/- 21 kg and after DS 46 +/- 20 kg. There were fewer side effects after DS: The number of daily stools was lower (p < 0.0002), as was the prevalence of diarrhea (p < 0.01), vomiting (p < 0.001), and bone pain (p < 0.001). Greater benefits related to several aspects of life were reported after DS than DG (p < 0.0001). The mean serum levels of ferritin, calcium, and vitamin A were higher (p < 0.001), and parathyroid hormone was lower. The yearly revision rate for excessive malabsorption was 1.7% per year after DG and 0.1% per year after DS. The two procedures were equally efficient for treating co-morbid conditions such as diabetes, hypertension, and hypercholesterolemia. Biliopancreatic diversion with sleeve gastrectomy/duodenal switch and a 100-cm common limb was shown to produce greater weight loss with fewer side effects.