Alimentary Limb Research Articles

A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS).

Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss. However, analysis of the quality of life (QoL) has never been reported. The BAROS, giving a score to each operated patient on weight loss, improvement in medical conditions, QoL, complications and reoperations, has proven to be a standard reference for evaluating bariatric surgery outcomes. In order to apply the BAROS to BPD, we sent a questionnaire to 1,800 BPD patients who had been operated between 1984 and 1998. The response-rate was 51.2%. Out of 1,709 questionnaires which actually reached their destination, we had 858 fully compiled returned. There were 615 women. 596 patients had had an ad hoc stomach (AHS) BPD, and 262 had had an ad hoc stomach ad hoc alimentary limb (AHS-AHAL) BPD. According to the scoring key, 3.5% were classified as a failure, 11% were fair results, 22.8% good, 39.5% very good, and 23.2% excellent results. Considering AHS BPD and AHS-AHAL BPD separately,while the mean excess weight percent loss was 70.5+/-23 and 64.7+/-17 respectively, the failure rate was 6% in the first group and 2% in the AHAL group, while 11% and 6% of cases respectively were fair results, 24% and 20% good, 36% and 47% very good, 23% and 25% excellent results. The BAROS evaluation of BPD highlights the importance of its flexibility: the new policy of adapting the procedure to individual characteristics caused a drop in the failure rate and an increase in good, very good and excellent results.

A technique of enteroenterostomy to prevent alimentary limb obstruction in laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y gastric bypass (RYGBP) has rapidly become a widely accepted treatment option for patients with morbid obesity, producing weight loss as dramatic as the open operation while minimizing the incidence of postoperative wound infection and incisional hernia. Pain is less and recuperation is improved. Currently, the technique for stapled closure of the enterotomy in laparoscopic RYGBP consists of aligning the alimentary and biliopancreatic limbs, creating an enterotomy on the antimesenteric side of each loop, and inserting a linear stapler through the enterotomies into the proximal segments of bowel. The stapler is fired once or twice in the same direction to create a side-to-side anastomosis between the two loops of bowel. In the final step, traction is used to pull up the enterotomy. The stapler is then laid across and fired to close the enterotomy. Stapled closure of the enterotomy may result in narrowing and potential obstruction of either the alimentary limb or the biliopancreatic limb, because it is often difficult to assess and control the amount of tissue being transected during this closure. On the other hand, the true corner of the enterotomy must be visualized and incorporated in the staple line to ensure complete closure. For this reason, sutures are placed on the edges of the enterotomy before stapling. This step requires careful consideration because narrowing of the alimentary limb is a significant technical hazard at this stage. Narrowing of the biliopancreatic limb is less likely, but inadvertent closure of the enteroenterostomy may occur, resulting in biliopancreatic limb obstruction and, in turn, anastomotic dehiscence. Our objective is to describe a method of stapled enteroenterostomy that avoids narrowing of the alimentary or biliopancreatic limb, yet offers an easy and secure closure of the enterotomy.

Short-term liver function after biliopancreatic diversion.

Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects. We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry. Compared with preoperative values, AST levels at 2 months significantly increased (Student's t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearman's Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P <0.0001), SG (P =0.01), and HI (inflammation P<0.0001, fibrosis P=0.001). Hepatocellular necrosis in our series peaks at 2 months, and decreases afterwards.WL at 2 months, preoperative BW, SG and HI seem to be of help in identifying patients at increased risk for acute liver damage, prompting the need for an enhanced surveillance.

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m(2). She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m(2). Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.

Techniques of Laparoscopic Roux-en-Y Gastric Bypass

Morbid obesity represents a challenge to healthcare as the underlying source of numerous risks and significant expenditure. Gastric bypass surgery has been validated as a means of significant and reproducible reduction in weight. In the laparoscopic era, the minimally invasive approach has been applied to this procedure with promising results. In our technique, we divide the stomach to create a small gastric pouch drained by a retrocolic, retrogastric Roux-en-Y alimentary jejunal limb. The gastrojejunostomy is performed in 2 layers, an inner stapled layer and an outer sutured layer. We, like other groups, have found that laparoscopic gastric bypass provides similar efficacy to open gastric bypass, but offers improved patient acceptance, quality of life, and significantly less wound complications.

Analysis of weight loss with the biliopancreatic diversion of Larrad: absolute failures or relative successes?

The authors studied whether morbidly obese patients who failed in stated weight loss criteria may be considered absolute failures or relative successes. 75 morbidly obese patients underwent biliopancreatic diversion (BPD) of Larrad, with a 4/5 gastrectomy (residual gastric volume 150-200 ml), a biliopancreatic limb divided 50 cm distal to Treitz' ligament, a 50-cm common limb and an alimentary limb of nearly all the bowel length (500-600 cm). Every patient had a follow-up of 5 years. A percent excess weight loss (%EWL) < 50% was considered a "failure". We analyzed the post-surgical changes in the preoperative obesity-related problems in these patients and the causes of the weight loss failure. At 5 years after the BPD of Larrad, 9 patients (12%) had a %EWL < 50%, with a mean %EWL of 36 in these patients. Most of these failed patients were cured or improved of their preoperative illnesses. The 2 males were alcoholics, and 6 of the 7 females had an abnormal psychological examination. Comparing the "failed" patients with the successful group, there is a statistically significant influence (p < 0.01) of lack of satiety, unmarried status, housewife or unemployed. Patients judged as a failure by weight loss criteria after bariatric surgery should not be considered absolute failures, because most of their preoperative illnesses were cured or improved, improving their quality of life. Thus, they are "relative successes".

Biliopancreatic diversion.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

Biliopancreatic diversion for obesity at eighteen years

Surgical attempts to treat obesity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their long-term efficacy in weight maintenance have arisen. Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the last consecutive 1217 underwent the "ad hoc stomach" type of diversion with a 200 cm alimentary limb, a 50 cm common limb, and a gastric volume varying between 200 and 500 ml. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow-up was 115 months with nearly 100% participation. In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss initial excess weight (IEW) at 2, 4, 6, and 8 years was 78 +/- 16, 75 +/- 16, 78 +/- 18, and 77 +/- 16 in the patients with IEW up to 120% and 74 +/- 12, 73 +/- 13, 73 +/- 12, and 72 +/- 10 in those with IEW more than 120%. A group of 40 patients who underwent the original "half-half" biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term. Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.

Equal Biliopancreatic and Alimentary Limbs: An Analysis of 106 Cases over 5 Years

In 106 consecutive biliopancreatic diversion patients, the small intestine was divided at its mid-point to create equal biliopancreatic and alimentary limbs, because several observations had suggested that this would lead to Improved nutrition post-operatively. In order to test this hypothesis, the progress of these patients was compared with a similar group who had undergone a standard Scopinaro biliopancreatic diversion with a 250 cm alimentary limb. Four particular areas were studied: weight loss, hypoproteinemia, iron deficiency anemia and disturbance of bone metabolism. Patients with equal limbs lost 71 % of their excess weight at 36 months, compared to 77% in the standard diversion. With the equal limbs the incidence of hypoproteinemia was reduced from 8% to 2% and the incidence of iron deficiency anemia decreased from 20% to 10%. The change had no effect on clinically symptomatic metabolic bone disturbance which occurred in 7% of the patients in both groups. In the authors opinion, these improvements justify continued division of the small intestine at its mid-point.

Distal Roux-en-Y Gastric Bypass Conversion Operation for Failed Vertical Banded Gastroplasty.

Forty-five cases of failed vertical banded gastroplasty were converted to gastric bypass with distal Roux-en-Y constructed with a 250 cm alimentary limb and a 150 cm common channel. The gastroenterostomy is side-to-side, unrestricted and is at least 3 cm wide. We believe that this wide anastomosis is responsible for the zero incidence of stomal ulcers in this group. A nasogastric tube is not used and the patient is placed on ranitidine 150 mg one b.i.d. for the first 4 weeks. The weight loss is excellent and sustained, and the resulting life-style is very close to that of a normal person. All varieties of foods are tolerated in adequate amounts, and diarrhea occurs only if the patient indulges in fatty foods. Hypoproteinemia is generally mild and transient except in five early cases where TPN was needed, and four of these required elongation of the intestinal segments. Wound infection was 4.5%, and there was no mortality.