Biliary Pancreatic Diversion Research Articles

Esophageal Perforation After Laparoscopic Sleeve Gastrectomy and Paraesophageal Hernia Repair Managed by Transhiatal Drainage

Laparoscopic sleeve gastrectomy (SG) was first established as a 2-stage procedure in high-risk patients undergoing gastric bypass or biliary pancreatic diversion with duodenal switch. It has since become increasingly used as a primary bariatric procedure. The 2 significant postoperative complications after this procedure are anastomotic staple line leakage or bleeding. True esophageal leaks after sleeve gastrectomy are extremely uncommon. We present a case of contained esophageal perforation after a laparoscopic sleeve gastrectomy and paraesophageal hernia repair managed successfully with laparoscopic-assisted transhiatal drainage. We review the literature on the management of this uncommon but highly morbid complication in patients undergoing bariatric surgery.

Biliopancreatic Diversion Revisited: Health-Related Quality of Life Outcomes of Biliary Pancreatic with Duodenal Switch

Bariatric surgery is associated with improved health-related quality of life (HrQoL). The biliary pancreatic diversion surgery with duodenal switch is the most uncommon of the bariatric procedures and little is known about the long-term effect on HrQoL. Although there are different instruments to assess HrQoL, the SF-36 includes both mental and physical functioning, and studies in Europe have reported short-term benefits after the biliopancreatic diversion with duodenal switch (BPD-DS) with the SF-36. In a single institution in the United States, where one surgeon performed the BPD-DS, 27 surveys were received, with a mean follow-up of 12 years. We report, to the best of our knowledge, for the first time in the United States, significant long-term improvement in HrQoL after BPD-DS in this cohort.

Long‐term Health Related Quality of Life Outcomes of Patients who have undergone Bariatric Surgery with the Biliary Pancreatic Diversion with Duodenal Switch

BackgroundOf the different procedures used for bariatric surgery, BPD/DS is the most uncommon and has been associated with the longest durable weight loss with significant improvement in obesity‐related comorbidities. Improvement in health‐related quality of life (HRQoL) is of paramount importance and an essential metric to evaluate additional outcomes. Previous studies have shown significant improvement following BPD/DS for up to 5 years after surgery.Methods: We studied HRQoL in 27 patients who have had BPD/DS at an academic medical center over a period of 19 years. This study had utilized the validated SF‐36 survey and concluded that for most patients, surgery improved their HRQoL.Results: Of the 27 respondents who had BPD/DS surgery, 77.8% were female, and 96.3% were White. Sex # % Female 21 77.8 Male 6 22.2 Race White 26 96.3 Black 1 3.7 Mean SD Age at Surgery 44.33 8.9 Pre‐Operative BMI 48.89 11.5 Time Lapse Since Surgery (Years) 12.3 0.6 Weight Loss (Kilograms) 41.90 30.4 Their average age at the time of surgery was 44.3 years (SD=8.9), their average pre‐surgery BMI was 48.9 (SD=11.5) and their average time since surgery was 12.3 years (SD=0.6). Mean SF‐36 scores are shown in Table 2. Table 2: SF‐36 Scores Mean SD Physical Component Score (PCS) 47.677 12.5408 Mental Component Scores (MCS) 48.308 12.0977 General Health 63.52 27.694 Physical Functioning 71.67 28.723 Role limitations due to physical health 62.04 43.506 Energy/Fatigue 53.08 28.812 Pain 72.5 24.789 Emotional well‐being 72.31 20.612 Role limitations due to emotional health 70.37 42.701 Social Functioning 79.81 20.334 ConclusionIn summary, our study was comprised of patients in the US who had undergone BPD/DS. Both, their physical and mental scores were close to the population norm.

Totally robot-assisted biliary pancreatic diversion with duodenal switch: single dock technique and technical outcomes.

The biliopancreatic diversion with duodenal switch (BPD/DS) requires operating in three different abdominal quadrants. Previous techniques have used either two docks or a hybrid technique in which the robot is used only to suture the duodeno-ileal anastomosis, while the rest of the operation was performed laparoscopically. Recently, a modification in technique has allowed all operative steps to be completed robotically with a single dock. The operative technique and its technical results are described. Operative technique is described. Baseline demographics, operative duration, length of stay, and adverse events (intraoperative, 30-days, and 1-year) of all primary totally robot BPD/DS cases are reported. From Nov. 2011 to Jan. 2014, 59 totally robotic BPD/DS operations were attempted. One was completed hybrid, and the rest were totally robotic. No robotic operation was converted to an open operation. Five trocars were placed, the small bowel was anchored to the anterior abdominal wall, and the robot was docked. Mean age was 44 ± 10 years with a mean preoperative BMI of 56 ± 9 kg/m(2). 69 % was female, and 71 % was Caucasian. Mean operative duration was 306 ± 80 min (60 min less than the hybrid technique). There were no mortality, leaks, venous thromboembolism, or bleeding requiring transfusion. Mean length of stay was 4.6 ± 4.3 days. Three patients were readmitted for nausea and vomiting. There was one superficial wound infection, and three patients needed reoperations in the first year, two for strictures, and one for debriding a suture abscess. All key technical components of the BPD/DS were performed with low morbidity and mortality with a single dock. Since the surgeon performed all key parts of the operation from the console, the need for experienced bedside assistance was minimized, resulting in shorter operative duration compared to the hybrid technique.

Complications from micronutrient deficiency following bariatric surgery

We report a case of clinically significant micronutrient deficiencies following biliary pancreatic diversion (BPD) surgery. Our patient was admitted to hospital six years after BPD surgery following a low impact humeral fracture complicated by postoperative wound infection. On presentation she complained of a widespread rash and loss of night vision. Laboratory testing confirmed hypoalbuminaemia, deficiencies of vitamins A, E and D and of the trace elements copper, zinc and selenium. Bone densitometry confirmed osteoporosis. The skin rash was thought to be due to zinc deficiency and improved with conservative measures and trace element replacement. Her night blindness resolved 48 hours after receiving high dose parenteral vitamin A. Six months later she was readmitted to our intensive care unit with wound dehiscence at her fracture site and clinical features of sepsis and encephalopathy. This case highlights the importance of devising treatment and follow-up guidance prior to surgery and multidisciplinary team involvement including the patient so that long-term metabolic complications are avoided.

Geltrude Mingrone: an insatiable curiosity

Geltrude Mingrone: an insatiable curiosity

Plasma insulin and glucose time courses after biliary pancreatic diversion in morbidly obese patients with and without diabetes

BackgroundThe exact mechanism for the dramatic effect of surgical procedures for obesity on type 2 diabetes remains unknown. MethodsFive diabetic morbidly obese patients and 5 nondiabetic morbidly obese patients undergoing biliopancreatic diversion were compared retrospectively. A 75-g trans-gastrostomy glucose tolerance test was administered on the fifth day postoperatively and a standard 75-g oral glucose tolerance test was performed on the seventh day postoperatively, with blood sampling for measuring plasma glucose and insulin levels at 0, 30, 60, 90, 120, and 180 minutes. ResultsAll 5 diabetic patients were shown, at the same time, still to have diabetes or an impaired glucose tolerance test when tested through the biliopancreatic limb but patients were normal when tested through the new alimentary channel. No significant difference was seen in the nondiabetic patients. ConclusionsBiliopancreatic diversion can completely normalize the glycemic cycle in type 2 diabetes patients in the week after the intervention, even before any significant weight loss has occurred. The surgical procedure itself, designed to exclude most of the stomach, duodenum, and part of the jejunum, directly affects carbohydrate homeostasis.

Biliary pancreatic diversion and laparoscopic adjustable gastric banding in morbid obesity: their long-term effects on metabolic syndrome and on cardiovascular parameters

BackgroundBariatric surgery is able to improve glucose and lipid metabolism, and cardiovascular function in morbid obesity. Aim of this study was to compare the long-term effects of malabsorptive (biliary pancreatic diversion, BPD), and restrictive (laparoscopic gastric banding, LAGB) procedures on metabolic and cardiovascular parameters, as well as on metabolic syndrome in morbidly obese patients.Methods170 patients studied between 1989 and 2001 were called back after a mean period of 65 months. 138 patients undergoing BPD (n = 23) or LAGB (n = 78), and control patients (refusing surgery and treated with diet, n = 37) were analysed for body mass index (BMI), blood glucose, cholesterol, and triglycerides, blood pressure, heart rate, and ECG indexes (QTc, Cornell voltage-duration product, and rate-pressure-product).ResultsAfter a mean 65 months period, surgery was more effective than diet on all items under evaluation; diabetes, hypertension, and metabolic syndrome disappeared more in surgery than in control patients, and new cases appeared only in controls. BPD was more effective than LAGB on BMI, on almost all cardiovascular parameters, and on cholesterol, not on triglyceride and blood glucose. Disappearance of diabetes, hypertension, and metabolic syndrome was similar with BPD and with LAGB, and no new cases were observed.ConclusionThese data indicate that BPD, likely due to a greater BMI decrease, is more effective than LAGB in improving cardiovascular parameters, and similar to LAGB on metabolic parameters, in obese patients. The greater effect on cholesterol levels is probably due to the different mechanism of action.

Delayed Rupture of a Splenic Artery Pseudoaneurysm After Biliopancreatic Diversion

Splenic artery pseudoaneurysm (SAP) is a known but rare complication of pancreatitis and blunt abdominal trauma. SAP caused by operative trauma has been rarely reported. We present a patient who presented with massive upper gastrointestinal (GI) bleed in shock. On exploratory laparotomy, a SAP was diagnosed. He must have sustained injury to his splenic artery while undergoing reinforcement of sleeve gastrectomy during an open biliary pancreatic diversion procedure 2 years back. Alternatively, the prolene suture might have eroded into the splenic artery to cause the SAP. Literature on iatrogenic SAP is reviewed. SAP should be considered in patients with history of foregut surgery with GI bleed and equivocal endoscopic findings.

Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique

Minimally invasive surgical techniques decrease the length of hospitalization and the morbidity for general surgery procedures. Application of minimally invasive techniques to obesity surgery had previously been limited to stapled techniques used primarily for the Roux-en-Y gastric bypass and laparoscopic band placement. The authors present the technique for totally intracorporeal robotically assisted biliary pancreatic diversion with a duodenal switch (BPD/DS) using five ports. After development of the technique in animal and human cadaver models, the da Vinci robot was first used in October 2000 to perform BPD/DS using five ports and a totally intracorporeal technique. Patient selection was based on standard surgery guidelines for the morbidly obese. This technique was applied for 47 patients with a mean body mass index (BMI) of 45 kg/m2 and a mean age of 38 +/- 10 years. The median operating time was 514 min (range, 370-931 min). The median operative time for the last 10 patients was 379 min (range, 370-582 min). Three patients underwent conversion to open surgery, and four patients experienced postoperative leaks with no mortality. The safety, feasibility, and reproducibility of a minimally invasive robotic surgical approach to complex abdominal operations such as BPD/DS is demonstrated. The BPD/DS allows for a sutured bowel anastomosis similar to the open technique using a minimal number of small access ports.

The role of robotic surgery in morbid obesity.

The purpose of this review was to form a collaborative opinion regarding the utility of robotic technology, specifically the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), for bariatric surgery. Eleven surgeons are currently using the da Vinci system to perform laparoscopic bariatric surgery. The surgeons were queried about the type of robotic bariatric surgery and number of cases performed, complications, and any available outcomes data. They were also asked to give their opinion of the current state of robotic bariatric surgery. Ten of the 11 surgeons responded. Six surgeons are currently using the system for Roux-en-Y gastric bypass, three for laparoscopic adjustable gastric banding, and three for biliary pancreatic diversion. Robotic technology is successfully being applied to bariatric surgery in a few advanced minimally invasive surgery centers throughout the United States.

Robotic assisted biliary pancreatic diversion with duodenal switch

Biliopancreatic diversion with duodenal switch is considered a technically more demanding bariatric operation. We endeavor to demystify this procedure by reviewing the technical points of the operation. In addition, we will discuss the history and evolution of the BPD-DS as well as detail our perioperative management. A better understanding of this procedure may help surgeons interested in developing their skill set or aid surgeons who will care for BPD-DS patients after surgery.

Current practices in the prophylaxis of venous thromboembolism in bariatric surgery.

Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of perioperative venous thromboembolism. Due to its clinically silent nature, primary prevention is the key to reduce morbidity and mortality. There is no clear consensus in the literature regarding the optimum approach to minimize this preventable phenomenon. Members of the American Society for Bariatric Surgery were surveyed regarding their current practices in the prophylaxis of venous thromboembolism in their bariatric patients. 31% of the members completed the survey. 62% were in private practice, and 38% practiced in an academic hospital. The number of bariatric surgeries done per year ranged from 5 to 325, with a mean of 85 procedures per member. The gastric bypass was the most commonly performed procedure at 61.7%, followed by vertical banded gastroplasty at 23.3%, biliary pancreatic diversion at 9.3%, laparoscopic gastroplasty at 4.0%, laparoscopic gastric bypass at 1.6%, and horizontal banded gastroplasty at 0.1%. 86% felt that their bariatric patients were at high risk for developing deep vein thrombosis (DVT) and pulmonary embolism (PE) with a self-reported incidence of 2.63% and 0.95%, respectively. 48% had at least one death due to PE. Routine prophylaxis is used by over 95% of members. 62% ranked the various methods of prophylaxis from most preferred to least preferred, while 38% used a combination of 2 or more prophylactic methods simultaneously. Low-dose heparin was the most preferred prophylaxis by 50% of members, followed by intermittent pneumatic compression stockings at 33%, low molecular weight heparins at 13%, and other methods at 4%. Over 83% indicated that safety with few complications, ease of administration, and effectiveness were the most important criteria for selecting their most preferred prophylactic method. Only 2% routinely performed testing to rule out venous thromboembolism before discharge, and 11% routinely discharged patients with prophylaxis. The prevailing opinion of members of the American Society for Bariatric Surgery is that morbidly obese patients are at high risk for developing perioperative venous thromboembolism. A vast majority routinely use prophylaxis. Despite these measures, fatal PE is still widespread. A lack of consensus in the method of prophylaxis was seen. A multicentric randomized controlled study comparing the efficacy of the various methods of prophylaxis will be the only manner to determine the best prophylaxis and its usefulness. This study will be costly and probably not warranted due to the low incidence of this condition in the morbidly obese patient.