Scopinaro Biliopancreatic Diversion Research Articles

Long-term comparative study on open versus laparoscopic biliopancreatic diversion.

To date, bariatric surgery has been proposed as the most effective treatment to resolve morbid obesity, a multifactorial chronic disease with an epidemic and increasing tendency. The purpose of this study was to determinate the impact of the laparoscopy on weight loss parameters in morbid obese patients who underwent surgery according to Scopinaro's biliopancreatic diversion (BPD) and evaluate early and late complications related to the open and laparoscopic approach of this technique. This is a longitudinal retrospective study in consecutive patients undergoing BPD due to morbid obesity between 1999 and 2015. From 2006 the laparoscopic technique was introduced in our group for obesity surgery. In both approaches, open and laparoscopic surgery, the procedure performed consists of a proximal gastric section with a long Roux-en-Y reconstruction. The following variables were assessed in the two groups: intervention duration (min), estimated blood loss (mL), conversions to open approach (%), preoperative stay, postoperative and global stay (days). Complications were divided into early and late postoperative complications. The early surgical complications were catalogued according to the Clavien-Dindo classification. Two hundred seventy-seven patients were consecutively enrolled and divided in two groups: open BPD and laparoscopic BPD. There were no significant differences in the comparison of the two groups and the mean age was 43.9years (19-60) with a mean BMI of 52.5kg/m2. A statistically significant reduction was observed in favor of the laparoscopic group with respect to the reduction in hospital stay and in the incidence of incisional hernia as a late complication. No statistically significant difference were found with respect to early postoperative complications. Laparoscopic BPD is a safe technique that allows a shorter hospital stay compared to open surgery and that allows a drastic reduction in the incidence of incisional hernias.

Revisional surgery in severe nutritional complications after bariatric surgical procedures: report of four cases from a single institution and review of the literature.

bariatric surgery is currently the only treatment that leads to long-term and sustained weight loss and decreased morbidity and mortality in morbidly obese individuals. Roux-en-Y bypass causes weight loss by restricting food intake associated with reduced intestinal absorption, in addition to multiple endocrine and satiogenic effects. Biliopancreatic diversion promotes weight loss mainly due to poor absorption of the nutrients ingested. Both procedures exclude parts of the gastrointestinal tract. to describe four cases of revisional surgery after primary bariatric surgery, due to serious nutritional complications, and to review the literature regarding this subject. a retrospective analysis of patients of Unicamps bariatric center database and review of the literatures were performed. four patients were identified, 2 women and 2 men, with a mean age of 48 years. The mean body mass index before revisional surgery was 23.7 kg/m2. Three patients underwent Scopinaro biliopancreatic diversion, and onde patient underwent Roux-en-Y gastric bypass. The revisional surgeries were revision, conversion, and reversion. One patient died. For the review of the literature 12 articles remained (11 case reports and 1 case series). Another five important original articles were included. fortunately, revision surgery is rarely necessary, but when indicated it has increased morbidity, It can be revision, reverion or conversion according to the severity of the patient and the primary surgery performed.

Remission of female sexual dysfunction in morbidly obese female patients with the Scopinaro procedure

BackgroundThe prevalence of obesity has increased in Spain in recent years. Obese women are at increased risk for sexual dysfunction, and important remission of this condition has been previously reported with bariatric surgery. ObjectivesThe major aim of this study was to assess the effects of the Scopinaro biliopancreatic diversion on female sexual dysfunction (FSD) using a validated Female Sexual Function Index (FSFI). MethodsEighty sexually active women with morbid obesity and with FSD underwent surgery. All patients completed the FSFI before surgery, as well as 6 and 12 months after surgery. The FSFI evaluates the sexual function using 6 items: desire, arousal, lubrication, orgasm, satisfaction, and pain. We used a<26.5 cut-point to assess the presence of FSD. This cut-point is used as a standard for the investigation. ResultsBefore surgery, all patients had FSD (mean 19.9±1.6). Six months after surgery, the FSD improved (mean 25.4±4.1; P<.001), and 12 months after surgery FSD resolved in most of the patients (mean 30.4±3.5; P<.001). All of the parameters evaluated by the FSFI (P<.001) improved significantly in all patients. ConclusionFSD improved significantly 6 months after biliopancreatic diversion among obese women with preoperative sexual dysfunction and continued improving up to 12 months later.

Biliopancreatic diversion with transient gastroplasty and duodenal switch: Long-term results of a multicentric study

Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS. Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments. The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null. Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Duodenal switch: a comprehensive view of a biliopancreatic diversion in metabolic surgery

The duodenal switch is a technique of Bariatric Surgery that modifies the Scopinaro biliopancreatic diversion, described by Hess and Marceaux in 1988, supported by the original description that made De Meester for the treatment of gastroesophageal reflux recurrent disease. It is a complex technique, probably the most laborious of all bariatric procedures until now known, which can and must be done by laparoscopy and consisting of several surgical steps. It involves the performance of a vertical gastrectomy with bougies of different diameter and a bypass Roux-en-Y into the duodenum, with different lengths limbs. Duodenoileal anastomosis is the most difficult and different techniques are described. It must be accompanied by closure of the defects and in most of the cases of an appendectomy and cholecystectomy. There have been greater than the gastric bypass Roux-en-Y in operating time, hospitalization, morbidity and mortality. Reported complications are up a 24% of the cases, early or late, these are metabolic one and easily controllable, so a good index of satisfaction with low percentage of review and no more than 1.5% mortality. Achieved a decrease of 70% of excess weight in the long term, with improvement in all co-morbidities reaching around a 95% diabetes and metabolic control of the dyslipidemias. Given the good results it should be seen as a technique of choice for the treatment of the obese patient with metabolical disorder.

Bleeding from duodenal ulcer in a patient with bilio-pancreatic diversion

Scopinaro's bilio-pancreatic diversion is considered as an acceptable malabsorptive surgical approach for the treatment of morbid obesity. We describe a case of acute recurrent gastro-intestinal bleeding in a patient with a previous Scopinaro's bilio-pancreatic diversion. At the first admission in our department, gastroscopy, colonoscopy, contrast-enhanced computerized tomography and angiography resulted negative for active bleeding. Hypovolemic shock indicated laparotomy and an intraoperative enteroscopy performed through a small enterotomy showed an ulcerative perforation sourced in an ischemic portion of a distended duodenal stump, with a bleeding branch of gastro-duodenal artery at the bottom. Hemorrhage was stopped with stitches. Two years later a new episode of duodenal bleeding associated with severe malnutrition occurred. A covered chronic ischemic perforation sustained by duodenal distension due to biliopancreatic limb sub-obstruction appeared to be the most probable etiology of the recurrent duodenal bleeding. The patient underwent again to laparotomy and adhesiolysis; hemorrhage was stopped by means of ligation of gastroduodenal artery and bilio-pancreatic diversion was converted into a standard Roux-en-Y gastroenterostomy with an entero-entero anastomosis 40cm from the Treitz ligament in order to restore an anatomo-functional condition guaranteeing normal absorption and intestinal transit. After Scopinaro's bilio-pancreatic diversion duodenal bleeding can represent a rare serious presentation of biliopancreatic limb obstruction; because of the complex anatomical reconstruction performed during this intervention, the duodenum results unavailable during upper gastro-intestinal endoscopy, and if a duodenal bleeding is suspected laparotomy followed by enteroscopy represents an effective diagnostic approach.

Roux-en-Y Reconstruction at Greater Curvature in Biliopancreatic Diversion: Effects on Early Postoperative Functional Recovery

Delayed gastric emptying after distal gastrectomy and reconstruction of alimentary tract with a gastroenteric anastomosis can significantly influence early and late postoperative course and the length of hospital stay. The purpose of this study was to compare the effect on postoperative functional recovery of two different Roux-en-Y reconstructions: at the gastric greater curvature and at the transected gastric staple line in the Scopinaro's biliopancreatic diversion. We conducted comparative study; 80 patients were enrolled and divided in two groups: group A (RY-GC) and group B (RY-SL) with 40 patients in each group. We compared the early postoperative functional recovery for both groups measuring four parameters: gastric stasis indicated with the volume of the gastric fluid collected per 24 h, day of removal of the nasogastric tube, day of starting the oral intake, and day of hospital discharge. There was statistically significant (p < 0.001) reduction in gastric fluid volume in favor of the RY-GC group starting from the first postoperative day resulting in earlier removal of nasogastric tube with earlier starting of oral feeding than RY-SL group, with no symptoms of stasis required nutrition suspension; while three patients in RY-SL group experienced persistence of nausea and vomiting and needed nutrition suspension for several days. There was statistically significant (p < 0.001) reduction in the hospital stay for RY-GC group. Roux-en-Y reconstruction at the greater curvature ensures a rapid functional recovery with early hospital discharge. The use of stapler devices made this method easier and safer and no complications have arisen with mechanical anastomoses.

Vitamin D Receptor Polymorphisms in Secondary Hyperparathyroidism After Scopinaro's Biliopancreatic Diversion

Secondary hyperparathyroidism is a frequent metabolic complication of bariatric surgery. Individual differences in calcium absorption determine chronic secondary hyperparathyroidism after biliopancreatic diversion in half of the patients who have normal levels of 25-hydroxyvitamin D. We aimed to evaluate if certain vitamin D receptor polymorphisms may be responsible for the latter. Cases and controls study including 57 patients after biliopancreatic diversion with a mean serum 25-hydroxyvitamin D above 20ng/mL, separated into those with secondary hyperparathyroidism (n = 26, cases) and those without it (n = 31, controls). Genotyping for restriction-length-fragment polymorphisms of the vitamin D receptor gene was carried out for FOK1, BSM1, APA1, and TAQ1, and haplotype structure was also constructed. There were no differences in the allelic or genotypes distribution of the four studied polymorphisms between patients and controls (P = 0.352 and P = 0.301 for FOK1, P = 0.733 and P = 0.924 for BSM1, P = 0.974 and P = 0.992 for APA1, and P = 0.995 and P = 0.928 for TAQ1, respectively). Haplotype analysis showed no differences between patients and controls (P = 0.495 for BAT, P = 1.000 for BAt, P = 0.508 for Bat and P = 0.924 for bAT haplotypes, respectively). Furthermore, haplotypes were not associated with serum PTH levels or with the ratio between serum PTH and 25-hydroxyvitamin D levels. Chronic secondary hyperparathyroidism after biliopancreatic diversion in patients with normal levels of 25-hydroxyvitamin D is not dependent on vitamin D receptor gene polymorphisms.

Laparoscopic Versus Open Biliopancreatic Diversion: A Prospective Comparative Study

Bariatric surgery is playing an increasingly important role in our society. The surgical approach should be chosen in consistent with the patients' problem. The purpose of this study was to compare surgical outcomes in patients who underwent laparoscopic Scopinaro's biliopancreatic diversion (BPD) versus open BPD in our institute experience. Eighty patients were enrolled and divided in two groups: laparoscopic group (VL) and open group (OP), with 40 patients in each group during two calendar years 2006-2007. We performed the same technique for both groups using the same staplers for anastomosis, with the same measurements for alimentary and common limbs in both groups. We compared the following variables in the two groups: operative time, intra and early postoperative complications, postoperative pain, consumption of analgesics, recovery of intestinal function, days to removal of NG tube and start of oral intake, hospital stay, and late complication-incisional hernia incidence. We found statistically significant reduction in favor of laparoscopic group regarding reduction in postoperative pain, consumption of analgesics, incidence of incisional hernia, operative time, and hospital stay-with early removal of NG tube and early oral intake. We did not find any statistically significant difference regarding intra, immediate and early postoperative complications and recovery of intestinal functions. Laparoscopic BPD is a safe technique; has good results without affecting the duration of the intervention; and ensures less postoperative pain with rapid functional recovery, less hospital stay, and drastic reduction of incisional hernia incidence.

Changes in lipid profile and insulin resistance in obese patients after Scopinaro biliopancreatic diversion

Obesity is associated with many cardiovascular risk factors. The aim of this study is to evaluate the effect of bariatric surgery (BS) in lipid profile and insulin resistance in obese patients. We studied changes in lipid parameters glucose, insulin, and insulin resistance (IR) before biliopancreatic diversion and 3, 6, 12, 18, and 24 months after surgery, in 115 obese patients divided in two groups: diabetics (DM) and nondiabetics (non-DM). In both groups, all parameters significantly decreased at 3 months; however, high-density lipoprotein cholesterol levels (HDL-c) and total cholesterol (TC) to HDL-c ratio decreased up to 6 months. At baseline, in DM, we found a negative correlation between body mass index (BMI) and TC to HDL-c ratio and glucose with HDL-c and homeostasis model assessment (HOMA) with BMI and a direct correlation between glucose with TC to HDL-c ratio and glucose with triglycerides. In non-DM, no correlations were found. Comparing both groups for each parameter, we found significant differences at basal levels for glucose, HOMA, triglycerides (TG), and TG to HDL-c ratio. Changes between basal levels and 1 year after surgery were significantly different in glucose and HOMA. BS offers excellent results in weight reduction and significantly improves IR, diabetes, and the lipid profile, decreasing global cardiovascular risk.

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

Short-, Mid- and Long-Term Results of Larrad Biliopancreatic Diversion

In an effort to reduce the complications of Scopinaro's biliopancreatic diversion (BPD), in 1989 we introduced the modification of lengthening the alimentary channel preserving most of the jejunum-ileum, by creating a short biliopancreatic limb (50 cm) and maintaining 50 cm of common limb (Larrad 50-50 BPD). Of 343 patients who consecutively underwent Larrad 50-50 BPD surgery, 325, 194 and 65 patients were evaluated at 2, 5 and 10 years after surgery, respectively, in terms of surgical morbidity, mortality, metabolic sequelae and weight. Mean age was 41.2 years (range 17-62), mean initial weight 151.2 kg (range 97-260), and BMI was 52.2 kg/m2. Maximum follow-up was 120 months. Mortality was 0.87% and surgical morbidity 7.6%. There were no cases of suture dehiscence, peritonitis or stomal stenosis. Percent excess weight loss (%EWL) stabilized 2 years after surgery and at 10 years was 77.8 +/- 11.2% for morbidly obese patients and 63.2 +/- 11.8% for super-obese patients. The main complications were 43.8% clinical incisional hernia, 2.5% severe diarrhea, 10.8% mild diarrhea and 9.2% constipation. 30% experienced anemia and/or iron deficiency, and 3% required iron parenterally or lifelong zinc supplements. 28% showed preoperative PTH elevation and 30% vitamin D deficiency; these values postoperatively increased to 45% and 43% respectively. Both these alterations were resolved using supplements, although 12% needed increased doses of vitamin D. The incidence of severe hypoproteinemia was 0.29%. No patient required surgical reversal. When independently evaluated, failure rates in terms of insufficient weight loss were 9% at 5 years and 11.3% at 10 years for morbidly obese, and 12.2% and 14% for super-obese patients respectively. According to the BAROS questionnaire, 75% of surgery outcomes were excellent or very good, 18% good, 5% fair and 2% failures. After 2, 5 and 10 years, Larrad's BPD has offered excellent results in terms of weight loss and quality of life, a low rate of metabolic sequelae, including a hypoproteinemia rate < 0.5%, and a revision surgery rate 0%.

Parathyroid Hormone and Bone Marker Levels in Patients with Morbid Obesity Before and After Biliopancreatic Diversion

Scopinaro biliopancreatic diversion (BPD) is associated with malabsorption of calcium and vitamin D, which manifests as a secondary hyperparathyroidism (SHP) and may lead to osteopenia. 96 morbidly obese patients were studied (age 19-60 years, 23 men and 73 women, with mean initial BMI 53) following intervention by Scopinaro BPD. The change in iPTH levels, urine DPD, Pyrilinks-D of DPC and serum CTx were studied at 0, 3, 6, 12, 18 and 24 months after surgery. Postoperatively, they were given supplements of calcium and vitamin D3. The control group consisted of 67 non-obese women and 10 men. The iPTH levels gradually increased after BPD, with a substantial difference compared to presurgery levels at month 6. In spite of the calcium and vitamin D supplements, 77% of the patients with presurgery SHP did maintain high levels of iPTH after 2 years. The percentage of SHP among the patients with normal pre-surgery iPTH was 58%. The basal figures of DPD/cre were significantly higher than in the control group, 9.06 (4.6-13.5) nM/mMcre vs 3.9 (2.8-5.6) in men and 6.75 (5.4-7.9) vs 7.67 (3.3-11.6) in women, but not CTx, 0.24 (0.02-0.89) vs 0.22 (0.07-0.55). After the operation, there was a noticeable increase which persisted at 2 years. There was a lack of correlation between the levels of iPTH and the bone resorption markers, i.e. the first ones decreased from month 6 in men and from month 12 in women, while the levels of iPTH continued to increase. In obese patients, we found no correlation between iPTH levels and BMI. Supplements of calcium and vitamin D did not prevent the appearance of SHP following BPD. The patients with high pre-surgery iPTH levels have a higher risk of malabsorption of calcium and vitamin D. Following malabsorptive bariatric surgery, there is an increase in bone resorption, which results in DPD and CTx increase. Those markers do not correlate with iPTH, and this may suggest that there is a phenomenon of bone reshaping parallel to the loss of weight.

Hand-sewn laparoscopic duodenal switch

t t t a g c The duodenal switch (DS) is an alternative operation to he Scopinaro biliopancreatic diversion. Hess and Hess [1] erformed the first case in March 1988 in 1 woman with a ody mass index (BMI) of 60 kg/m and a BMI of 29 kg/m 7 years later. Marceau et al. [2] published the first report on he procedure, followed by Baltasar et al. [3,4], who pubished additional series. Ren et al. [5] performed the first aparoscopic DS (LDS) in July 1999 and Baltasar et al. [6,7] ublished the second world experience. The LDS used in our technique is a laparoscopic sleeve astrectomy with 60-cm gastric volume and a pylorusreserving biliopancreatic diversion with a common chanel (CC) of 65 cm, an alimentary loop (AL) of 185 cm and he remaining biliopancreatic loop (BPL) as the proximal mall bowel.

Revision of Failed Vertical Banded Gastroplasty to Non-resectional Scopinaro Biliopancreatic Diversion: Early Experience

The most commonly performed revision operation following failed vertical banded gastroplasty (VBG) is Roux-en-Y gastric bypass, although revision to biliopancreatic diversion (BPD) with duodenal switch is now another common option. We describe the surgical technique for revision of a failed VBG to a non-resectional Scopinaro BPD in a series of patients, as well as the outcome in terms of complications and mean % excess weight loss (%EWL). A retrospective review was conducted on all patients who underwent revision to BPD at Mercy Bariatrics, Western Australia, between June 2001 and April 2005. This yielded 20 patients who had revision to BPD, 9 of whom had VBG as their initial operation. The mean %EWL was measured at regular intervals postoperatively (3, 6, 12, and 24 months). Mean %EWL at 12 and 24 months was 69.5 and 76.7, respectively. These results are comparable to %EWL after a primary BPD. Nutritional manifestations were found to be the most common of the minor complications. Our technique for revision of a failed restrictive operation to a non-resectional Scopinaro BPD is described. The preliminary results in terms of %EWL and complications are comparable to other revisional malabsorptive operations. Prospective randomized controlled trials are needed to further evaluate effects of revision to a non-resectional Scopinaro BPD and to ensure that the results (in terms of %EWL) are reproducible.

Gastro-ileal Stenosis and Gastroparesis after a Biliopancreatic Diversion

Biliopancreatic diversion (BPD) is a very effective bariatric operation particularly for super-obese patients (BMI > or = 50 kg/m(2)). We present the development of a stricture at the gastro-ileal anastomotic site, with subsequent dilatation and aperistalsis of the stomach in a female patient who had undergone a standard open Scopinaro BPD. The patient remained symptomatic and persisted in losing weight, despite endoscopic balloon dilatations of the stricture and surgical revision of the anastomosis. She finally underwent conversion to a standard Roux-en-Y proximal gastric bypass. We describe the development of the stricture after the use of the stapling gun, subsequent gastric dilatation and dysmotility.

Early Clinical and Surgical Results of Biliopancreatic Diversion

Scopinaro biliopancreatic diversion (BPD) for morbid obesity results in significant longterm weight loss and reduction or resolution of obesity-associated co-morbidities. The aim of our work was to describe the early results after BPD. 59 morbidly obese patients (BMI >40) underwent open BPD from December 2001 to December 2004. We analyzed a consecutive series of 19 patients who have been followed >4 months. We present the data of basal and early visits (2 and 4 months). Initial excess weight percent loss (IEW%L) was 5.2% at 2 months and 13.7% at 4 months. Glycemia, cholesterol, triglyceride levels and blood pressure improved at each visit. All parameters have significant differences from the basal values. 3 patients had sleep apnea syndrome, and overnight CPAP was able to cease in 2 patients by 4 months. 6 patients (31.5%) had albumin <2.5 g/dl, without clinical findings of malnutrition. Total calorie (857+/-79.8 cal/day) and protein (59.8+/-23 g/day) intakes at 4 months were low, with a low intake of multivitamins and oligoelements from food. There was no mortality in this series. Early postoperative morbidity was incisional hernia (21.1%), anastomotic leak (5.2%), wound infection (15.7%), intra-abdominal infection (5.2%), and intestinal obstruction (5.2%). BPD showed early effectiveness in weight loss and co-morbidity improvement. Calorie, protein, oligoelement and vitamin dietary intakes were below recommendations, so that strict multidisciplinary follow-up and supplementation to prevent or treat nutritional deficiencies are mandatory.

Impact of Age on Long-Term Complications after Biliopancreatic Diversion

The aim of the study is to evaluate the importance of age on the mid- and long-term results and complications after biliopancreatic diversion (BPD). Our study comprises 132 morbidly obese patients who underwent Scopinaro BPD from February 1995 to April 2001, with follow-up from 24 to 96 months. The patients, 53 males (40%) and 79 females (60%), with mean preoperative BMI 50.2 (35.4-81.5), and mean age 42 (20-65), were divided in 4 groups. Group A age 20-35, 43 patients; Group B age 36-45, 33 patients; Group C age 46-55, 31 patients and Group D age >55, 25 patients. Incidence of long-term specific complications after BPD were analyzed, including protein malnutrition, reversals, anastomotic ulcer, and incisional hernia. Mean postoperative BMI was similar in all Groups. After 60 months the following BMI values were observed. Group A 30.8, Group B 34.9, Group C 35.9, Group D 32. Incidence of long-term complications were not significantly different (chi(2)) in the 4 Groups, and were respectively: protein malnutrition 6.9%, 12.1%, 6.4%, 16.0%; anastomotic ulcer 11.6%, 9%, 6.4%, 16.0%; reversal 2.3%, 9.0%, 1.32%, 8.0%; ventral hernia 34.8%, 45.4%, 54.8%, 32.0%. From the preliminary results, it appeared that the incidence of the complications was higher in group D (>55 years old), whereas group C (46-55 years old) showed a lower complication rate. However, the prevalence of complications in all groups was not statistically different on chi(2) analysis. No age limit for bariatric surgery could be determined from the age ranges studied.

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.

Long-term Result of Treatment of Prader-Willi Syndrome by Scopinaro's Bilio-pancreatic Diversion. Study of Three Cases and the Effect of Dextrofenfluramine on the Postoperative Evolution.

The Prader-Willi Syndrome shortens the life of patients due to the morbid obesity which it entails. The compulsive hyperphagia associated with it makes a dietetic treatment or a gastroplasty difficult. This study presents the case histories of three patients suffering from the Prader-Willi syndrome who were operated on by means of a Scopinaro's bilio-pancreatic diversion. Following a marked reduction the first year, the weight loss stabilized and then tended to diminish. The observation of three cases which continued for two and a half to six years did not reveal any considerable metabolic problems. The deficiency of iron, vitamins D and B12 as well as folic acid had to be made up by supplementation. These results are comparable with the most favorable ones in the literature. Even if the effect on the weight loss is not spectacular, the operation manages to hold off the development of the obesity, inexorable for those with the Prader-Willi syndrome, and prevents lethal complications, without having notable side effects. Lifting coercive dietary measures improves the quality of life.