Biliopancreatic Diversion, Duodenal Switch (BPD-DS)

The original version of this procedure (without the duodenal switch) was developed by Dr. Scopinaro in Italy. This operation creates an impairment of nutrient absorption, called malabsorbtion, as the primary factor in weight loss. This is done by removing about two-thirds of the stomach, and arranging the small intestine so that the section where food mixes with digestive juices is fairly short. In the U.S., the Scopinaro procedure has been modified to something called the Biliopancreatic Diversion – Duodenal Switch (BPD-DS), which is sometimes done laparoscopically. These operations may be more effective in achieving excellent weight loss in the extremely obese, but bring with them a higher rate of true malnutrition, which is very rare for those who undergo standard Gastric Bypass. The BPD-DS is represented at the right.

“Long Limb” Gastric Bypass

Surgeons are working to capitalize on the weight loss experience of the BPD operations above without creating malnutrition. They use the tiny stomach pouch that has established success in the standard Gastric Bypass (GBP), and make the small bowel connection much further downstream (the Roux limb of small bowel is longer) so that food and digestive juices mix for a shorter distance in the gut. In our opinion, any GBP with a Roux limb less than 225 cm is NOT a long limb GBP, and it is not always a long limb at 225 cm. In order to do a true long limb GBP, it is necessary for the surgeon to measure backward from the ileo-cecal valve (where the small intestine connects with the colon). The long limb GBP procedure is reported to result in more weight loss than the “standard” GBP, but (similar to the BPD-DS) there is a somewhat higher rate of electrolyte (blood salt) disturbances and other nutritional complications. We are considering the role of such modifications in our patients who are super obese (BMI of greater than 60).

Fobi modification of the Gastric Bypass

Dr. Fobi and others have chosen to address the problem of inadequate weight loss after GBP, which occurs in about 15% of patients, by placing a firm ring of synthetic material around the tiny stomach pouch just above the gastro-jejunal anastomosis. The idea is to provide very strict lifelong restriction to the amount and the physical density of food intake, in distinction to the progressive increase in tolerance to solids that patients experience after a GBP where the pouch is not reinforced. The use or not of a reinforcing ring in this area is one of the most deeply divisive issues in bariatric surgery today. At this time no solid comparative data exists. In our practice we have not routinely reinforced the pouch or anastomosis with any synthetic material, and our patients in general achieve excellent weight loss with good tolerance of healthy food.

Vertical Banded Gastroplasty (VBG)

This operation emphasizes the volume restriction aspect of calorie control, by creating a tiny stomach pouch that exits into the lower stomach through a small fixed outlet that is reinforced by a permanent calibrated band on the stomach outlet. The operation was devised by Dr. Mason, one of the original GBP surgeons, as he sought to devise the safest and most straightforward operation for morbid obesity. The VBG was once the most frequently performed operation for morbid obesity in the U.S. However it is now an outmoded procedure because long term studies have demonstrated that it does not maintain weight loss as well as the Roux-en-Y GBP. The VBG also requires a high rate of revision surgery. Last, the decrease in operative risk that Dr. Mason hoped for when he devised the VBG has not materialized. The Vertical Banded Gastroplasty does not have a role in current surgical practice.

Jejuno-Ileal Bypass (JIB)

This is the operation that sticks in the minds of many physicians who disapprove of bariatric surgery as a field. This is a surgically simple procedure that bypasses most of the small bowel absorptive surface. The operation was first developed in the 1950s, and was the first available surgical therapy for morbid obesity. It became very common in the mid to late 70s because it was technically easy to do, created very large amounts of weight loss, and required minimal effort on the part of the patients. Unfortunately, years after the operation many patients developed kidney or liver disease, and some progressed to die as a delayed result of the operation. The JIB is not done any more, and patients who have undergone this operation should have regular follow-up with a physician. Reversal of the JIB is sometimes needed, but not automatic; this is considered individually with each patient.

Gastric Pacing

Some experiments show that if a low-level shock is applied to the correct location on the stomach, then the nerves that stimulate hunger will be suppressed. Placement of the electrical leads onto the gastric wall is minimally invasive and has a low degree of surgical risk. The gastric pacer is not yet generally available, but clinical trials show that, for many patients, it can produce weight loss that is better than medication treatment. We anticipate this may be a useful procedure for patients who do not need to lose a lot of weight, or to stimulate some weight loss in preparation for one of the standard weight loss procedures.

Revision Gastric Bypass

This procedure revises the stomach anatomy from a different weight loss procedure to a Gastric Bypass.

Source: sabariatric.com, September 15, 2009