**5. Biliopancreatic diversion with duodenal switch**

The biliopancreatic diversion with duodenal switch (BPDDS) procedure is often referred to as DS surgery. This technique is a modification of the original biliopancreatic diversion defined by Scapinaro et al. [18, 19] in 1979. The three main components of this technique are pylor-protected gastric tube formation, distal ileoileal anastomosis, and proximal duodenoileal anastomosis (**Figure 4**). Three intestinal limbs are formed in this method. Food passes through one limb (Roux limb), the fluid of the digestive organs (bile) from one limb (biliopancreatic limb), and food and digestive fluids from the common limb. While the small curvature of the stomach is removed and the pylor is preserved in biliopancreatic diversion with duodenal switch surgery, the pylor was also removed by distal gastric resection in the original surgery of Scapinaro. The gastric pouch is 250 ml in size, and malabsorption is created by Roux-en-Y reconstruction of the distal intestines in both techniques. The main limb length is 50–100 cm and the alimentary limb 250 cm, and the biliopancreatic limb is connected to a location 100 cm proximal to the ileocecal valve. Since the pylor is preserved in the biliopancreatic diversion with duodenal switch technique, complications such as loop formation, dumping, and marginal ulcers are less common. The method can also be performed in stages to reduce complications. If adequate weight loss cannot be provided with laparoscopic sleeve gastrectomy, the biliopancreatic diversion with duodenal switch procedure is performed 6–12 months later. Glucose control in severely obese patients with type 2 diabetes is better with biliopancreatic diversion with duodenal switch surgery than medical treatment. Although the technique is well described and provides effective weight loss, biliopancreatic diversion with duodenal switch procedure is not commonly used. While early weight loss is provided by the sleeve gastrectomy, impaired fat absorption is responsible for the long-term weight loss. The decrease in ghrelin and increase in peptide YY after the biliopancreatic diversion with duodenal

**81**

**Author details**

Turkey

Tülay Diken Allahverdi

*Treatment Options in Morbid Obesity*

morbid obesity surgery.

*DOI: http://dx.doi.org/10.5772/intechopen.88823*

switch procedure also increase weight loss. Mechanical changes as well as hormonal changes may therefore be responsible for the weight loss in this technique [20]. The surgical mortality rate is around 1%. The patients require high doses of vitamin and mineral supplementation after the surgery. There is significant improvement in the comorbid conditions after biliopancreatic diversion with duodenal switch. While 92% of diabetics and 90% of those with sleep apnea show full resolution, 80% of asthmatics decrease the dose of their medication [21, 22]. Close follow-up and vitamin supplements are necessary to prevent postoperative malnutrition. This method can be recommended as a revision method for severely obese patients, those who cannot exercise and stick to a diet after restrictive methods, and after any previous unsuccessful surgeries. This method should not be performed in those who cannot be monitored closely, who do not have adequate income for vitamin support, and previously suffered from calcium, iron, vitamin, and mineral deficiencies.

Vertical banded gastroplasty, laparoscopic mini-gastric bypass (LMGB), and laparoscopic large curvature plication (LLCP) are methods that are rarely used in

University of Kafkas, School of Medicine, Department of General Surgery, Kars,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: drtulaydiken@hotmail.com

provided the original work is properly cited.

**Figure 4.** *Biliopancreatic diversion and duodenal switch.*

#### *Treatment Options in Morbid Obesity DOI: http://dx.doi.org/10.5772/intechopen.88823*

*Obesity*

the surgery. The complication and mortality rate are less than the absorption-disrupting techniques [7]. Prolapse (3%), displacement (<3%), band erosion (1–2%), and port and tube complications (5%) can be seen. Although a high reoperation ratio is the major disadvantage, the technique is still popular in the USA [17].

The biliopancreatic diversion with duodenal switch (BPDDS) procedure is often referred to as DS surgery. This technique is a modification of the original biliopancreatic diversion defined by Scapinaro et al. [18, 19] in 1979. The three main components of this technique are pylor-protected gastric tube formation, distal ileoileal anastomosis, and proximal duodenoileal anastomosis (**Figure 4**). Three intestinal limbs are formed in this method. Food passes through one limb (Roux limb), the fluid of the digestive organs (bile) from one limb (biliopancreatic limb), and food and digestive fluids from the common limb. While the small curvature of the stomach is removed and the pylor is preserved in biliopancreatic diversion with duodenal switch surgery, the pylor was also removed by distal gastric resection in the original surgery of Scapinaro. The gastric pouch is 250 ml in size, and malabsorption is created by Roux-en-Y reconstruction of the distal intestines in both techniques. The main limb length is 50–100 cm and the alimentary limb 250 cm, and the biliopancreatic limb is connected to a location 100 cm proximal to the ileocecal valve. Since the pylor is preserved in the biliopancreatic diversion with duodenal switch technique, complications such as loop formation, dumping, and marginal ulcers are less common. The method can also be performed in stages to reduce complications. If adequate weight loss cannot be provided with laparoscopic sleeve gastrectomy, the biliopancreatic diversion with duodenal switch procedure is performed 6–12 months later. Glucose control in severely obese patients with type 2 diabetes is better with biliopancreatic diversion with duodenal switch surgery than medical treatment. Although the technique is well described and provides effective weight loss, biliopancreatic diversion with duodenal switch procedure is not commonly used. While early weight loss is provided by the sleeve gastrectomy, impaired fat absorption is responsible for the long-term weight loss. The decrease in ghrelin and increase in peptide YY after the biliopancreatic diversion with duodenal

**5. Biliopancreatic diversion with duodenal switch**

**80**

**Figure 4.**

*Biliopancreatic diversion and duodenal switch.*

switch procedure also increase weight loss. Mechanical changes as well as hormonal changes may therefore be responsible for the weight loss in this technique [20]. The surgical mortality rate is around 1%. The patients require high doses of vitamin and mineral supplementation after the surgery. There is significant improvement in the comorbid conditions after biliopancreatic diversion with duodenal switch. While 92% of diabetics and 90% of those with sleep apnea show full resolution, 80% of asthmatics decrease the dose of their medication [21, 22]. Close follow-up and vitamin supplements are necessary to prevent postoperative malnutrition. This method can be recommended as a revision method for severely obese patients, those who cannot exercise and stick to a diet after restrictive methods, and after any previous unsuccessful surgeries. This method should not be performed in those who cannot be monitored closely, who do not have adequate income for vitamin support, and previously suffered from calcium, iron, vitamin, and mineral deficiencies.

Vertical banded gastroplasty, laparoscopic mini-gastric bypass (LMGB), and laparoscopic large curvature plication (LLCP) are methods that are rarely used in morbid obesity surgery.
