Biliopancreatic Diversion With a Duodenal Switch

Walter J. Pories, MD

Disclosures

March 08, 2001

Question

Is biliopancreatic diversion with duodenal switch an approved procedure for the treatment of morbid obesity? If so, what are the indications, success rate, and morbidity rate?

Response from Walter J. Pories, MD

The biliopancreatic diversion with duodenal switch is a relatively new procedure that has yet to be shown as safe and effective in long-term studies.[1] Proponents state that the operation is technically easier than gastric bypass and is associated with an equal risk of complications (1% to 10%) and mortality.[2,3,4] Advocates also report weight loss rates ranging from 65% to 80% of excess initial weight and deny that malnutrition is a clinically significant problem.[2]However, anemia, hypocalcemia, and hypoalbuminemia have been reported in patients undergoing this procedure.[3] Furthermore, diarrhea and halitosis are common side effects.

My major concern is that the experience with this procedure is limited to the short term. I have not been able to find a long-term study with an acceptable follow-up rate. Accordingly, my bias is that the enthusiasm for the procedure is premature and may not be well founded at this time.

The indications for this operation are the same as for a gastric bypass. Patients with a body mass index (BMI) > 40 who do not have associated comorbidities and patients with a BMI > 35 who have significant illnesses associated with the obesity are good candidates for this procedure. In short, we are more likely to operate on patients with a lower BMI if they have comorbidities such as sleep apnea, diabetes, hypertension, and pseudo-tumor cerebri. Contraindications for this surgery include uncontrolled depression or other psychologic disease, substance abuse, alcoholism, failure to agree to a long-term follow-up, inadequate intelligence to understand the operation, and patients with unrealistic expectations.

Based on our experience and reports in the literature on other surgical procedures for the treatment of morbid obesity, I am also concerned about the long-term effects of this "malabsorptive operation," especially in regard to deficiencies of B12, B6, iron, and folic acid.

Please do not interpret my remarks as a condemnation of the procedure. It may turn out to be a fine alternative to gastric bypass. At the present time, however, I and many other bariatric surgeons consider the procedure experimental, interesting, and perhaps even promising. Accordingly, I believe that until we have better data on its efficacy and safety, the biliopancreatic diversion with duodenal switch procedure should be performed only at institutions that are conducting rigorous clinical trials.

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