Transcript Laparoscopic Biliopancreatic Diversion with Duodenal

Biliopancreatic
Diversion/Duodenal Switch
Alfons Pomp, MD, FACS
Weill Medical College of Cornell
University
Disclosure

Consultant/speaker bureau
Covidien
Ethicon Endo Surgery
W.L.Gore Associates
CHUM Hotel-Dieu
I come to bury Cesar not to
praise him
I come to praise surgical
treatment of T2DM
Thanks

Dr Sharma 50% of type 2 diabetics CDA
guidelines target glucose
 Hypoglycemics lower Hb1Ac; at the price
of weight gain
 Dr Genest; weight gain is associated with
HTN and other problems “metabolic
syndrome” –cardiovascular risk
93% of diabetic patients ARE
NOT well controlled for
glucose, cholesterol and blood
pressure
Only 7% of adult diabetic patients from
NHANES (1999-2000) achieved:
• A1C <7%
• PA <130/80 mm Hg
• Total Cholesterol < 200 mg/dL
Saydah SH et al. JAMA. 2004
The Metabolic Syndrome:
Current Perspective
Body Size
 BMI
 Central Adiposity
Insulin Resistance
+
Hyperinsulinemia
Glucose
Metabolism
±
Glucose
intolerance
Uric Acid
Metabolism

Uric acid
  Urinary uric
acid clearance
Dyslipidemia

TG
  PP lipemia
  HDL-C
  PHLA
 Small, dense LDL
Hemodynamic

SNS activity
  Na retention
 Hypertension
CORONARY HEART DISEASE
Adapted from Reaven G. Drugs. 1999;58 (suppl):19-20
Novel Risk
Factors

CRP
  PAI-1
  Fibrinogen
Does Tight Glycemic Control Reduce
Cardiovascular Disease or Mortality?

ACCORD
– Intensive group:
 non-fatal MI,  hypoglycemia & weight gain
– Trial stopped b/o  mortality in intensive group (Why?)

ADVANCE
– No difference between intensive & conventional treatment in
macrovascular disease or mortality (either overall or CV)

VADT
– No differences between intensive & conventional treatment in
cardiovascular events
– Severe hypoglycemia was strong predictor or CVD events & death
Conventional BariatricMetabolic Procedures
Santayana

“Those who cannot remember
the past are condemned to
repeat it”
George Santayana, The Life of Reason, Vol. 1, 1905
Obesity Surgery Through the
Years…
Bilio-pancreatic Diversion



Nicola Scopinaro, Italy 1976
Large gastric pouch
Alimentary limb
– 250 cm


Biliopancreatic limb
Common channel
– 50-75 cm

Mechanism:
– mildly restrictive
– malabsorptive
1Scopinaro
N. World J Surg 1998;22:936.
BPD – with Duodenal Switch



Doug Hess, 19881
“Sleeve” gastric pouch
Alimentary limb
– 40% of bowel (250-300 cm)

Common channel
– 50-100 cm (arbitrary)

Benefits over BPD:
– no dumping
– decreased marginal ulcer
– better tolerated
1Hess
DS Obesity Surgery 1998;8:267-282.
15
Duodenal Switch - Today

Laparoscopic Approach
– Michel Gagner, 19991
“Sleeve” gastric pouch
 Alimentary limb: 150 cm
 Common channel: 100 cm


Two mechanisms
– Primarily malabsorptive
– Somewhat restrictive
1Ren,
Gagner. Obesity Surg 2000; 10:514-523
Duodenal Switch - Results

Excellent weight loss
– 73% EWL



Long-term follow-up
– 70% EWL at 15 years



Resolution of co-morbidities
Short and Long-term
complications
Nutritional complications
– Protein deficiency
3-4 day stay
Complicated procedure
– Vitamin deficiencies
– Need experienced team

Lifelong follow-up
– Labs q6 months!
– Supplements 5x day!

Behavioral changes
– Diarrhea
– Odor
Henry Buchwald JAMA 2004
GB
GBP
BPD
Improved diabetes
%
47.9
83.7
98.9
FBS (mmol/l)
-3.1
-3.4
-5.8
Insulin (pmol/l)
Meta-analysis
JAMA 2004
-49.5 Buckwald-153.7
-115.3
Cholest tot (mmol/l)
-0.3
-0.96
-1.97
LDL (mmol/l)
-0.11
-0.89
-1.36
Tri decreased
77%
91%
100%
HTA resolved
43.2%
67.5%
83.4%
See also Prachand et al J GI Surg Feb 2010
Risk/benefit ratio
comparison between procedures
GB
GBP
BPD
0.1
0.3
1
Operative complication %
9
15
15
Success rate %
50
60
90
Reoperation rate %
20
10%+
2
Operative mortality %
Manageable side effects
Bacterial overgrowth
%
Treatment
Mild (bloating discomfort)
20
dietary cancelling
probiotic
Moderate (proctitis nocturnal
2
metronidazole
diarrhea, abdominal distension)
Severe (bypass enteritis)
Current Surg 2003; 60: 274-277
0.4
reversal
Deficiencies are infrequent and correctable
25 years gives no sign of latent damage.
10 years post duodenal switch
Normal
n
range
Vitamin A mmol/l
325
Vitamin D nmol/l
Inadequacy
Deficiency
%
%
range
%
>1.2
91.4
7.7
<0.7
0.9
307
>50
72.3
21.0
<30
6.5
Calcium mmol/l
367
>2.10
85
12.0
<2 .00
Iron mmol/l
363
>8
84.3
12
<4
3.8
Ferritine Ug/l
348
>9
83.6
13.8
<4
2.6
Hgb g/l
365
>120
83.6
10.4
<110
6
PTH pmol/l
338
<90
79.2
16.5
>150
4
3
Courtesy of
Lee Kaplan
Gastric
Restriction
Gastric
Band

Gastrectomy
Altered gastric
function
Gastric
exclusion
Duodenal
exclusion
Enhanced
distal nutrient
delivery
Malabsorption

Sleeve
RYGB





DJB
Ileal
EndoBPD/DS
Interluminal
position Sleeve
±


?











Mechanisms of diabetes control after BPD/DS
Nutrients reach the distal ileum
within minutes of the ingestion of food
and this stimulates the secretion of
GLP-1 by L-cells located in this area
« Distal mechanism »
Mechanisms of Surgical Treatment of T2D
The exclusion of the duodenal
nutrient passage may offset an
abnormality of gastrointestinal
physiology responsible for
insulin resistance and type 2
diabetes
« Proximal mechanism »
Choosing the operation

Do you really want to
take medications every
day for the rest of
your life?

4 operations
– Lap band
– Sleeve gastrectomy
– Gastric bypass
– Duodenal Switch
Summary - BPD
Excellent long-term weight loss
(65%)
Resolution of most co-morbidities
100% DM, 80% HTN
Potential malnutrition or mineral/vitamin
deficiency requires intense life-long monitoring
Laparoscopic approach still being investigated
Words for the Wise

This operation is not for every patient (nor
for every surgeon)
 “TRIFECTA”
motivated, intelligent patient
financial resources ($1000-1500/year)
compulsive (12-15 supplements/5 doses)
Super Obese (>50 or >60 BMI)

Band is not be the best option
 DS results are superior to GBP
long term data does not support sustained
weight loss BMI <35 in this group
 High risk group
Staged procedure may be best option
“lower” risk procedure, evaluate patient
diet
Overeating
Food preservatives
Infectious
Algorithm for treating metabolic syndrome?

Lifestyle changes
 Diet
 Drugs
–
–
–
–

Lipid lowering agents
Antihypertensive agents
ASA
Anti-diabetic agents
GI-Bariatric Surgery
Traditional wisdom can be long on
tradition and short on wisdom
Warren Buffet
Surgical Treatment of Obesity and Metabolic Disorders