Lemise

Biliopancreatic diversion with duodenal switch (VSG/DS) vs. Gastric bypass

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Dr. Callery,

I am a 57 y.o.female 412#, 5' 9", BMI~61. I have comorbidities of DMll on oral medication only, HTN, sleep apnea on CPAP, minimal GERD, severe osteoarthritis and in need of knee and hip replacements. I have researched biliopancreatic diversion with duodenal switch, VS. Gastric bypass. From what I have read, I feel that a BPD with DS is probably the best surgery for me because it helps super obese lose the highest percentage of excess weight, and maintain weight loss longer, also the pouch is larger allowing a larger intake, no dumping syndrome, no ulcer issues.

 

The BPD with DS allow for superior resolution of comorbidities , and I will still be able to have Nsaids.
I am aware of all the requirements for lifetime supplements and vitamins, Iron, Protein, etc., although it appears there is that potential for that with the gastric bypass as well. I know the mortality rate is higher with BPD with DS, and I am aware of the increased frequency in stools and gas, and the smell.

 

My surgeon feels that the gastric bypass is the more appropriate surgery for me because there are fewer side effects. He also,states that the type of surgery I have will not decide how much weight I lose, that my utilization of my tool ( and my compliance) will decide my weight loss success. Also I am not sure how much he has experience he has doing the BPD with DS, although he has done it.

 

He also mentioned that he had a patient that was end stage diabetes with glaucoma and he did the BPD with DS to preserve what eyesight he had left, and another who needed a transplant and needed to lose a lot of weight first.
Based on the provided information would you tend to agree with him, and am I missing something to feel that the BPD with DS would be the better surgery for me?

Thank you for your time and help.
Lemise

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Dear Lemise,

 

The sleeve gastrectomy with duodenal switch (VSG/DS) is the procedure that I think you are referring to as "BPD with dodenal switch". (Click on the first thumbnail of the VSG/DS is pasted below.) The BPD, biliopancreatic diversion, on the other hand is not used in this country much. BPD involves removing the lower half of the stomach and then creating a long limb gastric bypass. (Click on the second thumbnail below.) Both the VSG/DS and the BPD feature a smaller stomach and a short common digestive channel. Both cause decreased absorption of protein, fats, and carbohydrates. Both are associated with greater weight loss and more nutritional complications than gastric bypass.

 

The big question that your surgeon is asking you is, "is the additional weight loss worth the nutritional consequences?" Advocates for VSG/DS argue yes. They say nutritional consequeces can be minimized by careful management. Gastric bypass advocates say no. They say you get the most benefit from the initial weight that you lose, and less benefit from the added weight loss that the VSG/DS confers. They also say that VSG/DS is very risky since many so many patients don't follow up on nutritional recommendations. These people can develop severe vitamin deficiencies, oxalate kidney stones, and protein/calorie malnutrition.

 

So it's a cost/benefit argument. If you undergo a VSG/DS it is absolutely essential that you be committed to long term metabolic follow up. You'll need to accept that you may develop oxalate kidney stones. Finally you may have significant problems with multiple daily bowel movements and seriously foul smelling intestinal gas.

 

If you do decide to have a VSG/DS, go to a surgeon who has a team committed to the long term metabolic management of your new anatomy. Don't rely on your primary care physician or a gastroenterologist.

 

By the way, many surgeons would argue in favor of a two step approach. Have a sleeve gastrectomy first. If you don't lose enough weight to achieve your health goals AND if you are actually very compliant with the dietary regimen, then consider a duodenal switch or gastric bypass as a second step.

 

There is one randomized prospective trial comparing VSG/DS and GBP.  At one year the weight loss is greater for DS. Long term side effects can't be evaluated because the length of follow up is too short. (First abstract pasted below.) There is another article that compares the two procedures, but in a non-randomized fashion. Again weight loss is greater for the VSG/DS group, but metabolic complications are also higher. (Second abstract below.)

 

Someday we may see a randomized prospective trial comparing DS and GBP for patients with a BMI greater than 50 with longer follow up. Until such time we all are going to have to rely on relatively low level scientific evidence and our best common sense.

 

 

Br J Surg. 2010 Feb;97(2):160-6. doi: 10.1002/bjs.6802.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity.

Abstract
BACKGROUND:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS:

Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS:

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION:

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

 

+++++++++++++++++++++++++

Surg Obes Relat Dis. 2010 Jul-Aug;6(4):408-14. doi: 10.1016/j.soard.2010.03.293. Epub 2010 Apr 8.
Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity-weight loss versus side effects. Abstract BACKGROUND:

Laparoscopic biliopancreatic diversion/duodenal switch (LDS) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the main surgical options for super-obese patients (body mass index >50 kg/m(2)).

METHODS:

We performed a medium long-term evaluation of 13 super-obese patients who had undergone LDS compared with a control group of 19 patients who had undergone LRYGB. The patients were assessed 31 months (range 17-38) and 34 months (range 26-62) after LDS and LRYGB, respectively, for body mass index changes, relief of co-morbidities, nutrition, quality of life, postoperative bowel function, and accumulated healthcare consumption.

RESULTS:

The mean body mass index decreased from 54.9 to 30.0 kg/m(2) in the LDS group and 57.8 to 39.8 kg/m(2) in the LRYGB group (P = .005). The hemoglobin A1c level was lower in the LDS group than in the LRYGB group (3.8 +/- .31% versus 4.3 +/- .43%, respectively; P = .01). The LDS patients reported greater energy intake than the LRYGB patients (3132 +/- 1392 kcal versus 2014 +/- 656 kcal, respectively; P = .021). The number of stools daily was 4.1 +/- 3.3 in the LDS group and 1.9 +/- 1.1 in the LRYGB group, P = .0482). Of the 12 patients in the LDS group, 6 reported fecal incontinence or soiling compared with 2 of 16 in the LRYGB group (P = .034). The number of outpatient visits was 5.6 +/- 4.6 for the LDS group and 2.0 +/- 1.9 for the LRYGB group (P = .016), and the number of telephone consultations was 5.0 +/- 5.6 and 1.4 +/- 1.6 for the LDS and LRYGB groups, respectively (P = .043).

CONCLUSION:

LDS resulted in greater weight loss than LRYGB in super-obese patients. However, the LDS patients in our series had more frequent gastrointestinal side effects, required greater doses of calcium and vitamin supplementation, and required more postoperative monitoring. Patient satisfaction was high in both groups.

 

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