Current Outcomes of Laparoscopic Duodenal Switch

Abstract

Background:
Biliopancreatic diversion with duodenal switch (BPD-DS) has long been considered as the bariatric procedure with the highest peri-operative and long-term complication rate. However, modern peri-operative care, including laparoscopic and staged-approach, has significantly reduced the complication rate related to this procedure. The goal of this article is to provide an overview of the current outcomes of laparoscopic BPD-DS in a high volume centre.

Methods:
All patients who had a laparoscopic BPD-DS with a hand-sewn anastomosis performed between 2011 and 2015 (N = 566) were reviewed. Data were obtained from our prospectively maintained electronic database and are reported as a Mean ± standard deviation.

Results:
The mean age of the 566 patients was 41 ± 10 years, with 78 % women. Initial body mass index was 49 ± 6 kg/m(2). There was no 90-days mortality. Hospital stay was 4.5 ± 3 days. Major 30-days complications occurred in 3.0 % (n = 17) of the patients and minor complications in 2.5 % (N = 14). Excess weight loss was 81 ± 14 % at 12 m, 88 ± 13 % at 24 m, 83 ± 14 % at 36 months. Total body weight loss (kg) was 57 ± 13 kg at 12 months, 63 ± 14 kg at 24 months and 61 ± 17 kg at 36 months. Hemoglobin A1C (HbA1C) dropped from 6.1 ± 1 % to 4.7 ± 0.5 % (p < 0.005) and the percentage of patients with an HbA1C above 6 % decreased from 38 to 1.4 % (p < 0.005). Over 21 ± 12 months follow-up, readmission was required in 3.5 % and reoperation in 0.5 % of the patients.

Conclusion:
The current short and medium-term complication rate of laparoscopic BPD-DS are similar to other mixed bariatric procedures with excellent metabolic outcomes.

Full text

Biertho et al. Ann Surg Innov Res (2016) 10:1
DOI 10.1186/s13022-016-0024-7
RESEARCH ARTICLE
Current Outcomes ofLaparoscopic
Duodenal Switch
Laurent Biertho1,2*, Frédéric Simon‑Hould1, Simon Marceau1, Stéfane Lebel1, Odette Lescelleur1
and Simon Biron1
Abstract
Background: Biliopancreatic diversion with duodenal switch (BPD‑DS) has long been considered as the bariatric
procedure with the highest peri‑operative and long‑term complication rate. However, modern peri‑operative care,
including laparoscopic and staged‑approach, has significantly reduced the complication rate related to this pro‑
cedure. The goal of this article is to provide an overview of the current outcomes of laparoscopic BPD‑DS in a high
volume centre.
Methods: All patients who had a laparoscopic BPD‑DS with a hand‑sewn anastomosis performed between 2011 and
2015 (N = 566) were reviewed. Data were obtained from our prospectively maintained electronic database and are
reported as a Mean ± standard deviation.
Results: The mean age of the 566 patients was 41 ± 10 years, with 78 % women. Initial body mass index was
49 ± 6 kg/m2. There was no 90‑days mortality. Hospital stay was 4.5 ± 3 days. Major 30‑days complications occurred
in 3.0 % (n = 17) of the patients and minor complications in 2.5 % (N = 14). Excess weight loss was 81 ± 14 % at 12 m,
88 ± 13 % at 24 m, 83 ± 14 % at 36 months. Total body weight loss (kg) was 57 ± 13 kg at 12 months, 63 ± 14 kg
at 24 months and 61 ± 17 kg at 36 months. Hemoglobin A1C (HbA1C) dropped from 6.1 ± 1 % to 4.7 ± 0.5 %
(p < 0.005) and the percentage of patients with an HbA1C above 6 % decreased from 38 to 1.4 % (p < 0.005). Over
21 ± 12 months follow‑up, readmission was required in 3.5 % and reoperation in 0.5 % of the patients.
Conclusion: The current short and medium‑term complication rate of laparoscopic BPD‑DS are similar to other
mixed bariatric procedures with excellent metabolic outcomes.
Keywords: Bariatric surgery, Biliopancreatic diversion, Duodenal switch, Laparoscopy
© 2016 Biertho et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
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publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Background
Biliopancreatic Diversion (BPD) was first described by
Nicola Scopinaro in 1979 [1]. is technique combined
an horizontal gastric resection with closure of the duo-
denal stump, a gastro-ileostomy and an ileo-ileostomy, to
create a 50-cm common channel and a 250-cm alimen-
tary channel. e technique was modified to a Duodenal
Switch procedure, based on the procedure described by
Dr DeMeester, to treat bile gastritis in the late 80’s [2].
It evolved in the following years to the “modern” BPD-
DS procedure, which includes a partial gastrectomy
performed along the greater curvature (i.e., a Sleeve Gas-
trectomy, SG), transection of the duodenum 3–4cm dis-
tal to the pylorus, and creation of a 250cm alimentary
limb [3, 4]. e biliary limb is anastomosed 100cm from
the ileo-caecal valve, to create the common channel.
e malabsorptive component of the procedure results
from the separation of food from the bile and pancre-
atic juice. is results in a reduction of caloric and food
absorption, particularly of lipids, and metabolic changes
through modifications of incretins levels. e excellent
long-term metabolic outcomes of the procedure have
never really be questioned. Nevertheless, Buchwald etal.
[5] reported that Bilio-Pancreatic Diversion represented
only 2 % of the 344,221 bariatric surgeries performed
worldwide in 2008. ere are multiple reasons for his
Open Access
Annals of Surgical Innovation
and Research
*Correspondence: laurentbiertho@gmail.com
2 Institut Universitaire de Cardiologie et de Pneumologie de Québec,
2725, Chemin Ste‑Foy, Quebec, QC G1V 4G5, Canada
Full list of author information is available at the end of the article

Page 2 of 5
Biertho et al. Ann Surg Innov Res (2016) 10:1
finding, including the increased technical complex-
ity, high complication and mortality rates reported in
the literature and increased risk of protein malnutrition
[6, 7]. However, there has been a number of significant
improvements in the peri-operative management of mor-
bidly obese patients since the first report of laparoscopic
BPD-DS in 1999 [8] and exposure to this procedure has
become of outmost importance for the management of
failure after sleeve gastrectomy.
e goal of this study is to describe the current morbid-
ity and medium term outcomes of BPD-DS in a tertiary
care center specialized in this technique.
Methods
All patients who had a laparoscopic BPD-DS using a
hand-sewn anastomosis at the Quebec heart and lung
institute, a university affiliated tertiary care center, were
included in this study. open BPD-DS has been per-
formed since 1989 in our Institution. Indication for sur-
gery follows the standard 1991 NIH recommendations
[9]. Laparoscopic BPD-DS was introduced in November
2006, and we first used a mechanical stapler for the duo-
denal anastomosis (21-mm circular stapled anastomo-
sis). is technique was associated with a higher rate of
complication (including stenosis, leak, bleeding) as was
reported previously [10]. We transitioned to hand-sewn
anastomosis, which has been our standard operative
technique since 2011. All patients who were operated
using this technique were included in this study, up to
February 2015. Data were extracted from a prospec-
tively maintained electronic database and reviewed
retrospectively.
Patients selection
Patient selection followed the standard NIH recom-
mendations for bariatric surgery [10]. All patients were
assessed by a bariatric surgeon, dietician, nurse special-
ized in bariatric surgery and social worker. Patients had
an electrocardiogram, chest X-ray, blood work, sleep
apnea testing and consultation in pneumology. Vitamins
or minerals supplementation were started when defi-
ciencies were discovered before the surgery. Consulta-
tion with a psychiatrist was requested when patient had
a history of psychiatric disease. Standard pre-operative
education specific to BPD-DS or sleeve gastrectomy was
given to all patients. Nutritional deficiencies were treated
before surgery according to standard supplementation
protocols.
Surgical technique
All patients followed our routine pre-operative prepara-
tion including a low-residue diet for 2days before sur-
gery, antibioprophylaxis (Cefazolin 2–3g at the time of
surgery) and thrombo-prophylaxis (standard or low-
molecular weight subcutaneous heparin). A 15-mmHg
pneumo-peritoneum is first created. e greater curva-
ture of the stomach is mobilized using ultrasonic shears
(Ace Ultrasonic, Ethicon EndoSurgery, Cincinnati, OH,
USA). A 34–44 Fr Bougie is used for the calibration of the
sleeve. e stomach is then transected along that Bougie
using an articulating linear stapler-cutter (Echelon-Flex
long 60, Ethicon EndoSurgery, Cincinnati, OH, USA),
staring 7–8cm from the pylorus, to create a gastric res-
ervoir, with an estimated volume of 250cc. e duode-
num is then transected 3–4cm from the pylorus, using
a blue cartridge. e ileo-caecal valve is then identified
and the small bowel is transected 250cm proximal, using
a white cartridge. e duodeno-ileal anastomosis is then
created. A hand-sewn anastomosis, using two posterior
layers and one anterior layer of absorbable sutures (3-0
V-lock© suture). e mesenteric window is closed using
a 2-0 Prolene suture. Routine cholecystectomy was also
performed.
Standard post-operative orders are used, including
ulcer prevention, thrombo-prophylaxis and feeding pro-
tocol. Patients were discharged when tolerating a soft
diet, with vitamins and minerals daily supplementations.
Patients received a multivitamin complex (Centrum
Forte), vitamin A 20.000IU, vitamin D 50.000 IU, cal-
cium carbonate 1000mg and ferrous sulfate 300mg.
Follow‑up
Patients were followed at the clinics at 4, 8, 12, 18 and
24 months post-op and yearly thereafter. Blood analy-
ses were performed at these times, including a complete
blood count, electrolytes, urea and creatinine, calcium,
parathormone levels, vitamin D, vitamin A, serum iron,
total iron binding capacity and ferritin. Supplements
were adjusted over time according to these analyses
using standardized supplementation protocols. e per-
centage of excess weight loss (EWL) was calculated as
followed: (initial weight–current weight)/(initial weight–
ideal weight). e ideal weight was calculated by multi-
plication the square of the patient’s height in meters by
23. e body mass index (BMI) was calculated by divid-
ing the patient’s weight in kilograms by the square of the
height in meters.
Statistical methods
e data are reported as the mean ± standard devia-
tion for continuous data or as percentages for categorical
variables. Statistical analysis was performed using a Stu-
dent’s t test for continuous variables, and the Pearson’s
Chi square test for categorical variables, except when a
low number of observations required Fisher’s exact test.
p<0.05 was considered statistically significant.

Page 3 of 5
Biertho et al. Ann Surg Innov Res (2016) 10:1
Results
e demographic data for the 566 patients is described
in Table1. Initial BMI was 49±6.1kg/m2. All patients
underwent a laparoscopic BPD-DS in our Institution, by
four different surgeons. One patient required conver-
sion to open surgery because of difficulties getting good
exposure and was kept in the series in an intention-to-
treat process. Post-operative complications are described
in Table2. Major complications occurred in 3% of the
patients and reoperation was required in 1.9 % of the
patients. A leak occurred at the duodenal anastomosis in
0.7% of the patients (n= 4) and at the gastric level in
0.2% (n=1). ere was no short- or medium-term mor-
tality, during a mean 21±12months follow-up. During
that period, readmission for a medical problem related
to the surgery was required in 3.5% of the population,
and a reoperation was required in 0.5% (Table3), includ-
ing two patients who required a surgical revision for
malnutrition.
Figure1 summarizes the percentage of EWL. EWL at
three years (n=60) was 83±14%, which corresponds to
a total body weight loss of 61±17kg. At that time, one
patient (1.7%) had a BMI above 35kg/m2, three patients
(5%) had a BMI between 30 and 35kg/m2, and 14 (23%)
had a BMI between 25 and 30kg/m2.
Tables4 and 5 summarizes some of the biological val-
ues, comparing data before to after surgery, at the time of
last available follow-up (mean 21± 12months). Before
surgery, 38 % of the population had an Hemoglobin
A1C (HbA1C) above 6%. After surgery, only 1.4% had
an HbA1C above 6% (p<0.005). ere was also a sig-
nificant drop in total cholesterol, low density lipoproteins
and triglycerides. ere was a significant improvement in
ferritin level, vitamin D-25-OH and vitamin B12. How-
ever, albumin, hemoglobin and vitamin A dropped sig-
nificantly. Even though the mean albumin level dropped
significantly, values were below normal (35gr/l) in only
two patients at 2years (2/182, 1.1%) and one patient at
3years (1/70 or 1.4%).
Discussion
e excellent long-term weight loss and correction of
obesity-related diseases after BPD-DS have never been
really challenged. In a meta-analysis of the bariatric lit-
erature, Buchwald et al. [9] reported that BPD is the
surgery offering the best long-term EWL (70.1 %) and
improvement in type 2 diabetes (98 %). However, BPD
has also been associated in the past, with some of the
highest mortality rate (1.1% compared with 0.28 % for
Table 1 Demographic data
Data are expressed as the mean±standard deviation for continuous data and
as percentages for categorical data
BPD‑DS
N 566
Age (years) 41 ± 9.5
% female patients 78 %
BMI (kg/m2) 49 ± 6.1
Weight (kg) 135 ± 22
Waist diameter (cm) 129 ± 35
Hip diameter (cm) 136 ± 37
Type II diabetes % (n) 50 % (282)
Hypertension, % (n) 46 % (259)
Sleep Apnea, % (n) 60 % (342)
Dyslipidemia, % (n) 30 % (171)
Number of comorbidities 4.4 ± 1.9
Table 2 Peri-operative data
Data are expressed as the mean±standard deviation for continuous data and
as percentages for categorical data
BPD‑DS
N 566
Operative time 199 ± 43
Blood loss 37 ± 49
Length of stay 4.5 ± 3.2
Mortality 0
Conversion 1 (0.2 %)
Table 3 Thirty-days complications
Data are presented as a percentage (number of cases)
Variable Percentage (N) Required reoperation
Major complications (N = 566)
Duodenal leak 0.7 (4) 0.7 (4)
Gastric leak 0.2 (1) –
Intra‑abdominal abscess 0.5 (3) 0.2 (1)
Pulmonary embolism 0.2 (1) –
Myocardial infarction 0.2 (1) –
Other 0.4 (2) 0.2 (1)
Obstruction 0.5 (3) 0.5 (3)
Digestive bleeding 0.4 (2) 0.4 (2)
Total 3.0 (17) 1.9 (11)
Minor complications
Pneumonia 0.4 (2)
Food intolerance 1 (6)
Stenosis 0.2 (1)
Atelectasis 0.2 (1)
C Difficile colitis 0.2 (1)
Pancreatitis 0.2 (1)
Wound infection 0.4 (2)
Total 2.5 (14)
Grand total 5.5 (31) 1.9 (11)

Page 4 of 5
Biertho et al. Ann Surg Innov Res (2016) 10:1
all procedures). More recently, modern peri-operative
care, the use of minimally invasive technique and staged
approaches have allowed a reduction of the mortality
rate to those observed after other bariatric surgeries [11].
Indeed, we observed a mortality rate of 0.1% in a series
of 1000 BPD-DS which included our initial cases of lapa-
roscopic BPD-DS and a significant portion of open DS
[10]. In this series, we did not experience any mortality in
a consecutive series of 566 patients.
In that series of patients, which included 228 laparo-
scopic cases and 772 open cases [10], the major com-
plication rate was 7.4 versus 3.0% in the present series
(p= 0.0002) and the minor complication rate was 9.1
versus 5.5% (p=0.01). e risk of leak using a circu-
lar-stapled anastomosis was 2.6 %, while the use of a
hand-sewn technique allowed to reduce that risk 0.4%,
which is consistent with the leak rate reported in recent
series of gastric bypasses [12]. In addition, the use of a
hand-sewn technique has allowed to virtually eliminate
the risk of anastomotic stenosis, which occurred in an
average of 10% of patients who had a circular-stapled
anastomosis.
e limitations of this study include its retrospective
nature. Even though data were entered prospectively
into our database, some complications might have been
missed. In addition, we looked at short term outcomes
and we do not have the 5–10year data on laparoscopic
technique to discuss the long-term metabolic changes.
However, we believe that the technical changes related
Fig. 1 Percentage of excess weight loss over time. Data are reported as the Mean ± standard deviation. Numbers above the curve represents the
number of available data at each interval
Table 4 Medium-term complications
Data are presented as a percentage (number of cases)
Variable Percentage (N) Required reoperation
Denutrition 1.8 (10) 0.4 (2)
Small bowel obstruction 0.5 (3)
Food intolerance 0.5 (3)
Gallstones 0.2 (1) 1
Other 0.5 (3)
Total 3.5 % (20) 0.5 % (3)
Table 5 Changes insome biological values overtime
Variable Before surgery After surgery p
Hemoglobin A1C (%, n = 473) 6.1 ± 1 4.7 ± 0.5 <0.005
Above six (%, n) 38 % (216) 1.4 % (8)
Fasting plasma glucose
(mmol/l, n = 236) 6.57 ± 2.1 4.7 ± 0.9 <0.005
Total cholesterol (mmol/l,
n = 236) 4.47 ± 0.9 3.2 ± 0.6 <0.005
HDL (mmol/l, n = 235) 1.22 ± 0.29 1.22 ± 0.29 NS
LDL (mmol/l, n = 233) 2.54 ± 0.79 1.55 ± 0.49 <0.005
Triglycerides (mmol/l,
n = 233) 1.59 ± 0.8 1.0 ± 0.4 <0.005
Total cholesterol/HDL 3.79 ± 1.0 2.8 ± 0.8 <0.005
Hemoglobin (g/l, n = 506) 135 ± 11 128.5 ± 13 <0.005
Ferritin (ng/ml, n = 477) 132 ± 153 157 ± 131 <0.005
Albumin (g/l, n = 502) 42.3 ± 2.45 39.9 ± 3.8 <0.005
Vitamin A (µmol/l, n = 394) 1.9 ± 0.45 1.53 ± 0.4 <0.005
Vitamin D‑25 (mmol/l,
n = 443) 51.6 ± 24 94.3 ± 39 <0.005
Vitamin B12 (pmol/l, n = 479) 300 ± 120 401 ± 160 <0.005

Page 5 of 5
Biertho et al. Ann Surg Innov Res (2016) 10:1
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to the laparoscopic approach should not impact the good
long-term outcomes we reported previously, and could
even be beneficial in decreasing the risk of ventral hernia,
small bowel obstruction and complications related to any
abdominal reoperation. In addition, we did not report
the changes in quality of life or side-effects related to the
procedure.
Conclusion
In experienced hands, laparoscopic BPD-DS is only
slightly more technically difficult than other bariatric
procedures, like RYGB. e rate of major peri-operative
complications is low, at 3%, which is in similar ranges
compared to other bariatric procedures. In addition,
BPD-DS offers some of the best weight loss and cure-rate
of obesity related diseases. It also allows a better eating
experience, by preserving the pyloric valve and avoiding
dumping syndrome. ese long-term benefits come at
the cost of certain gastrointestinal side effects and long-
term compliance with vitamin supplementation.
Authors’ contributions
Study conception and design: LB. Acquisition of data: LB, FSH, SL, SM, OL, SB.
Analysis and interpretation of data: LB. Drafting of manuscript: LB. Critical revi‑
sion: FSH, SL, SM, OL, SB. All authors read and approved the final manuscript.
Author details
1 Department of Bariatric Surgery, Quebec Heart and Lung Institute, Laval
University, Quebec, Canada. 2 Institut Universitaire de Cardiologie et de Pneu‑
mologie de Québec, 2725, Chemin Ste‑Foy, Quebec, QC G1V 4G5, Canada.
Acknowledgements
We wish to acknowledge the help of Mrs. Paule Marceau, research assistant, in
the collection, verification and analysis of the data.
Competing interests
L. Biertho is co‑director of a Research chair in bariatric and metabolic surgery.
S Lebel, FS. Hould, S. Marceau, O. Lescelleur, S. Biron and L. Biertho have no
financial relationships relevant to this manuscript to disclose.
Received: 3 June 2015 Accepted: 12 January 2016
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