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Original article

Is biliopancreatic diversion with duodenal switch indicated for patientswith body mass index �50 kg/m2?

Laurent Biertho, M.D.*, Simon Biron, M.D., M.Sc., Frederic-Simon Hould, M.D.,Stefane Lebel, M.D., Simon Marceau, M.D., and Picard Marceau, M.D., Ph.D.

epartment of Surgery, Division of Bariatric and General Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada

Received June 8, 2009; revised January 26, 2010; accepted March 22, 2010

bstract Background: Biliopancreatic diversion with duodenal switch (DS) has been the standard surgicalapproach for the treatment of morbidly obese patients at our institution since the early 1990s. Thepublished data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] �50 kg/m2). The aim of the present study was topresent our long-term results with the DS in patients with an initial BMI of �50 kg/m2.Methods: This was a retrospective study of all patients with a BMI �50 kg/m2 who had undergoneDS from June 1992 to May 2005. The data are reported as the mean � standard deviation.Results: The data from 810 consecutive patients, with a mean initial BMI of 44.2 � 3.6 kg/m2,were reviewed. The mean follow-up was 103 � 49 months. Major perioperative complicationsoccurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% �22%, and the excess weight loss was �50% in 89% of patients. Malnutrition required readmissionin 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (�30 g/L) was1.1%, hemoglobin deficiency (�100 g/L), 1.6%, iron deficiency (�4 mmol/L) 2.1%, and calciumdeficiency (�2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%,and 37% would have preferred to lose more weight.Conclusion: These results showed that in non super-obese patients, DS was very efficient in termsof weight loss and patient satisfaction. This was associated with a 1.5% risk of revision formalnutrition. However, nutritional deficiencies required frequent readjustment of supplements,particularly for calcium, vitamin A, and vitamin D. (Surg Obes Relat Dis 2010;6:508–515.) © 2010American Society for Metabolic and Bariatric Surgery. All rights reserved.

2

Surgery for Obesity and Related Diseases 6 (2010) 508–515

eywords: Bariatric surgery; Duodenal switch; Body mass index �50 kg/m

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Biliopancreatic diversion with duodenal switch (DS) wasntroduced at our institution in the early 1990s [1] andecame our standard surgical approach for most morbidlybese patients. Of the bariatric procedures, DS is known toffer some of the best long-term weight loss for patients

Presented at the 26th Annual Meeting of the American Society foretabolic and Bariatric Surgery, Grapevine, Texas, June 21–26, 2009.

*Correspondence: Laurent Biertho, M.D., Department of Surgery, Di-ision of Bariatric and General Surgery, Laval Hospital, 2725 Cheminte-Foy, Quebec, QC GIV 4G5 Canada.

gE-mail: Laurentbiertho@hotmail.com

550-7289/10/$ – see front matter © 2010 American Society for Metabolic and Boi:10.1016/j.soard.2010.03.285

2,3]; however, because it has been associated with greateroncerns relating to protein and vitamin deficiencies, it hassually been reserved for super-morbidly obese patientsbody mass index [BMI] of �50 kg/m2) for whom greatereight loss is desired. When the initial preoperative BMI is50 kg/m2, Roux-en-Y gastric bypass (RYGB) or adjust-

ble gastric banding is usually preferred, because the long-erm results with DS in this particular population have noteen well established and the concern for malnutrition hasersisted. The need to address these concerns also becomesmportant when one considers the increased application ofhe DS for patients who have undergone previous sleeve

astrectomy and require a second-stage procedure to

ariatric Surgery. All rights reserved.

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509L. Biertho et al. / Surgery for Obesity and Related Diseases 6 (2010) 508–515

chieve better weight loss. The addition of the DS allowshe surgeon to stay away from the scarred tissues at the levelf the stomach and could potentially reduce the risk of leakt the level of the gastrojejunostomy. Thus, more informa-ion is needed on the safety and efficacy of the DS inatients with a BMI �50 kg/m2.

ethods

From June 1992 to May 2005, 810 successive patientsith a BMI �50 kg/m2 underwent primary DS at a singleniversity-affiliated tertiary care center. The surgery wasovered by the public health system and was free of charge,ith a first-come first-served system (except for very sickatients, who receive priority). Morbid obesity is considereddisease in itself and refusal of surgery is rare, representing1% of patients [2]. The present study reviewed the data

ollected prospectively in our database, maintained effi-iently for almost 25 years for all patients. Before 1998, thereoperative data were extracted from the patient’s chart.fter 1998, the preoperative information was systematicallybtained from a written questionnaire. The indications forurgery followed the National Institutes of Health [4] guide-ines, and the decision was made in collaboration with aultidisciplinary team. The patients were well informed

bout the risks and benefits of the procedure, and theysually participated in a support group before surgery.

urgical technique

The patients received a mechanical bowel preparationhe day before surgery and intravenous antibiotics and sub-utaneous heparin 2 hours before surgery. Pneumatic com-ression devices were used during surgery and until ambu-ation. The surgical technique of DS has been previouslyescribed [2]. It consisted of an open approach. A 250-cm3

leeve gastrectomy was created, and the duodenum wasransected about 4 cm distal to the pylorus and anastomosedo a 250-cm alimentary limb, with a 100-cm common chan-el. Routine cholecystectomy and appendectomy were alsoerformed. Regular subcutaneous heparin was given for therst postoperative day and then switched to low-molecular-eight heparin. The patients were discharged with the same

egimen for 3 weeks once they were tolerating a soft diet.itamin and mineral supplementation was started within therst month after surgery and included ferrous sulfate 300g, vitamin D 50,000 IU, vitamin A 20,000 IU, calcium

arbonate 500–1000 mg, and a multivitamin complex.hese supplements were adjusted during follow-up, andducation in following a high-protein diet was reinforced.he complications were defined as major if they were life-

hreatening.

ollow-up

The patients were usually seen at 3, 6, 9, and 12 months

ostoperatively. Thereafter, they were seen annually by us

T

t our obesity clinic or by their family physician, who sents the report. Blood work consisted of a complete bloodount, liver enzymes, albumin, transferrin, iron, ferritin,alcium, parathyroid hormone, vitamin A, vitamin B12, andolic acid. About 50% of the results entered into the data-ase came from our own laboratory, using the Roche Hita-hi and Modular systems. A team of nurses remained inontact with these patients and their family doctor, makingyearly average of 6 telephone calls per patient. Informa-

ion regarding complications and hospitalizations were re-orded. We have constantly made a great effort to reach allf our patients. Every 5 years, a written questionnaire wasent to each patient to complete and verify the collectednformation. The questionnaire included 2 questions regard-ng the degree of satisfaction, 1 about the overall results and

about the weight loss itself (the percentage of responderso the questionnaire in 1997, 2002, and 2006 was 92%,4%, and 60%, respectively).

To assess the nutritional parameters, we compared thereoperative values with the most recent postoperativealue, when both were available. Special attention wasiven to the yearly evaluation of albumin levels. Patientsho were readmitted with a diagnosis of “malnutrition”resented with albumin deficiency (�30 g/L), were unableo tolerate sufficient oral intake, or had not complied withutpatient management.

The data are reported as the mean � standard deviationor continuous variables or as percentages for categoricalariables. Statistical analysis was performed using Stu-ent’s t test for continuous variables and the chi-square testor categorical variables, except when a low number ofbservations required Fisher’s exact test. P �.05 was con-idered statistically significant.

esults

A total of 810 consecutive patients (637 women and 173en) with a preoperative BMI of �50 kg/m2 who had

able 1ajor postoperative complications

omplication Patients (n)

uodenal-ileal leak 11astric leak 6bdominal abscess 3ile leak 3ancreatic leak 1eritonitis 1bdominal hemorrhage 1ancreatitis 1leural effusion 1neumonia 3eptic shock 3 (including 2 deaths)ulmonary embolism 5 (including 2 deaths)etabolic acidosis 1 death

otal 40 (4.9%; including 5 deaths [.61%])

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510 L. Biertho et al. / Surgery for Obesity and Related Diseases 6 (2010) 508–515

ndergone DS and had been followed up for a mean of03 � 49 months (range 36–201). Their mean age at sur-ery was 41.1 � 10.5 years. The mean weight and BMI was20 � 16.5 kg and 44.2 � 3.6 kg/m2 (range 33–49),espectively.

Before surgery, 230 patients (28%) were being treatedor diabetes, 302 (37%) were being treated for hypertension,nd 205 (25%) used an apparatus for sleep apnea. The datae used had been entered into our database within the pastyears, for a mean follow-up of 103 � 49 months. Of the

10 patients, 749 (96%) visited the clinic or their familyoctor with at least partial blood work during the 2 yearsreceding our review. The percentage of patients who phys-cally attended our clinic tended to decrease during theollow-up period, decreasing to 547 patients (70%) in theong term.

During surgery, 7 complications (.9%) occurred, includ-ng 1 liver laceration and 6 spleen injuries, necessitatingplenectomy in 3. Major postoperative complications oc-urred in 40 patients (4.9%) and included 5 operative deaths.6%) within 30 days of surgery (2 patients died of pulmo-ary embolism, 2 of septicemia, and 1 of metabolic acido-is; Table 1). A total of 66 minor complications (8%) oc-urred, including 12 wound infections, 15 pulmonarynfections, and 35 intestinal disturbances, presenting as il-us, food intolerance, or gastric retention. The mean hospi-al stay was 6.9 � 5.4 days.

ong-term results

eight loss. The patients’ weight loss remained stable dur-ng follow-up and represented 76% � 22.3% of the initial

Fig. 1. Mean excess weight loss during follow-up.

able 2atient satisfaction level

atisfaction Responders Scale (n)

1

bout weight* 491/805 (61) 24 (5)verall satisfaction† 359/413 (87) 1 (.3)

Data in parentheses are percentages.* From 1997 (n � 143), 2002 (n � 217), and 2006 (n � 315) question

† From 1997 and 2002 questionnaires.

xcess weight (Fig. 1). After a mean of 8.6 years, only 11%f patients had an excess weight loss of �50%. The BMIas �35 kg/m2 and 30 kg/m2 in 92% and 71% of patients,

espectively.

o-morbidities. Among the surviving patients, 210 (92.5%)f the 227 with diabetes preoperatively were cured and 17till required oral medication. Of the 302 patients treatedor hypertension, 180 (60%) no longer required medica-ion. Of the 205 using a breathing apparatus preopera-ively for sleep apnea, only 5 (2%) required an apparatusostoperatively.

atient satisfaction. In the 2002 written questionnaire, tovaluate overall patient satisfaction, we used a 5-point scale,nd 91% graded their satisfaction as 4 or 5 (Table 2). In006, the question was simplified to a yes or no answer, and98 (95%) of 315 responded that they were satisfied withhe results. To measure the satisfaction for the weight losstself, we also used a 5-point scale, and the same questionas repeated in 1997, 2002, and 2006. The most recent

esponse on record was included. Of the 805 patients (ex-luding the early deaths), we had results for 491 patients61%; Table 2). Our interpretation of the data was that 63%ere very satisfied with their weight loss and 37% wouldave liked to lose more weight.

ong-term complications. Rehospitalization for somethingelated to bariatric surgery was needed in 127 (15.8%) of05 patients, for a total of 160 rehospitalizations (Table 3).n 35 patients (4%), the rehospitalization was for malnutri-ion. In 90%, the readmission occurred within the first yearfter surgery, and they required only medical treatment. In2 patients (1.5%), surgery for malnutrition was requiredfeeding jejunostomy in 3, lengthening of the commonhannel in 9, and reversal of the intestinal switch in 2). Theengthening of the common channel (typically from 100 to00 cm along the biliary limb) was successful in 6 patients.he other 3 patients required another procedure to increase

he common channel further. Revision by lengthening of theommon channel was also required for diarrhea in 2 pa-ients. In 12 patients (1.5%), revision was done for insuffi-ient weight loss and consisted of repeat gastrectomy in 4

3 4 5

4 (11) 103 (21) 113 (23) 197 (40)3 (.8) 28 (8) 78 (22) 247 (69)

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511L. Biertho et al. / Surgery for Obesity and Related Diseases 6 (2010) 508–515

ntestinal shortening in 5, and repeat gastrectomy with in-estinal shortening in 3.

able 3auses of late hospitalization during follow-up

ause Patients (n) Required surgery (n)

elayed fistula 4 4elayed abscess 1 1alnutrition 43 15iarrhea 7 2

nsufficient weight loss 4 4bdominal pain 22 1uodenal ulcer 3 1

ncisional hernia 32 32ntestinal obstruction 21 13leal hemorrhage 1 1ile dyskinesia 1 1otal 139 (17.26) 75 (9.3)

Data in parentheses are percentages.A total of 21 other hospitalizations were for reasons unrelated to bari-

tric surgery.

able 4hanges in nutritional markers at last survey point

utritional marker Preope

lbumin (n � 612)Mean (g/L) 41.6Insufficiency (�30 but �34.9 g/L) 1.9%Deficiency (�30 g/L) 0.6%

emoglobin (n � 686)Mean (g/L) 138.7Insufficiency (�100 but �120 g/L) 4.8%Deficiency (�100 g/L) 0.1%

ron (n � 436)Mean (mmol/L) 14.3Insufficiency (�4 but �10 mmol/L) 27.1%Deficiency (�4 mmol/L) 0%

olic acid (n � 510)Mean (nmol/L) 20.7Insufficiency (�4.5 but �9.5 nmol/L) 11.6%Deficiency (�4.5 nmol/L) 1.4%

itamin B12 (n � 520)Mean (pmol/L) 259.2Insufficiency (�110 but �145 pmol/L) 7.9%Deficiency (�110 pmol/L) 3.5%

itamin A (n � 456)Mean (�mol/L) 2.46Insufficiency (�0.7 but �1.4 �mol/L) 9.2%Deficiency (�0.7 �mol/L) 0.2%

alcium (n � 586)Mean (g/L) 2.29Insufficiency (�2�2.15) 7.8%Deficiency (�2) 0.3%

arathyroid hormone (n � 387)Mean (ng/L) 41.9Moderate increase (�75 but �100 ng/L) 5.7%Marked increase (�100 ng/L) 3.3%

lkaline phosphatase (n � 543)Mean (U/L) 87.9Insufficiency (�130 but �150 U/L) 7.7%

Deficiency (�150 U/L) 3.7%

valuation of nutritional status

The evaluation of the nutritional condition of these pa-ients was obtained by comparing the most recent resultsith those obtained before surgery, if both were available.he percentage available varied from 50% to 88%, depend-

ng on the examinations used (Table 4).

lbumin. As shown in Fig. 2, the albumin level changeduring the follow-up period. It had decreased at the end ofhe first year and then recovered. The mean level remainedlightly lower at 40.7 g/L, instead of 41.6 g/L (P �.0001).ccasional episodes of hypoalbuminemia occurred and re-uired counseling. At the last follow-up, the prevalence ofevere hypoalbuminemia (�30 g/L) had not significantlyncreased compared with before surgery.

nemia. The hemoglobin level was lower at the last surveyhan before surgery, but this was not associated with aignificant decrease in the mean iron level. The prevalence

Postoperatively P value

40.7 � 3.9 �.00015.1% .0051.1% .5

130.7 � 13.2 �.000117.2% �.00011.6% .006

14.1 � 4.8 .617.9% .0022.1% .004

32.9 � 11.7 �.00011.4% �.00010.6% .3

440.8 � 215.1 �.00012.1% �.00010.8% .002

1.84 � 0.74 �.000125.4% �.0001

1.8% .04

2.23 � 0.12 �.000123.9% �.00013% .0009

67.9 � 42.6 �.000117.6% �.000115.5% �.0001

94.6 � 36.3 .0017.7% .9

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f iron insufficiency (iron �4–10 �mol/L) decreased from7% to 18% (P � .002), and deficiency remained rare.itamin B12 and folic acid were also significantly increased

fter surgery.

itamin A. The vitamin A levels were significantly de-reased. The prevalence of insufficiency (�0.7 to �1.4mol/L) had increased from 9% to 25%, and deficiency

�0.7 �mol/L) was present in 1.8%.

one metabolism. The calcium level was slightly decreasedrom 2.3 � 0.1 to 2.2 � 0.1 g/L (P �.0001). The meanarathyroid hormone and alkaline phosphatase levels wereoth significantly increased.

ong-term mortality

The long-term mortality rate was 3%, with 25 patientsying during a mean follow-up of 8.6 years. The causes areisted in Table 5. Of these 25 patients, 7 died of cancer, 5 ofuicide, 4 of trauma, 2 of cardiac causes, 2 of pulmonaryauses, and 1 of stroke. Also, 2 deaths were directly relatedo the bariatric surgery—1 patient died of intestinal obstruc-ion 3 years after DS and 1 of malnutrition 1.5 years afterS. For 2 patients, the cause of death was unknown.

iscussion

DS is known for its good weight loss results [2,3]. In aecent meta-analysis, Buchwald et al. [5] reported thateight loss was greatest after DS (73%), followed by gastricypass (63%), gastroplasty (56%), and adjustable gastricanding (49%). Because of the power of the DS in inducingostoperative weight loss, it is often considered in super-bese patients, for whom greater weight loss is needed.owever, physicians have hesitated to use it in patients withBMI �50 kg/m2 because of its risk of malnutrition. We

ave used DS as our procedure of choice for almost allorbidly obese patients, including those with a BMI �50

g/m2. We believe that our results are even better for thisarticular group of patients than in super-obese patients.

The present survey results have confirmed the excellentong-term weight loss in this population, with a mean excess

Fig. 2. Prevalence of low albumin levels during follow-up.

eight loss of 76% � 22.3%, and only 11% had an excessT

eight loss �50%. The overall patient satisfaction (scale 4nd 5) was high (�90%), and only 63% were very satisfiedith their weight loss. This discrepancy, we believe, em-hasizes patients’ desire to lose as much weight as possibleo improve their quality of life.

The strength of the DS in terms of the resultant weightoss and high level of patient satisfaction must be weighedgainst the risks involved. Our mortality rate of .6% forpen surgery compared well with the rates reported byuchwald et al. [6] from their meta-analysis. Their 30-dayortality rate was .3% for restrictive procedure, .4% for

estrictive/malabsorptive (gastric bypass) surgery, and .8%or malabsorptive procedures. Large collected series haveeported a mortality rate of .4–.5%, and even lower mor-ality rates have been reported after laparoscopic restrictiveurgery [7,8]. However, a national survey from Medicareeported a mortality rate as great as 1.9% after bariatricurgery [9].

The characteristics of our unselected population withnly rare refusal and medical care being free of charge havencreased the significance of our results. Also, many pa-ients underwent surgery in the 1990s when the mortalityas greater than it is currently.The risk of protein malabsorption after DS was compa-

able to that after distal RYGB [10,11]. About 4% of pa-ients might require rehospitalization and alimentary sup-ort for severe protein deficiency or food intolerance. Theseatients will usually recover with intravenous alimentationr with nasoenteric feeding tube placement for a shorteriod. Only 12 of our patients (1.5%) required revision.

At the survey, severe protein deficiency was present in%. Such deficiencies can occur after any type of bariatricurgery but seems to be less frequent after standard RYGBnd rare after purely restrictive surgery [11–13]. If a patientevelops protein malnutrition after standard RYGB, it issually associated with a surgical complication or an un-erlying disease. In a series of RYGB patients with a Si-astic ring-reinforced pouch, the malnutrition rate was re-

able 5auses of long-term mortality

ause Patients (n) Years after surgery

ancerBreast 2 4, 10Lung 2 3, 8Pancreas 2 4, 7Kidney 1 5

uicide 5 3, 4, 10, 12, 12rauma 4 1, 3, 8, 9ardiac 2 3, 6ulmonary 2 3, 3troke 1 1elated to bariatric surgery 2 .5, 1nknown 2 .5, 4

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orted to be 4% [13]. Protein malnutrition has been reportedn up to 13% after distal RYGB [14,15].

In the present series, the prevalence of iron insufficiency�10 mmol/L) decreased from 27% before surgery to 20%fter surgery. At 1 year of follow-up after RYGB, thencidence of iron insufficiency (low ferritin level) has been–66% [10,16]. Skroubis et al. [17] demonstrated an in-reasing percentage of iron insufficiency (ferritin �9 ng/L) from 26% preoperatively to 39% at 4 years, with a

ecrease again to 25% at 5 years after RYGB.After DS, vitamin B12 and folic acid were increased, with

nly a multivitamin used as the supplement (containing 0.6g folic acid and 20 �g vitamin B12). This was in contrast

o the decrease in both vitamin B12 and folic acid reportedfter RYGB [18–20].

After DS, the absorption of vitamin A is compromised,nd the blood levels often tend to remain lower than normal.t the survey, a deficiency was present in �2%. It is,owever, rarely clinically apparent, and oral supplementa-ion is usually enough to correct any deficiency. Because weave not experienced permanent damage and because theeficiency is easy to treat, we have not considered vitamin

to represent a major issue.Metabolic bone disease is of concern after any bariatric

urgery. It is well known that any gastric operation increaseshe risk of bone disease [21]. In the present series, calciumas less than normal in 27% of patients, the parathyroidormone level was increased in 33%, and alkaline phospha-ase in 14%. This increases the concern, but signs havehown that bone is resistant despite these changes. At 10ears after surgery, our morphologic and radiologic studiesid not reveal major bone damage [22]. Furthermore, ourlinical experience has not revealed obvious clinical boneailure within 30 years of follow-up. The risk of boneisease might be less after DS than after RYGB [23,24],ecause it better preserves the role of the stomach. How-ver, this risk is especially minimized with appropriateurveillance, and the benefit of improvements in quality ofife to outweigh the risk, considering that any damage iseversible.

One limitation of the present study was that, although theata were collected prospectively, the survey was still ret-ospective. Some data were missing and some of the resultsere from a self-administered questionnaire with the lack of

ccuracy. Despite our constant effort to obtain records of allomplications, it is still possible that some were missed.nother limitation was that the use of different methods for

he biochemical analyses might have influenced the results,problem with all long-term follow-up. However, the com-leteness of the gathered data and the high rate of follow-upompared with that usually reported after bariatric surgery,as decreased the effect of the small percentage of missing

ata.

onclusion

Our results have suggested that DS is highly efficient inerms of weight loss in non super-obese patients, bringingreat satisfaction to the patients. The long-term risks ofalnutrition and nutritional deficiencies exist but are usu-

lly manageable with medical treatment and only seldomequire reoperation.

isclosures

The authors have no commercial associations that mighte a conflict of interest in relation to this article.

eferences

[1] Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard S.Biliopancreatic diversion with a new type of gastrectomy. Obes Surg1993;3:29–35.

[2] Marceau P, Biron S, Hould FS, et al. Duodenal switch: long-termresults. Obes Surg 2007;17:1421–30.

[3] Prachand VN, Davee RT, Alverdy JC. Duodenal switch providessuperior weight loss in the super-obese (BMI � or � 50 kg/m2)compared with gastric bypass. Ann Surg. 2006;244:611–9.

[4] Consensus Development Conference Panel. Gastrointestinal surgeryfor severe obesity: National Institute of Health Consensus Develop-ment Conference Statement. Am J Clin Nutr 1991;55:615S–9S.

[5] Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetesafter bariatric surgery: systematic review and meta-analysis. Am JMed 2009;122:248–56.

[6] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends inmortality in bariatric surgery: a systematic review and meta-analysis.Surgery 2007;142:621–32.

[7] Nguyen NT, Morton JM, Wolfe BM, Schirmer B, Ali M, TraversoLW. The SAGES Bariatric Surgery Outcome Initiative. Surg Endosc2005;19:1429–38.

[8] Steffen R, Biertho L, Ricklin T, Piec G, Horber FF. LaparoscopicSwedish adjustable gastric banding: a five-year prospective study.Obes Surg 2003;13:404–11.

[9] Flum D, Salem L, Broeckel Elrod JA, Patchen Dellinger E, CheadleA, Chan L. Early mortality among Medicare beneficiaries undergoingbariatric surgical procedures. JAMA 2005;294:1903–8.

10] Bloomberg RD, Fleishman A, Nalle JE, Herron D, Kini S. Nutritionaldeficiencies following bariatric surgery: what have we learned? ObesSurg 2005;15:145–54.

11] Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery.Curr Opin Clin Nutr Metab Care 2004;7:569–75.

12] Ledoux S, Msika S, Moussa F, et al. Comparison of nutritionalconsequences of conventional therapy of obesity, adjustable gastricbanding, and gastric bypass. Obes Surg 2006;16:1041–9.

13] Faintuch J, Matsuda M, Cruz MA, et al. Severe protein-calorie mal-nutrition after bariatric procedures. Obes Surg 2004;14:175–81.

14] Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of proximal todistal gastric bypass for failed gastric bypass for superobesity. JGastrointest Surg 1997;1:517–25.

15] Brolin RE, LaMarca LB, Kenler HA, Cody RY. Malabsorptive gas-tric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195–203.

16] Mechanick JI, Kushner RF, Sugerman HJ, et al. American Associa-tion of Clinical Endocrinologists, the Obesity Society, and AmericanSociety for Metabolic & Bariatric Surgery Medical Guidelines for

Clinical Practice for the perioperative nutritional, metabolic, and

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514 L. Biertho et al. / Surgery for Obesity and Related Diseases 6 (2010) 508–515

nonsurgical support of the bariatric surgery patient. Surg Obes RelatDis 2008;4:S109–84.

17] Skroubis G, Sakellaropoulos G, Pouggouras K, Mead N, NikiforidisG, Kalfarentzos F. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 2002;12:551–8.

18] Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reductionsurgery (APGARS) neuropathy. Obes Surg 2004;14:182–9.

19] Halverson JD. Micronutrient deficiencies after gastric bypass formorbid obesity. Am Surg 1986;52:594–8.

20] Marcuard SP, Sinar DR, Swanson MS, Silverman JF, Levine JS.Absence of luminal intrinsic factor after gastric bypass surgery for

indicated for patients with bod

radeoff for the increased risks of the super-obese and

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i

21] Bisballe S, Ericksen EF, Melsen F, Mosekilde L, Sorensen OH,Hersov I. Osteopenia and osteomalacia after gastrectomy: interrela-tions between biochemical markers of bone remodelling, vitamin Dmetabolites and bone histomorphometry. Gut 1991;32:1303–7.

22] Marceau P, Biron S, Lebel S, et al. Does bone change after biliopan-creatic diversion? Gastrointest Surg 2002;6:690–8.

23] Vilarrasa N, Gomez JM, Elio I, et al. Evaluation of bone disease inmorbidly obese women after gastric bypass and risk factors impli-cated in bone loss. Obes Surg 2009;19:860–6.

24] Johnson JM, Maher JW, Samuel I, Heitshusen D, Doherty C, DownsRW. Effects of gastric bypass procedures on bone mineral density,calcium, parathyroid hormone, and vitamin D. J Gastrointest Surg

morbid obesity. Dig Dis Sci 1989;34:1238–42. 2005;9:1106–11.

Editorial comment

Comment on: Is biliopancreatic diversion with duodenal switch

y mass index �50 kg/m2?

Is biliopancreatic diversion with duodenal switchBPD-DS) indicated for patients with a body mass indexBMI) �50 kg/m2? This is a very valid question that theseuthors have attempted to answer and have done a good job onhe basis of their experience and documentation of follow-up.he question raised is actually a starting point for many ques-

ions but comes back to the fundamental issue of every surgicalrocedure: the benefits must outweigh the risks. Althoughany bariatric surgeons consider the initial weight and BMI in

heir algorithm for procedure selection, many others educateheir patients and allow their patients to choose. It is then theatients’ perception of the benefit/risk ratio that becomes par-mount. However, is weight stratification necessary in choos-ng the best procedure for weight loss surgery patients?

Evidence has shown that as the initial weight and BMIncrease, the outcomes for the procedures diverge. Snyder etl. [1] described the “fulcrum” effect of the initial weight onhe outcomes after laparoscopic adjustable gastric banding.n their series, patients with a starting BMI of �46 kg/m2

ad obtained 50% excess weight loss (EWL) at 1 yearompared with patients with a starting BMI of �46 kg/m2,ho had achieved only a 33% average EWL at 1 year [1].onsidering the patients with a greater initial weight andMI, average outcome differences between the BPD-DSnd Roux-en-Y gastric bypass (RYGB) of 5–10% EWLave been well documented [2–4]. This difference in EWLan translate into many pounds in the super-obese andreater categories, likely leading to improved co-morbidesolution and patient satisfaction. It has generally beenccepted that both weight loss and overall risk increase ashe procedure increases in invasiveness and complexityrom laparoscopic adjustable gastric banding to laparo-copic sleeve gastrectomy, from laparoscopic sleeve gas-rectomy to RYGB, and from RYGB to BPD-DS. Althoughhe increased benefits of BPD-DS are likely an acceptable

bove, the question remains whether this tradeoff is stillcceptable for patients with a lower BMI who weigh less.dditional questions include what is the benefit/risk ratio

or those with a BMI �50 kg/m2 or even �40 kg/m2;hether patients should pursue the procedure with the mostossible weight loss, as long as they are comfortable withhe risk profile; and whether the more aggressive proceduresre even appropriate for lighter patients and should theyven be offered.

The authors of this report have proposed the use ofPD-DS for patients with a BMI of �50 kg/m2. They haveutlined well the most common current use of this proce-ure in only super-obese patients who will benefit the mostrom the increased weight loss. However, they suggest thatf BPD-DS can be offered with the same perioperative risks RYGB, the increased risk of developing nutritional issuesight be acceptable to patients with a BMI of �50 kg/m2.The authors address the technical complexity issue by

resenting their extensive 13-year experience with 810 pa-ients. They report a 5.8% major perioperative complicationate, including 5 deaths (.6% mortality rate). The mostommon complication was leak at the duodenoileostomy.lthough reports in the published data have differed, thisverall complication rate is reasonably comparable to whatas been seen for BPD-DS and not dramatically differentrom that reported for RYGB. Among surgeons who per-orm this procedure often and have acquired the experienceo possess a perioperative complication profile similar toheir complication profile for RYGB, the issue of increasederioperative risk could be null. However, surgeons whoannot perform BPD-DS with the same risk profile as forYGB might be on more shaky ground by offering thisrocedure to those who do not require the enhanced weightoss as much as those with a greater BMI.

Aside from the operative risk argument, the real remain-

ng question is whether the additional nutritional risk is