Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI ≥50 kg/m2?
Received 9 February 2009; received in revised form 27 March 2009; accepted 28 April 2009. published online 14 May 2009.
Abstract
Background
Biliopancreatic diversion with or without the duodenal switch (BPD-DS) is a major bariatric procedure. The morbidity and mortality are likely to increase with an increasing body mass index (BMI), especially when >50 kg/m2. Controversy exists regarding the potentially increased risks of a single-stage procedure compared with the risks of sleeve gastrectomy first followed by the malabsorptive procedure after an initial weight loss.
Methods
From March 2003 to October 2008, 90 patients with a BMI ≥50 kg/m2 were candidates for single-stage BPD-DS. Two study periods were identified: before and after February 2007, corresponding to the periods during and after the learning curve. The results were analyzed globally and by comparing the 2 periods using Fisher's exact test and the t test for unpaired values.
Results
Of the 90 patients, 79 were women, the average BMI was 55.2 ± 4.7 kg/m2, 13 patients were super-super obese, and 4 patients underwent laparoscopic sleeve gastrectomy only. Of the 86 patients who underwent single-stage BPD-DS, 37 underwent surgery before (31 laparoscopically; group 1) and 49 after (48 laparoscopically; group 2) February 2007. BPD-DS was done as revision surgery for 14 patients with a failed restrictive procedure. The global rate of conversion to open surgery was 13.9%; 35.5% for group 1 versus 2% for group 2 (P = .0001). The morbidity decreased significantly between the 2 periods, with a rate of 16.3% for group 2 compared with 45.9% for group 1. Also, 1 postoperative death occurred in group 1.
Conclusion
Single-stage BPD-DS in the super obese appears to be a relatively safe procedure with a low rate of conversion when a laparoscopic approach is used. Although from the published data, the morbidity and mortality are increased for super obese patients, especially men, the BMI itself cannot be considered a contraindication for single-stage BPD-DS, because other factors such as surgical experience also influence the outcome. Despite these variables, performing a sleeve gastrectomy first should be considered for heavier, male, and at-risk patients.
aSociété de Chirurgie Viscérale, Clinique de l'Anjou, Angers, France
bUnité Transversale de Nutrition Clinique, Hopital de Rangueil, Toulouse, France
Reprint requests: Philippe Topart, MD, Société de Chirurgie Viscérale, Clinique de l'Anjou, 87, rue du chateau d'Orgemont, Angers 49044 Cedex 01 France
ABSTRACT