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Comment on: Long-term outcome after biliopancreatic diversion with duodenal switch: a single-center experience with up to 20 years’ follow-up

Published:November 16, 2022DOI:https://doi.org/10.1016/j.soard.2022.11.007
      This article [
      • Süsstrunk J.
      • Schneider R.
      • Peterli R.
      • Slawik M.
      • Woelnerhanssen B.
      • Kraljević M.
      Long-term outcome after biliopancreatic diversion with duodenal switch: a single-center experience with up to 20 years’ follow-up.
      ] is another valuable addition to the previously published articles on the long-term results of the biliopancreatic diversion with duodenal switch (BPD-DS) since Hess et al. published the first 10-year follow-up report in 2005 [
      • Hess D.S.
      • Hess D.W.
      • Oakley R.S.
      The biliopancreatic diversion with the duodenal switch: results beyond 10 years.
      ]. There is no question that BPD-DS remains the most effective procedure to achieve and control weight loss with an average total weight loss of 40% and, to some extent, provides the best outcomes on co-morbidities, especially in the subgroup of patients with a body mass index ≥50 [
      • Bolckmans R.
      • Himpens J.
      Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch.
      ]. The authors must be commended for their in-depth analysis of their results but, at first glance, this article is unlikely to increase the already very limited adoption of this technique by bariatric surgeons because of the high rate of additional abdominal surgeries as well as the revisions or reversals required for excessive weight loss and/or protein malnutrition which have always been the main concern after this procedure. Hess et al. [
      • Hess D.S.
      • Hess D.W.
      • Oakley R.S.
      The biliopancreatic diversion with the duodenal switch: results beyond 10 years.
      ] and Marceau et al. [
      • Marceau P.
      • Biron S.
      • Marceau S.
      • et al.
      Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion.
      ] have both reported respective relatively low revision rates of 4.3% and 1.4% for malnutrition, but, in the Quebec City experience, 8% of the patients had to be readmitted for this reason and 4.5% were treated by a temporary jejunostomy feeding tube. Although a 10% to 13% malnutrition-related revision rate is not uncommon like in the present report, another series relied solely on parenteral nutrition without the need for elongation of the common channel for 5.1% of 268 patients over a 9-year follow-up [
      • Strain G.W.
      • Torghabeh M.H.
      • Gagner M.
      • et al.
      The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years.
      ]. What could be more disturbing in the present article is the 29.3% global rate of reoperations but, as the authors pointed out, it compares rather favorably to what has been already published in the long-term series with rates ranging from 16.2% to 42.5% and even 84% [
      • Bolckmans R.
      • Himpens J.
      Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch.
      ,
      • Marceau P.
      • Biron S.
      • Marceau S.
      • et al.
      Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion.
      ,
      • Strain G.W.
      • Torghabeh M.H.
      • Gagner M.
      • et al.
      The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years.
      ,
      • Skogar M.L.
      • Sundbom M.
      Early complications, long-term adverse events, and quality of life after duodenal switch and gastric bypass in a matched national cohort.
      ]. It makes sense that, as time goes by, there can be a greater likelihood that patients need additional abdominal surgeries and this can explain why all these long-term studies exhibit high reoperation rates. In the present case, not closing the mesenteric defect may have played a role although this approach accounted for only one third of the patients and the predominance of laparotomies may well explain the incisional hernias. The choice of considering impaired vitamin serum concentration just once over the entire follow-up as a deficiency could appear excessively negative in the context of such a malabsorptive procedure even if adequate control remains difficult to achieve, possibly due to a lack of compliance over time [
      • Bolckmans R.
      • Himpens J.
      Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch.
      ,
      • Marceau P.
      • Biron S.
      • Marceau S.
      • et al.
      Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion.
      ,
      • Strain G.W.
      • Torghabeh M.H.
      • Gagner M.
      • et al.
      The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years.
      ]. Because of the vitamin deficiencies, the impact of BPD-DS on osteoporosis which is reported in the present article remains controversial as it has been studied in only one of the long-term series without any difference between 69 patients waiting for surgery and a small group of 87 patients a mean 6 years after BPD-DS [
      • Marceau P.
      • Biron S.
      • Marceau S.
      • et al.
      Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion.
      ]. Just like what has been uncovered with the sleeve gastrectomy, which is part of the procedure, BPD-DS can also lead to gastroesophageal reflux (GERD), and this has been reported by only 1 article in addition to the present one with the same proportion of patients reporting these symptoms [
      • Bolckmans R.
      • Himpens J.
      Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch.
      ]. Despite the side effects and reoperations, most of the studies have reported a high satisfaction rate after BPD-DS [
      • Bolckmans R.
      • Himpens J.
      Long-term (>10 yrs) outcome of the laparoscopic biliopancreatic diversion with duodenal switch.
      ,
      • Marceau P.
      • Biron S.
      • Marceau S.
      • et al.
      Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion.
      ,
      • Strain G.W.
      • Torghabeh M.H.
      • Gagner M.
      • et al.
      The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years.
      ,
      • Skogar M.L.
      • Sundbom M.
      Early complications, long-term adverse events, and quality of life after duodenal switch and gastric bypass in a matched national cohort.
      ]. To be fair, the long-term results should be assessed in comparison to the Roux-en-Y gastric bypass (RYGB). The Swedish registry has compared 333 BPD-DS and 1332 RYGB performed for a mean BMI of 55 over a mean follow-up of 4.6 years [
      • Skogar M.L.
      • Sundbom M.
      Early complications, long-term adverse events, and quality of life after duodenal switch and gastric bypass in a matched national cohort.
      ]. Although BPD-DS resulted in more long-term adverse events with significantly more frequent abdominal reoperations and a higher rate of malnutrition, there was a greater improvement in quality of life compared with RYGB, in part but not entirely related to a significant reduction of 22.8 versus 16.9 in BMI. Despite its efficiency, the evidence of a higher rate of long-term complications after BPD-DS still discourages its use and the authors themselves performed only a limited number of cases beyond this series. There is no “one procedure fits all” within the surgical armamentarium. For these reasons, except in the case of preexisting GERD, BPD-DS remains a valuable option to treat super obesity and address the need for conversion from previous bariatric procedures.
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      References

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