Biliopancreatic diversion with duodenal switch (BPD/DS)

Overview

A biliopancreatic diversion with duodenal switch (BPD/DS) is a weight-loss procedure that is done in two major steps. It is performed less often than other bariatric procedures.

The first step is sleeve gastrectomy. In a sleeve gastrectomy, about 80% of the stomach is removed. This leaves a smaller tube-shaped stomach the size of a banana. The valve that releases food to the small intestine, called the pyloric valve, remains. The first part of the small intestine, called the duodenum, also remains attached to the stomach.

The second step changes the digestive tract by connecting a lower part of the small intestine to the duodenum. This allows food to bypass a large portion of the small intestine. A BPD/DS both limits how much you can eat and reduces the absorption of nutrients, including proteins and fats.

BPD/DS is generally done as a single procedure. However, in some circumstances, it may be done in two separate operations — sleeve gastrectomy first, followed by the intestinal bypass once weight loss has begun.

While a BPD/DS is very effective, it has risks, including malnutrition and vitamin deficiencies. BPD/DS is often considered for people with severe obesity, particularly those with a BMI of 50 or higher. It also may be considered for those with obesity-related conditions, such as type 2 diabetes, that have not responded to other treatments.

Why it's done

Biliopancreatic diversion with duodenal switch (BPD/DS) is done to help you lose excess weight and reduce your risk of serious weight-related health conditions. It also can improve blood sugar control through changes in gut hormones that affect insulin production and sensitivity. Weight-related health conditions include:

• Heart disease.
• High blood pressure.
• High cholesterol.
• Severe sleep apnea.
• Type 2 diabetes.
• Stroke.
• Cancer.
• Infertility.

BPD/DS is typically done only after you've tried to lose weight through lifestyle changes, such as diet and exercise, and sometimes with medicines.

You also must be willing to make permanent changes to lead a healthier lifestyle both before and after surgery. This may include long-term follow-up plans that involve monitoring your nutrition, your lifestyle and behavior, and your medical conditions.

Check with your health insurance plan or your regional Medicare or Medicaid office to find out if your policy covers weight-loss surgery.

Risks

As with any major surgery, a biliopancreatic diversion with duodenal switch (BPD/DS) poses possible health risks, both in the short term and the long term.

Risks associated with BPD/DS are similar to those of any abdominal surgery and can include:

• Bleeding.
• Infection.
• Reactions to anesthesia.
• Blood clots.
• Lung or breathing issues.
• Leaks in the gastrointestinal system.

Longer term risks and complications of a BPD/DS may include:

• Blockage of the bowel, called an obstruction.
• Dumping syndrome, which can involve nausea, weakness and diarrhea. The syndrome is less common with BPD/DS than it is with some other bariatric procedures.
• Gallstones.
• Hernias.
• Low blood sugar, known as hypoglycemia, especially after meals.
• Malnutrition, including deficiencies in protein, iron, calcium, vitamin D, vitamin B-12, and fat-soluble vitamins A, D, E and K.
• A hole in the stomach, called a perforation.
• Ulcers, although less common than with some other bariatric procedures.
• Vomiting.
• Ongoing diarrhea due to fat malabsorption.
• Bone loss or osteoporosis.

Rarely, complications of a BPD/DS can lead to serious organ injury or failure.

How you prepare

In the weeks leading up to your surgery, you may be required to start a physical activity program and to stop any tobacco use.

Right before your procedure, you may have restrictions on eating and drinking and which medicines you can take.

Now is a good time to plan for your recovery after surgery. For instance, arrange for help at home if you think you'll need it.

What you can expect

A biliopancreatic diversion with duodenal switch (BPD/DS) is done in the hospital. The length of your hospital stay will depend on your recovery and the surgical approach used. In some experienced hospitals, a one-night hospital stay may be routine for BPD/DS.

During the procedure

The details of your surgery depend on your individual situation and your surgeon's approach. Some operations are performed using traditional open surgery with a larger abdominal incision. Most are done laparoscopically, using several small incisions and specialized instruments.

You are given general anesthesia before your surgery begins. Anesthetic is medicine that keeps you asleep and comfortable during the procedure.

• The first step of a BPD/DS. The first step is similar to sleeve gastrectomy. The surgeon removes a large portion of the stomach, creating a narrow, tube-shaped sleeve. The pyloric valve, which controls emptying from the stomach into the small intestine, is preserved. The first portion of the small intestine, called the duodenum, remains attached to the stomach.
• The second step of a BPD/DS. The surgeon divides the small intestine and connects a lower portion of it, called the ileum, to the duodenum. This allows food to bypass much of the small intestine. These changes to the digestive tract help reduce calorie and nutrient absorption. Digestive juices from the bypassed section of intestine mix with food farther downstream.

Sometimes, the procedure may be performed in two stages — first the sleeve gastrectomy, followed later by the intestinal bypass portion.

After the procedure

Immediately after a BPD/DS procedure, you may have liquids but no solid food as your stomach and intestines begin to heal. You'll then follow a special diet plan that changes slowly from liquids to pureed foods. After that, you can eat soft food. You move on to firmer foods as your body is able to tolerate them.

Because BPD/DS significantly reduces the body's ability to absorb nutrients, your diet will remain carefully structured. You'll need to eat small portions and focus on high-protein foods. Many people require protein supplements to help meet daily protein needs.

You will need lifelong vitamin and mineral supplementation after surgery. This typically includes:

• A high-potency multivitamin.
• Calcium with vitamin D.
• Vitamin B-12.
• Iron.
• Fat-soluble vitamins A, D, E and K.

These supplements are essential to prevent serious micronutrient deficiencies, including anemia, bone loss and neurological complications.

You'll have frequent medical checkups, especially during the first year after surgery. Blood tests are typically done every few months at first and then at least once a year for life to monitor vitamin levels, iron stores, protein status and bone health.

As your body adjusts to rapid weight loss during the first six months, you may experience:

• Body aches.
• Feeling tired, as if you have the flu.
• Feeling cold.
• Dry skin.
• Hair thinning and hair loss.
• Mood changes.

These symptoms are usually temporary and improve as your weight stabilizes and your body adapts.

Results

After a biliopancreatic diversion with duodenal switch (BPD/DS), it may be possible to lose 70% to 80% of your excess weight within two years. BPD/DS is associated with some of the greatest weight loss among bariatric procedures. However, the amount of weight you lose and maintain depends on your long-term commitment to healthy eating and physical activity habits.

In addition to helping with weight loss, a BPD/DS may improve or resolve conditions commonly associated with obesity, including:

• Gastroesophageal reflux disease.
• Heart disease.
• High blood pressure.
• High cholesterol.
• Obstructive sleep apnea.
• Type 2 diabetes.
• Stroke.
• Infertility.

BPD/DS has particularly strong effects on blood sugar control. Many people with type 2 diabetes experience substantial improvement or remission after surgery.

BPD/DS also may improve your ability to perform daily activities and enhance your overall quality of life.

When weight-loss surgery doesn't work

Some people may not lose as much weight as expected after weight-loss surgery. Or they may regain some of the weight over time. Recurrent weight gain can happen for several reasons. Lifestyle habits, such as eating high-calorie foods or not getting enough physical activity, can contribute. However, biological factors, changes in metabolism, or stretching of the stomach or intestine over time also may play a role.

If weight loss slows or weight regain occurs, your healthcare team may recommend adjustments to your eating plan, increased physical activity, behavioral counseling or weight-loss medicines. Additional procedures may be recommended for some people.

Long-term success after BPD/DS depends on lifelong follow-up, healthy lifestyle habits and regular medical monitoring.