This operation combines food restriction and malabsorption. There are two versions of this procedure, the classic BPD developed by Prof Scopinaro in 1979 and the BPD with duodenal switch (DS). These operations provide an excess weight loss of > 85%, but are also associated with potentially more serious long term complications than other bariatric operations and are generally reserved for patients who are super obese (ie: BMI >50) or who have failed other bariatric surgical procedures.
The goal is to restrict the amount of food consumed and bypass the majority of the normal digestive process. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so that they meet the ingested food closer to the end of the small intestine. Since food bypasses the duodenum much of the small intestine, some vitamins and minerals are not absorbed and it is therefore necessary to take life-long vitamin supplements to make sure deficiencies do not occur.
Classic BPD (Scopinaro) Procedure
In this operation approximately ¾ of the stomach is removed to provide restriction of food intake. The small intestine is then dissected 250cm from where it joins the colon. The 250cm segment is then joined to the stomach to create the “alimentary limb”. All the food moves through this segment, but not much is absorbed. The bile and pancreatic juices move through the “bilio-pancreatic” limb which is connected to the alimentary limb, 50cm from its end. This 50cm segment is now called the common limb and is where the bile and pancreatic juices meet the ingested food and absorption of nutrients takes place. Digestion of fat is not affected by this procedure and it is therefore important to restrict fat intake, otherwise stools will be frequent and loose.
The absorption of fat soluble vitamins is also affected, particularly vitamin A (eyesight) and D (bone strength) and it is necessary to take lifelong supplements of both these vitamins. It is possible to vary the length of the common limb, but the longer the common limb, the less the weight loss.
Another side effect of this procedure is the dumping syndrome. This occurs because the valve that normally controls stomach emptying is removed as part of the partial gastrectomy. As a result, food exits the stomach remnant rapidly, drawing fluid into the intestine and causing fainting, crampy pain and diarrhea in some patients. To overcome this problem BPD with DS is performed.
BPD with DS
This operation is a variation of BPD in which stomach removed is restricted to the outer margin, leaving a sleeve and stomach with the outlet valve (pylorus) intact. This results in normal gastric emptying and eliminates dumping syndrome. The procedure is otherwise the same as the classic BPD operation.
Advantages of BPD
The procedure results in a higher degree of weight loss ( >85%) than other bariatric procedures as has been demonstrated by the long term results of Prof Scopinaro.
BPD with DS has the advantage of eliminating dumping syndrome as a long term complication.
Risks of BPD
- For all malabsorptive operations, bowel motions can be liquid and frequent and smelly especially if fat in the diet is maintained. Over time this can reduce, especially if a low fat diet is maintained.
- Life-long follow up and monitoring of nutrients is required and must be agreed to before any surgery is performed. Life-long vitamin supplements of vitamin A & D (fat soluble) are required and also a multivitamin supplement of water soluble vitamins. If these are not followed serious nutritional illness that may result in life-long disability can occur.
- Changes to the intestinal “plumbing” arrangements can result in increased risk of gallstone formation and the need for gallbladder removal as a result.
Laparoscopic Surgery and BPD
BPD is the most difficult of all bariatric procedures to perform laparoscopically (ie with key-hole surgery). Classic BPD is the easier variation to perform but the DS route is extremely difficult.
Either procedure is most frequently performed in the context of one or more previous obesity operations and this makes the possibility of laparoscopic surgery even more difficult. Each case must be assessed individually, but often the final decision can only be made at the time of surgery.
BPD and other Bariatric Operations
Although BPD can produce the best weight loss of all the bariatric operations, it also has the most potential for long-term nutritional complications and is least likely to be performed with laparoscopic (key-hole) surgery. It should therefore be reserved for patients who are super obese (BMI >50) or on patients in whom other bariatric operations have failed.
This is a larger operation than most other bariatric procedures and requires a hospital stay of 3 days for laparoscopic procedures and 6-7 days for open procedures.
Patients can return to office style work in approximately 3 weeks and work in 6 weeks (often less for bariatric procedures)
A low fat diet and life-long vitamin supplements must be maintained.
Potential Complications of BPD
The general complications of surgery have previously been outlined. Complications which are specific to BPD are as follows:
Peri operative (ie. during surgery and in the immediate post operative period)
- Anastomotic leak which can result in peritonitis and the need to re-operate.
- Staple line bleeding, requiring blood transfusion and possible re-operation.
- Gastric stricture
- Internal adhesions and bowel obstruction.
- Vitamin deficiencies (especially fat soluble)
- Protein malabsorption
- Stomach ulcers
- Dumping syndrome
- Diarrhea/fatty stools/abdominal bloating
In summary, BPD with DS is used as a last resort operation and although generally produces good weight loss this cannot be guaranteed and it has a potentially higher complication rate both short and long term than other obesity procedures.
All patients MUST be followed up by medical practitioners who have experience with BPD patients FOR LIFE