Biliopancreatic Diversion with Duodenal Switch
Biliopancreatic Diversion (BPD) was developed in the 1970s by Nicola Scopinaro from Genoa, Italy . The biliopancreatic diversion with duodenal switch (BPD-DS), known as duodenal switch (DS) was created in 1988 by Doug Hess, Bowling Green, Ohio,  and was first published by Picard Marceau, Québec, Canada  in 1993.
Doug Hess incorporated three main components into the DS:
- Vertical gastrectomy with excision of the greater curvature to significantly reduce gastric volume capacity and provide restriction (a sleeve gastrectomy).
- Division of the duodenum between the pyloric valve and the sphincter of Oddi, preserving the normal function of the pylorus and gastric emptying, to avoid dumping syndrome.
- Bypassing the proximal small bowel results in decreased absorption of nutrients, promoting weight loss. Deriving from experience with BPD the BPD-DS maintains a longer common channel to reduce the risk of vitamin and protein deficiencies.
The first laparoscopic BPD-DS was performed by Michel Gagner in 1999. Laparoscopic Sleeve Gastrectomy (LSG) was initially conceived as the first of a two-step procedure to reduce perioperative morbidity. Subsequently, the sleeve gastrectomy became a stand-alone operation. The size of the Bougie used is however smaller than in BPD-DS, to increase the restriction. Nowadays, SG has become the most popular bariatric operation worldwide.
A total of 6 trocars are usually required. The operation starts with a sleeve gastrectomy. For a single-stage BPD-DS, the SG should be large enough to decrease the risk of post-operative malnutrition (ie Bougie size no smaller than 60 French). Hiatal hernias are repaired selectively by most surgeons. Stapling is started 6-7 cm from the pylorus, along the bougie.
The first duodenum is dissected from its posterior attachment and divided with a 60 mm linear stapler 2 to 3 cm distal to the pylorus. Staple-line reinforcement can be useful.
The common channel is measured from the ileo-caecal valve and marked at 75 to 100 cm. The alimentary limb is then divided at 250 cm from the ileo-cecal valve and connected to the post-pyloric duodenum. The duodeno-ileostomy can be performed by different techniques (circular stapled, linear stapled or totally hand-sewn). The hand sewn end-to-side anastomosis is the most common technique and is associated with many benefits (5).
The ileo-ileal anastomosis is created at 75 to 100 cm from the ileo-caecal valve with a linear stapler. The opening of the anastomosis is closed with absorbable sutures. The mesenteric window and Petersen defect are closed with non-absorbable sutures to avoid an internal hernia. Drainage, post-operative nasogastric tube or Foley catheter are not recommended. Testing of the anastomosis is left to the surgeon’s choice (with methylene blue or with a gastroscope).
Duodenal Switch is associated with some of the best long-term weight loss of all procedures, at 40% total weight loss. Resolution of comorbidities, including Type 2 diabetes (90%), hypertension (60%), sleep apnea (70%) and dyslipidemia (90%) is also well described. It is also superior to Roux-en-Y gastric bypass procedure or sleeve gastrectomy for most metabolic complications.
This procedure is however associated with increased gastro-intestinal side-effects, including higher number of bowel movements, bloating, and malodorous gas. Patients need to comply with strict vitamin supplementation and to increase protein intake. Long-term risk of protein malnutrition is not uncommon.
Nowadays, sleeve gastrectomy is the most common bariatric procedure and BPD-DS is more and more performed as a staged operation (SG followed, if needed, 18 to 24 months later by a second-stage DS). A variation of the BPD-DS known as the Single anastomotic duodeno ileostomy (SADI) is described in another section of the website.
- S c o p i n a ro N, Gianetta E, C iva l l e ri D et al. Biliopancreatic bypass for obesity: initial experience in man. Br J Surg 1979; 66: 618-20.
- Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8: 267-82.
- Marceau P, Biron S, Bourque RA et al. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 1993; 3: 29-36.
- Chu C, Gagner M, Quinn T, Voellinger DC, Feng JJ, Inabnet WB, Herron D, Pomp A: Two-stage laparoscopic BPD/DS. An Alternative Approach To Super-Super Morbid Obesity. Surgical Endoscopy 2002; S187.
- Weiner, R.A., Pomhoff I, Schramm M, Weiner S, Blanco-Engert R.: Laparoscopic biliopancreatic diversion with duodenal switch: three different duodeno-ileal anastomotic techniques and initial experience. Obes Surg. 2004 Mar;14(3):334-40