Laparoscopic Biliopancreatic Diversion With Duodenal Switch

8. Laparoscopic Malabsorptive Procedures. Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Technique And Preliminary Results.

Michel Gagner, MD, FRCSC, FACS, Franz W. Sichel Professor of Surgery
Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, New York.

SAGES 2001: Laparoscopic Bariatric Surgery

Introduction

Intermediate results with laparoscopic adjustable gastric banding, the most popular laparoscopic operation for morbid obesity in several countries, has been deceiving for superobese patients. At the time this abstract was written, the Food and Drug Administration in the United States is evaluating the results of the procedure. For these two main reasons, the most commonly performed laparoscopic bariatric operation in the United States is the laparoscopic Roux-en-Y gastric bypass. The early results of this approach compare favorably with the open approach, with fewer wound and pulmonary complications, decreased abdominal wall hernia formation and faster recovery. However, the long-term results of open gastric bypass published recently by MacLean et al., reports a 43% failure for superobesity BMI >50, which corresponds to the average american patient. For this reason, I have looked for an alternative in these patients in order to achieve a higher success rate longterm. The biliopancreatic diversion with duodenal switch as modified by Marceau from Scopinaro's initial operation appears to combine a restriction with a sleeve gastrectomy and a malabsorption by the creation of a duodeno-ileal anastomosis. This operation is the most common malabsorptive operation for obesity in America and can be performed laparoscopically.

Operative Technique

The first step involves the opening of the gastrocolic omentum superior to the gastroepiploic arcade. All the transverse small vessels and short gastric vessels are coagulated with the ultrasonic coagulating shears. The proximal gastric fundic area can be quite difficult to access from subcostal trocars and the medial border of the spleen can be prominent with large folds of fat from the gasrto-splenic ligament hiding the dissection plane. The dissection will stop when one has reached the lateral border of the left crus or identified the gastro-esophageal junction. Then, I focused my attention to the distal antrum, inferior pyloric and proximal duodenal areas. Adhesions between the anterior part of the pancreatic body are frequently encountered posteriorly and have to be divided in order to adequately perform later the sleeve gastrectomy, otherwise too much stomach superiorly will be left.

The second part consists of the division of the duodenum with a laparoscopic stapler endo-GIA-II from USSC (Tyco Healthcare) with a 45 mm cartridge in length and 3.5 mm in thickness. The duodenum has to be prepared by dissecting superiorly close to the serosa of the duodenum to avoid any vascular injuries superiorly. The transection is performed 2-2,5 cms distal to the pylorus, farther than when one perform a pylorus-preserving pancreatoduodenectomy.

The sleeve gastrectomy is achieved by dividing the greater curvature of the stomach from the lesser curve longitudinally. Approximately 10 cms from the pylorus, an endoGia 60 mm long and 4.8 mm thick is used because the proximal antrum is thicker. The firing is done aiming towards the left side of the gastroesophageal junction. The anesthesiologist will insert a 60Fr bougie and this will be guided along the lesser curvature of the stomach with a laparoscopic babcock forceps, therefore preventing the creation of a too narrow lumen. Another firing of the same cartridge is done, and then 3-5 more firing of a thinner cartridge (3.5), same length, to complete the sleeve gastrectomy. The specimen is extracted using a large plastic bag and remove through the 15 mm trocar on the right side. A semi-rigid nasogastric tube 18 Fr is then used to construct an anvil passing tube to position the anvil in the duodenum, ready for the end to side duodeno-ileal anastomosis. The flexible anvil of a circular stapler CEEA -25 is used (Tyco Healthcare, USSC, Norwalk, Connecticut). A small duodenotomy is made and the tube retrieved from the peritoneal cavity through a trocar.

A very crucial step involves the exact measurement of the different bowel limbs involved, as it can impair and create a more pronounced micronutrient deficiency or result in inadequate weight loss. A pre-measured 50cms long umbilical tape is run on the antimesenteric side of the bowel using Dorsey laparoscopic bowel forceps of 5 mm (Karl Storz, Tutlingen, Germany) starting from the ileocecal valve until we reach 100 cm (twice the length of the umbilical tape). A silk suture 2-0 is applied to mark the future site of the enteroenterostomy. Then the bowel is run an additional 150 cms to make a total distal limb of ileum of 250 cms. At this point the bowel is transected with an endo-Gia 45 mm long and 2.5 thick. A small distance of mesentery is often taken with the ultracision (1-1.5 cm).

The duodenoileal antecolic anastomosis is performed using the CEEA-25 passed though the abdominal wall after the 15 mm trocar site has been. The end of the ileal limb is then closed with one or 2 firings of endo-GIA II 45 mm 2.5 mm thickness.

The last anastomosis, is performed usually by standing on the left side of the patient with the first assistant, and a side to side enteroenterostomy is achieved with the other segment of divided ileum and the 100 cm silk mark. A small enterotomy of 3-5 mm is on the antimesenteric side, and an Endo-GIA II 60-mm long 2.5 mm thick introduced, and fired once. The entorotomy is closed with a running suture of 2-0 silk with intracorporeal knot tying techniques.

Preliminary results.

Seventy two consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity in the first 15 months. Median patient body mass index (BMI) was 57.3 kg/ m2 (range 41-89 kg/ m2) with 75% of patients considered superobese (BMI >50). Mean age was 45 ± 1 years ( ± SEM) with 16 males and 56 females. All procedures were successfully performed laparoscopically except one. There were 2 intraoperative leaks. Median operative time was 200 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p < 0.05). Mean blood loss was 150 ml. Median length of stay was 4 days (range 3- 210 days). There were 2 operative mortalities (30d). Major morbidities occurred in 12.5% patients including one anastomotic leak with a severe wound infection, one venous thrombosis, and four suture line hemorrhages. Follow up at 3, 6 and 12 months resulted in 32%± 3% , 46% and 60% excess body weight (EBW) loss. The post-operative quality of life appeared to be enhanced. All patients who were diabetic were off all treatment, 75% from anti-hypertensive by the third post-operative month, and 67% had a resolution from sleep apnea.

Discussion

According to Marceau, the open duodenal switch results in a successful decrease of 78% of excess weight. When compared to a regular biliopancreatic diversion, the complications of anastomotic ulcerations, hypoproteinemia, diarrhea and dumping were less frequent and less pronounced. Recently, MacLean reported a subgroup of patients, with a BMI higher than 50, which was only successful in 40% of cases with an isolated gastric bypass. For this reason we have persisted in using a biliopancreatic diversion with duodenal switch for the superobese and beyond. Our relatively high operating time at this point may reflect a learning curve with the access method which correlated significantly with body mass index. A higher morbidity was encountered in patients with a BMI >65 (50% vs 8%). Our initial criteria for this operation has been patients with a BMI equal or above 60. We also have used it if patients need a gastric remnant in continuity with the GI tract for future follow-up, if there is inability to have a gastric bypass due to anti-arthritic medications, or if intelligent well informed compliant patients are asking for this specific modification.

I have found that the performance of an antecolic anastomosis is appropriate for most, because the anastomosis is lower in a duodenoileostomy that in an isolated gastric bypass, it seems better tolerated from the point of vue of tension. The duodenoileal anastomosis itself can be difficult to achieved if the ileum wall is thin and mesenteric fat pronounced. A hand-sewn technique with or without endo-GIA could also be used, with perhaps a longer operating time, and risk of leakage.

Reoperation for failed laparoscopic biliopancreatic diversion are anticipated, and maybe in the range of 5-10%. The inadequate weight loss may require a shortening of the common channel, or even the alimentary limb and those who will suffer from severe protein deficiency unresponsive to dietary modification, will need the reverse. This can be performed laparoscopically, as it has been performed in my own practice for Roux-en-Y gastric bypass failures.

In conclusion, this small experience and preliminary result shows that laparoscopic biliopancreatic diversion with duodenal switch is feasible. It may decrease the abdominal wall and pulmonary morbidity seen with the open approach. It will not decrease the gastrointestinal complications and nutritional problems seen with the open experience. A longer follow-up is needed to evaluate the weight loss and late complications. It may play a significant role in the management of superobese patients requiring surgical intervention.

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