Biliopancreatic Diversion: Objectives, Advantages, and Disadvantages

What is Biliopancreatic Diversion?

Biliopancreatic diversion (duodenal switch) is a bariatric surgery procedure primarily aimed at weight loss in patients with severe obesity, at least of the 2nd degree (body mass index of 35 or greater). Unlike restrictive surgeries, such as gastric banding, which reduce stomach capacity, biliopancreatic diversion is a malabsorptive procedure that reduces intestinal absorption of fats and starches, but NOT that of simple sugars found in fruits, sweets, sugary drinks, milk, and alcohol. Biliopancreatic diversion results in a weight loss of approximately 65/75% of excess weight present before surgery. Compared to restrictive procedures like gastric banding, which necessitate significant dietary restriction (due to reduced stomach volume), biliopancreatic diversion requires less patient adherence, allowing for a relatively free diet except for simple sugars. While this is a major advantage, it does not imply an endorsement of an unbalanced diet.

Objectives of Biliopancreatic Diversion

The goal of biliopancreatic diversion is to reduce the absorption of certain nutrients, leading to sustained weight loss. Since obesity is a risk factor for many diseases, biliopancreatic diversion offers numerous benefits, including reduced risk of:

• mortality;
• acute myocardial infarction
• stroke;
• orthopedic diseases;
• diabetes mellitus;
• dyslipidemia;
• various other diseases directly or indirectly related to obesity;

Today, biliopancreatic diversion is an effective weight-loss method, but it must be coupled with the patient's commitment to weight loss and long-term maintenance of a healthy weight through a balanced diet and regular physical activity.

Minimum Weight and Indications for Biliopancreatic Diversion Surgery

Ideal Candidates for Biliopancreatic Diversion

Bariatric surgery is generally recommended for patients aged 18 to 65 with one of the following:

• Third-degree obesity (body mass index of 40 or more) with or without other pathologies;
• Second-degree obesity (body mass index of 35 or greater) with one or more obesity-related pathologies, including:
  • diabetes mellitus;
  • hypertension;
  • dyslipidemia;
  • sleep apnea;
  • severe orthopedic conditions related to excess weight;

There isn't a strict weight limit, as body weight alone isn't the sole determining factor (depending on height). This is why body mass index is used instead of weight.

Patient Evaluation

Beyond weight, patients undergo evaluation of psychological, behavioral, and general health factors to determine suitability:

• assess surgical tolerance and overall health;
• assess obesity-related complications (metabolic, cardiac, or respiratory);
• assess whether the patient has made at least one or more serious attempts at following a structured diet in the past;
• assess the patient's relationship with food, potential psychological disorders, presence of eating disorders (such as bulimia), and ability/willingness to cooperate with medical professionals;

Contraindications to Biliopancreatic Diversion

Not all healthy patients (with a BMI of 35 or greater) are suitable candidates post-evaluation. Approximately half are deemed unsuitable. Psychologically suitable patients generally demonstrate:

• a thorough understanding of the procedure, including the associated risks (it's a complex surgery), and the need for lifelong vitamin, iron, and calcium supplementation;
• strong motivation and willpower;
• commitment to managing a complex and prolonged postoperative recovery;
• commitment to maintaining results through proper diet, sufficient physical activity, and potential medication;

Furthermore, bariatric surgery is generally contraindicated in cases of alcoholism, drug addiction, terminal illness, or significant psychological/psychiatric conditions that impair self-care or adherence to the follow-up program.

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Biliopancreatic Diversion: Advantages and Disadvantages

Advantages of Biliopancreatic Diversion

Biliopancreatic diversion surgery offers several advantages, including:

• substantial weight loss achieved rapidly;
• sustained weight loss;
• long-term control of metabolic syndrome values and cardiovascular parameters;
• possibility of laparoscopic intervention;
• reduced patient adherence, allowing for a relatively free diet except for simple sugars;

Reduced patient adherence and sustained weight loss are significant advantages compared to other techniques such as gastric bypass and gastric banding.

Disadvantages of Biliopancreatic Diversion

Like any surgical procedure, biliopancreatic diversion has disadvantages:

• it is a more complex surgical technique compared to other procedures like bypass and banding;
• it is relatively more expensive than other bariatric surgery options;
• lifelong dietary supplements are necessary due to nutritional deficiencies;
• significant foul-smelling stools and flatulence due to unabsorbed fats;

Which Bariatric Surgery is the Most Effective?

Many factors influence surgical success or failure, but generally, the effectiveness of bariatric surgery is directly proportional to the invasiveness of the procedure:

• Gastric banding and its variants have an effectiveness of 40-60%;
• Gastric bypass and its variants have an effectiveness of 60-70%;
• Biliopancreatic diversion and its variants have an effectiveness of 65-75%;

These figures are estimates only. A specific procedure's effectiveness can vary depending on individual patient factors.

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