What is a bilio-pancreatic diversion with duodenal switch (BPD/DS)?

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

Biliopancreatic diversion with duodenal switch (BPD/DS) is a complex bariatric surgical procedure that combines both restrictive and malabsorptive components, resulting in significant and sustained weight loss of approximately 70-80% of excess body weight, making it one of the most effective bariatric procedures for treating severe obesity. 1

Anatomical Components and Surgical Technique

The BPD/DS procedure consists of two main components:

1. Restrictive component:

   • Creation of a sleeve gastrectomy where approximately 60-80% of the stomach along the greater curvature is removed
   • This creates a tubular stomach (150-200 ml capacity) based on the minor curvature
   • A 60-Fr bougie is typically used to size the sleeve 2

2. Malabsorptive component:

   • Transection of the proximal duodenum
   • Creation of a duodeno-ileal anastomosis (duodenal switch) where the proximal portion of the duodenum is connected to the distal small intestine (typically 250 cm from the ileocecal valve)
   • The biliopancreatic limb (which carries bile and pancreatic enzymes) is anastomosed to the ileum approximately 100 cm proximal to the ileocecal valve
   • This creates a common channel of about 100-150 cm where digestion and nutrient absorption primarily occur 1

Effectiveness and Outcomes

BPD/DS produces superior weight loss compared to other bariatric procedures:

• 35-40% reduction in initial body weight
• 70-80% loss of excess weight 1
• Sustained weight loss over long-term follow-up
• Significant improvement or resolution of obesity-related comorbidities:
  • 88.9% resolution/improvement of type 2 diabetes
  • 86.6% resolution/improvement of hypertension
  • 55.5% resolution/improvement of hyperlipidemia 2

Indications and Patient Selection

BPD/DS is typically reserved for:

• Patients with BMI ≥40 kg/m² (severe obesity)
• Most commonly used for super-obesity (BMI >50 kg/m²)
• Can be considered for patients with BMI 35-50 kg/m² with significant obesity-related comorbidities
• Patients who have failed other weight loss interventions 1

Complications and Considerations

BPD/DS has higher complication rates than other bariatric procedures:

• Perioperative mortality: 2.5% 3
• Major morbidities: 15% including anastomotic leaks, venous thrombosis, staple-line hemorrhages, and subphrenic abscess 3
• Nutritional deficiencies are common:
  • 32% vitamin D deficiency
  • 25% zinc deficiency
  • Iron, calcium, and other vitamin deficiencies 2
• Malabsorption of nutrients requiring lifelong supplementation
• Higher incidence of short and long-term complications compared to other procedures 1

Current Usage

BPD/DS is performed less frequently than other bariatric procedures:

• Represents a small percentage of all bariatric surgeries worldwide
• Has been largely replaced by sleeve gastrectomy and Roux-en-Y gastric bypass as preferred procedures
• Is performed less frequently due to its technical complexity and higher complication rates 1

Follow-up Requirements

Due to the significant malabsorptive component, patients require:

• Lifelong vitamin and mineral supplementation
• Regular nutritional monitoring
• Close follow-up to prevent protein-calorie malnutrition
• Monitoring for vitamin D, calcium, iron, and other micronutrient deficiencies 2

Conclusion

BPD/DS is a technically complex but highly effective bariatric procedure that provides superior weight loss compared to other surgical options. However, its use is limited by higher complication rates, significant nutritional concerns, and the technical expertise required to perform it safely. Patient selection must be careful, with thorough preoperative counseling about the risks, benefits, and lifelong follow-up requirements.