DS/BPD Description

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• Most of your stomach is stapled off and removed from the body
• Most of your small bowel is bypassed.
• This means you could suffer protein malnutrition in a few years in addition to other types of malnutrition
• Less than 25 percent of WLS surgeons DO this surgery because they say the weight loss isn't any better than the others and therefore, not worth exposing their patients to the increased risks.
• The long term risks with the DS/BPD may be similar to those of the old intestinal bypass, according to the ASMBS

DS Myths

• "I have a normal stomach" - a stomach the size of a thumb is far from normal
• "I can eat anything I want" Dr Simpson warned that if you don't follow a careful and nutritious diet you will get VERY ILL so no, you cannot eat anything you want
• "This surgery works better than the others."  This has not been seen in side by side comparisons. In fact the weight loss at the 3 year point is the same as the RNY and the Lap Band.
• "The DS is reversible" - nope - it isn't. All they can do is lengthen the part of the small bowel which is connected. 

Following is a more technical description of what is done in a DS/BPD:

The most powerful weight loss surgery available, the DS/BPD is a combination of a long limb intestinal bypass called a BPD (bileopancreatic diversion) with a specific type of stomach stapling called a "sleeve gastrectomy" which removes 75 - 90 percent of the stomach but leaves the structure in tact as far as the lower stomach valve.  Some DS patients can possibly digest vitamin B12.  However, one surgeon has told his patients to seek iron infusion right after surgery because in his experience, 50 percent of his DS patients required iron infusion later on.  Because the gall bladder often goes bad in this procedure, it is usually removed at the time of surgery to avoid later surgery for removal.  DS patients are expected to cannibalize muscle and bone tissue for a few months after surgery and if they do not, this can cause a bad type of malnutrition.  Scopinaro suggests testing patients to make sure they are obtaining protein from muscle and calcium from bone mass (see Scopinaro paper)

The procedure provides for stapling about 10 percent of  the stomach into a sleeve shape (4-8 oz) and removing the rest of the stomach from the body.  The small bowel is cut 1-2 inches below the lower stomach valve and several feet above the colon - these two pieces are then connected leaving the patient about about 7 - 9 feet* of small bowel which is not bypassed. The bypassed segment of small bowel (11-15 feet) is connected through a hole in the part of the small bowel connected to the stomach, about 29-39 inches from the colon.  The part between where the bypassed bowel is connected and the colon is called "the common channel". Supposedly food is supposed to meet with bile and pancreatic secretions and some digestion takes place there.  In reality, several providers have theorized that most of the bile and pancreatic juices are reabsorbed BEFORE they get to the common channel (see Marceau below - also see the Hess report).  This procedure has some advantages over the gastric bypass in that patients can eat vegetables with less problems (because of the stomach valve being preserved) and patients do not suffer narrowing of the stomas, but the long limb intestinal bypass may cause anemia, protein malnutrition, osteoporosis and other nutritional deficiencies in the long run. It is also not reversible and difficult to take down. DS patients should follow a low fat nutritional program to avoid frequent stools (diarrhea) and also to avoid kidney stones, as fat is not digested well in this surgery.  Also the digestion of fat soluble vitamins can be a long term issue.  The Caveats on this surgery are lifetime medical follow up, an understanding on the part of the patient that although it may FEEL like they can "eat anything", not following dietary restrictions carefully may lead to serious illness.  A certain percentage of patients will become seriously ill regardless of how compliant they are. (One of the prominent DS surgeons has commented to several patients that he has found 50 percent of his DS patients cannot absorb enough iron to avoid anemia and thus, require iron infusions). Another caveat with this surgery, is that people looking into the DS/BPD should realize that there is a silence among the post op patients available in the support groups about complications, weight regain or unsatisfactory weight loss etc.

On afferent loop (overgrowth of bacteria in DS causing bowel obstruction)

"Evidence exists that the absence of bile and pancreatic juice, the shortness of the gut, the protein malnutrition, and possibly the presence of undigested food in the colon are all factors predisposing to bacterial overgrowth."

(DS/BPD - Marceau, Surg Clin North Am - 01-Oct-2001; 81(5): 1113-27)

On possible long term issues with the DS:

"The BPD and the duodenal switch involve permanent removal of part of the stomach and bypassing of a large amount of intestine. It is more radical than the original intestinal bypass operation that was abandoned many years ago. BPD is associated with horrific side effects including kwashiorkor. It takes several years for the body to be fully depleted of stored nutrients so most likely recent post ops have not been affected yet. DS patients should be followed by a gastroenterologist."

Paul Ernsberger, PhD, Department of Nutrition, Case Western Reserve School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4906
Web address: http://www.cwru.edu/med/nutrition/ernsberger.htm
Email: pre@po.cwru.edu   FAX: (216) 368-6644

* according to the Hess Report

According to the ASBMS, all procedures which include an intestinal bypass of any kind (including a shorter one like the gastric bypass) can get at least SOME of the list repercussions below:

**** Some modern procedures utilize a lesser degree of malabsorption combined with gastric restriction to induce and maintain weight loss. Any procedure involving malabsorption must be considered at risk to develop at least some of the malabsorptive complications exemplified by JIB. The multiple complications associated with JIB while considerably less severe than those associated with Jejunocolic anastomosis, were sufficiently distressing both to the patient and to the medical attendant to cause the procedure to fall into disrepute.

Listing of jejuno-ileal bypass complications:

Mineral and Electrolyte Imbalance:

* Decreased serum sodium, potassium, magnesium and bicarbonate.
* Decreased sodium chloride
* Osteoporosis and osteomalacia secondary to protein depletion, calcium and vitamin D loss, and acidosis,

Protein Calorie Malnutrition:

* Hair loss, anemia, edema, and vitamin depletion

Cholelithiasis:

Enteric Complications:

* Abdominal distension, irregular diarrhea, increased flatus, pneumatosis intestinalis, colonic pseudo-obstruction, bypass enteropathy, volvulus with mechanical small bowel obstruction.

Extra-intestinal Manifestations:

* Arthritis
* Liver disease, occurs in at least 30%
* Acute liver failure may occur in the postoperative period, and may lead to death acutely following surgery.
* Steatosis, "alcoholic" type hepatitis, cirrhosis, occurs in 5%, progresses to cirrhosis and death in 1-2%
* Erythema Nodosum, non-specific pustular dermatosis
* Weber-Christian Syndrome
* Renal Disease:
* Hyperoxaluria, with oxalate stones or interstitial oxalate deposits, immune complex nephritis, "functional" renal failure.

Miscellaneous:

* Peripheral neuropathy, pericarditis, pleuritis, hemolytic anemia, neutropenia, and thrombocytopenia.

http://www.asbs.org/html/story/chapter2.html