Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

What is Biliopancreatic Diversion with Duodenal Switch (BPD-DS)?

Biliopancreatic Diversion with Duodenal Switch (BPD-DS) is a type of bariatric surgical procedure to control your weight.

Also, known as the duodenal switch, BPD-DS combines a sleeve gastrectomy surgery and intestinal bypass in a complex procedure.

During a BPD-DS surgery, your surgeon removes about 70 percent of your stomach. The remaining portion of your stomach assumes the shape of a tube, as with a sleeve gastrectomy.

Your surgeon will divide the lower intestine to allow for the bypassing of two-thirds of the intestine. The intestinal bypass leaves a small section of the intestine to promote the interaction of digestive enzymes and food.

The intestinal bypass begins at your duodenum hence the name duodenal switch. The procedure limits your ability to absorb vitamins, calories, and minerals.

The weight loss realized through BPD/DS is significantly more than when sleeve gastrectomy surgery or gastric bypass.

The bypassed large section of the small intestine is reattached to the last section of your small intestine. This alters the breakdown of digestive juices and bile. It leads to more weight loss because of a reduction in absorbed calories.

BPD/DS can cause nutritional problems among other complications. Your healthcare provider will advise you on the benefits and risks that accompany BPD/DS.

BPD/DS is mainly recommended for patients with a body mass index (BMI) of 50 or higher. This is class III obesity.

People who have clinically severe obesity also have metabolic syndrome, including high blood sugar and high cholesterol. If not, they are at a high risk of suffering obesity-induced diseases.

The duodenal switch is associated with considerable improvements in Type 2 Diabetes symptoms and other metabolic syndromes. It also leads to a significant reduction in weight.

If you have a BMI of 40 and below but have preexisting health conditions, your surgeon may also recommend the duodenal switch. Examples of these health problems are:

• Lung diseases

• High cholesterol

• Sleep apnea

• Nonalcoholic fatty liver disease 

• Types 2 diabetes

Types of BPD-DS surgeries 

BPD-DS can be performed through open surgery or laparoscopically. In the traditional open surgery, your surgeon makes an incision in your stomach. Your surgeon gains access to the inside of your stomach through this incision.

They close the larger section of your stomach with surgical staples. This creates a new stomach pouch.  

Laparoscopic BPD/DS is a minimally invasive surgery where your surgeon makes smaller cuts in your belly.

The procedure involves the use of a laparoscope attached to a small computer screen for increased accuracy and precision in performing the surgery.

The risk for complications is greatly reduced plus the recovery time is shorter. 

Preparing for BPD-DS 

Before Duodenal Switch surgery, you will undergo a screening process so that the healthcare team can determine that you qualify for surgery.

Some steps of this screening process are:

Thorough medical testing to ensure you are in good health to withstand the procedure. Screening for tobacco, drug, and alcohol.

If you are using these drugs, the healthcare team will enroll you into a program to help you quit.

Psychological assessment and counseling to determine your emotional and mental preparedness for duodenal switch surgery that could be life-changing.

You will need to prove that you have tried other methods of weight loss in the past without success.

You will be enrolled in a program to help you understand what duodenal switch surgery entails.

After the bariatric team has taken you through the above steps and fixed a date for the procedure, you will be put on a diet for the next few weeks.

The goal is to help you lose some weight before the duodenal switch procedure as this can increase the safety of your surgery.

You will be asked not to eat or drink anything after midnight on the scheduled date of your surgery.

Make sure you are accompanied by your spouse, friends, or family member on the day of surgery.

Procedure 

The two main techniques of performing a duodenal switch are open surgery and laparoscopic surgery. 

The laparoscopic procedure is a minimally invasive surgery that involves the use of “keyhole” incisions as opposed to a large incision that opens up the abdominal cavity as in the case of open surgery. 

Laparoscopic surgery is the procedure of choice for many patients and surgeons.

However, your surgeon may recommend open surgery as it may be more effective in managing your condition.

Your surgeon can start a laparoscopic surgery and later convert to open surgery.

The duodenal switch involves two main steps – A sleeve gastrectomy that removes almost 70% of your stomach and an intestinal bypass. 

Your surgeon may opt to perform a sleeve gastrectomy as a standalone surgery followed by an intestinal bypass at a later date.

Your surgeon may recommend administering both surgeries separately after assessing your condition and if they feel this is the safest route to take. 

The duodenal switch involves two methods – biliopancreatic diversion which is the original method and the loop duodenal switch which is the modified version. 

In biliopancreatic diversion, 80-90% of your small intestine is bypassed. By bypassing most of the intestines, there is a significant decrease in the amount of nutrients that get absorbed from your food.

The biliopancreatic diversion is associated with a drastic reduction in weight. However, with this method, you are highly predisposed to malnutrition.

In the modified duodenal switch, your surgeon bypasses about 60% of your small intestine, minimizing the risk of malnutrition. 

The modified duodenal switch divides your small intestine into two and reconnects them near the end of the small intestine. This way, a large portion of your small intestine gets bypassed. 

The procedure takes a few hours to administer. After duodenal switch surgery, you will be taken to a recovery room.

The bariatric team will continue monitoring your progress to ensure you do not suffer any complications.  

After BPD-DS 

Your surgeon will schedule periodic post-surgery appointments over the next one to two years. You will also need to have follow-up appointments from time to time for the rest of your life.

During the first two years after surgery, you will experience the most weight loss. That is why your surgeon needs to monitor your health and progress more closely.

Your healthcare provider will also schedule regular blood tests to determine whether you have any nutritional deficiencies.

You will need to take nutritional supplements to overcome malnutrition. You will take these nutritional supplements for life.  

Benefits of BPD-DS

The duodenal switch comes with several advantages:

• The success rate of the duodenal switch is among the highest in all bariatric procedures

• It comes with the greatest overall weight loss

• Long-term improvement in metabolism, blood sugar, and blood lipid levels

• People who have Type 2 diabetes and go through the duodenal switch experience total remission for this condition

• Dumping syndrome after the duodenal switch is rare. Therefore, you need not avoid fats and sugar intake

• The risk of death after the duodenal switch is considerably reduced

Recovery

Most patients are ready to go home on the same day of the procedure. Others will remain in hospital for a day or two until their health condition has stabilized.

You will continue with your recovery journey at home. You should be fit enough to resume work in a few weeks post-surgery.

As you recover, you are likely to experience drastic changes that could manifest in the following symptoms:

• Rapid weight loss

• Mood swings

• Hormonal imbalance

• Fatigue

• Hair loss

• Nausea

• Fever-like symptoms

Your dietician will recommend a strict diet that you will need to follow to hasten your recovery.

The dietary guidelines will also stipulate what you need to eat, and what you will need to avoid.

Such strict dietary guidelines are essential because they allow time for your digestive system to heal.

The doctor will start a clear liquid diet. Then move on to a complete liquid diet, pureed foods, and finally, a soft diet.

Risks/Complications

Like all other bariatric surgeries, duodenal switch surgery comes with certain risks:

• Excessive bleeding

• Blood clots

• Wound infection

• Some patients may develop serious reactions to anesthesia

A duodenal switch may present with the following complications:

• Small bowel obstruction – your small intestine could get obstructed by scar tissue

• Hernia – Hernia occurs after an organ pushes via a gap in the muscle wall of your stomach

• Anatomic leaks – The duodenal switch entails the surgical severing of your small intestine which is later reconnected at a later stage of your intestine

In case of a leakage at the point of connection, this may cause abdominal cavity infection.

The above complications are rare with duodenal switch but they could happen. A laparoscopic procedure along with the modified loop duodenal switch helps to reduce such risks.

Cost of BPD-DS in India

A duodenal switch procedure in India costs approximately Rs. 2,00,000 (about $ 2,500). However, the cost could increase up to Rs. 4,00,000 (that is, $ 5,000) depending on several factors:

Type of hospital

If you choose a private hospital, you are likely to pay more than what the same procedure costs at a public hospital.

Private hospitals and clinics have invested in state-of-the-art facilities plus they do not enjoy a waiver on operational costs from the government like public hospitals do.

Use of insurance

Certain insurance products will not cover duodenal switch surgery and you have to incur the expenses. Check with your insurance provider whether they can cover this procedure.

Hospital accreditation

Accredited healthcare facilities that offer duodenal switch surgery will charge more on account of their higher standards and quality improvements.

Type of surgery

Laparoscopic duodenal switch is more effective and precise than open surgery but it will cost you more.

Length of stay in hospital

The longer you spend in the recovery room, the higher the overall cost of the procedure.

Surgeon location

The cost of duodenal switch surgery in India will be determined by the city where your surgeon is located.

Surgeons who practice in metro cities such as Bangalore, New Delhi, and Mumbai will charge more than their peers in first and second-tier towns. This is because the operational costs in the metro-cities are higher.

Complexity of the surgery

If the procedure is complex, this will increase the risk associated with it. The cost of such surgery will therefore increase.

Some factors that may affect the complexity of duodenal switch surgery are pre-existing health conditions like type 2 diabetes or heart disease.

Anesthesia fee

Duodenal switch surgery is administered via local or regional anesthesia. You will have a session with your anesthetist before surgery to establish the most suitable anesthesia for you.

Your anesthesiologist will monitor you throughout the surgery for enhanced safety during surgery. The anesthesia fee will differ based on the qualifications of your anesthesiologist.

Choosing the best healthcare facility for duodenal switch surgery in India

If you are an international patient who wishes to undergo a duodenal switch surgery in India, here are the factors that you may have to consider in choosing the best hospital for this service:

Experience

Check the levels of experience of bariatric surgeons in the healthcare facility that you are interested in. These should have conducted many duodenal switch surgeries successfully.

Look out for testimonials from satisfied patients who have undergone the same procedure in these facilities.

Reputation

Choose a healthcare facility that has a good track record and reputation for offering top-notch quality care. And successful surgical procedures.

Cost

Look at how much different hospitals are charging for duodenal switches. This will allow you to identify a healthcare provider who is within your budget. That way, you will be assured of value for your money.

Accreditation

Check whether a hospital has received the relevant accreditation from credible organizations. Accreditation is proof of evidence that the hospital offers high-quality healthcare services that meet certain set standards.

Above all, consult your primary care provider for suggestions or recommendations as they are more knowledgeable about which healthcare facilities will meet your healthcare needs. Such consultations will help you make the right decision.

References

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