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Beyond the Gastric Bypass

Rare weight loss surgery for the extremely obese

by Lindy Keane Carter

Dietitian Dr. Nina Crowley (left) confers with Dr. Rana Pullatt about their patient’s eating habits.
Dietitian Dr. Nina Crowley (left) confers with Dr. Rana Pullatt about their patient’s eating habits.

MUSC Health has become one of the few hospitals in the Southeast to offer biliopancreatic diversion duodenal switch (BPD/DS) surgery, a technically challenging but highly effective weight loss procedure. In December 2015, Rana C. Pullatt, M.D., MS, Associate Professor of Surgery, assisted by T. Karl Byrne, M.D., Professor of Surgery, performed the laparoscopic surgery. Pullatt and Byrne are thought to be the only bariatric surgeons in South Carolina who perform this complicated procedure. Their patient was a woman who weighed more than 400 pounds and had a body mass index (BMI) of 65 kg/m2. Four weeks after the surgery, she had lost 35 pounds. Pullatt’s goal for her is a BMI of 40 kg/m2.

Society places a huge amount of blame on the super-obese (BMI ≥ 50 kg/m2), says Pullatt. “So I’m passionate about giving them a chance to regain control of their bodies. We know that 95% of patients will fail a diet. This surgery is the only solution that works long term.” A 2006 study showed that for 350 super-obese patients, DS achieved successful weight loss (defined as Estimated Body Weight Loss >50%) in 84.2% of the patients after three years compared with gastric bypass (59.3% after three years). 1

Bariatric surgery causes weight loss in one of three ways: by restriction (reducing the size of the stomach to limit food intake), malabsorption (bypassing a portion of the small intestine to limit absorption of calories and nutrients), or a combination of the two. In 2010, the most common bariatric surgical procedures were some form of gastric bypass ( 54.68%), some form of gastric banding (39.62%), and sleeve gastrectomy (2.29%). BPD/DS represented less than 1% of bariatric surgeries (.89%)2 as it still does today, yet it is recognized as the most sustainable weight loss surgery because it bypasses more of the small intestine, allowing for more malabsorption.

DS is the combination of vertical sleeve gastrectomy (in which the stomach is stapled, reducing it by as much as 70%) and an intestinal bypass. In the latter, the first part of the small intestine (the duodenum) is divided, the last part of intestine is brought up and connected to the outlet of the newly created stomach, and thus about three-fourths of the small intestine no longer receives the food and calorie stream. DS done laparoscopically is technically difficult because of the potential for the surgeon’s disorientation when rerouting the intestine. Furthermore, DS in general is difficult because it is reserved for the super-obese.

“DS, like all other bariatric procedures,” says Byrne, “requires physicians to discuss risks vs. benefits with the patient. Complications with DS are higher, but it may be more beneficial than gastric bypass or sleeve gastrectomy.” As is the case with any bariatric surgery, vitamin supplements will be required for the rest of the patient’s life, and DS patients need higher doses of fat-soluble vitamins and proteins due to the more aggressive malabsorption resulting from the procedure. Other complications include the potential for bowel obstruction and leakage of the stomach or the new intestinal connections.

References

1 Prachand V, et al. Annals of Surgery 2006 October; 244(4): 611-619.

2 DeMaria E, et al. Surgery for Obesity and Related Diseases 2010;6(4):347-355