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Bilio-Pancreatic Diversion (Duodenal Switch Option)

This is also called the Scopinaro procedure, invented by Dr.Scopinaro from Italy. It is a purely malabsorptive procedure.

The Procedure

This procedure is also performed laparoscopically. About 60% of the stomach is removed from the duodenum side, leaving an upper stomach that can hold more than 250 ml or more than 8 oz. This is still a fairly good size stomach, so the patient has very minimal restriction and can eat a normal size meal.

The upper part of the stomach is connected to a shortened intestine, which is about 250 cm ( 8 ft ). The Bilio-Pancreatic Limb (the rest of the small intestine) where the bile and the digestive fluid drains into is connected to the Common Channel.

The Common Channel where the digestive fluid mixes with the food is about 50 cm ( 1..6 ft ).This means that the effective segment of the small intestine left for absorption is only about 10% of the entire length of the small intestine.

How This Procedure Works

The food that we consume needs digestive fluid for the calories and nutrients to be maximally absorbed. Digestion starts from the saliva in the mouth, followed by the stomach where the acid will interact with the food; then the bile from the liver that works on the fat; followed by the pancreatic enzymes secreted from the pancreas. Enzymes from the pancreas, such as the lipase (for fats), amylase (for carbohydrates), and protease (for protein) are needed to digest most of the food that we eat.

We normally have about 20 ft of small intestine to digest and absorb food. About 90% of the small intestine is excluded from the digestive process in this procedure. These patients can eat, but they are not absorbing most of the food, that include calories and nutrients from the food.

Whatever the small intestine did not absorb, the undigested food will then drain into the large intestine. The large intestine, or the colon, does not absorb calories or nutrients, it only absorbs water. So the fecal material that is expelled from the body of a normal person is usually in a semi-solid form.

The colon also contains a lot of bacteria. Mixture of undigested food from the PBD with the normal bacteria in the colon will produce foul smelling gas or feces.

Technique

Laparoscopically 6 small incisions are made. About 60% of the stomach is removed and the patient is left with still a fairly good size stomach to retain food. However the food is diverted to a shortened small intestine, cutting down on the absorption surface of food. We normally have about 20 feet of intestine for absorption. Only 8 feet is being utilized with this procedure. The common channel is made short. The range is between one and a half feet to about 5 feet.

Effectiveness of the Procedure

Weight loss is one of the best in the world (about 70% EWL excessive weight loss) in 15 years.

Advantages and disadvantages:

Dr. Scopinaro presented his long-term weight loss data as one of the best in the world. The main problem is malabsorption of nutrients in the food. Not only the calorie absorption is affected, the absorption of some of the essential vitamins and minerals is also hampered. Patients will be required to take multivitamins, B12, Iron, Calcium, and Vitamin A,D,E and K. Diarrhea and foul smelling stool are also a problem. With the passage of time, they do improve.

Side Effects

Aside from all of the complications of the RNY Gastric Bypass, too much malabsorption of calories and protein may result in severe malnutrition.

Average bowel movement is about 3.3 BMs per day. The stools and gas may be foul smelling and very soft

Aside from the daily multivitamins; calcium, B12 and Iron requirements, there is also the need to supplement the fat soluble vitamins such as vitamin A,D,E and K.

Some patients will develop “dumping Syndrome” from eating sweets or fatty foods. Symptoms include light headed ness, cold sweats; hot flashes; palpitations; nausea; stomach cramps; or diarrhea.

Indication for BPD

Dr. Scopinaro uses this procedure for all morbidly obese patients.

We selectively use this for patients who have failed previous RNY gastric bypass or are extremely large. The common channel that we utilize is between 100 cm to 150 cm, or about 3 to 5 feet. Constipated morbidly obese patients may also benefit from this procedure. The patient must be compliant for close post -operative follow-up.

Some insurance plans do not cover this procedure.