Chapter 28

Nicola Scopinaro introduced the biliopancreatic diversion in 1976, when he started studies in dogs, aiming at reducing or preventing serious complications from the jejunoileal bypass, such as unstable diarrhea, electrolyte disturbance, hypovitaminosis, protein malnutrition, hepatic insufficiency, nephrolithiasis, nausea, vomiting, and polyarthritis.1 (Please see Chapter 13.)

Due to the lack of blind-loop syndrome and malabsorption being selective as to starch and fat, the biliopancreatic diversion is free of those complications pertaining to the jejunoileal bypass.1,2

From the surgical model proposed at first by Scopinaro, several modifications were made in the length, at times of the alimentary limb, now in the biliopancreatic limb or the common channel, and also in the size of the remaining stomach, always in an attempt to achieve the best weight-loss results with minimal nutritional complications.3 After 1984 a standard was set consisting of a gastrectomy with the remaining stomach with a volume from 200 to 500 mL, a 2.5-m alimentary limb, and a 50-cm common channel. It is crucial for the measurement of the intestinal loops to be taken always on the antimesenteric side with maximum traction (please see Chapter 10) (Figure 28–1).4

###### Figure 28–1.

BPD standard.

Cholecystectomy was added to the procedure due to the high rate of biliary stones, probably due to a failure of the enterohormonal stimulus, with dismotility of the gallbladder associated with an increase in cholesterol biliary excretion.3

Laparoscopic surgery for the treatment of morbid obesity began in the 1990s with the implantation of lap bands, both adjustable or not, by Catona, Belachew, Forsell, and Cadiére,5–7 and by Clark and Wittgrove, who introduced the first laparoscopic gastric bypass.8 (Please see Chapters 14 and 16.)

In 1999, Gagner did the first biliopancreatic diversion with duodenal switch laparoscopically.9 In 2000, Paiva did the first biliopancreatic diversion—as described by Scopinaro—through laparoscopy.10

It is apparent that laparoscopic surgery has many advantages compared to conventional surgery. These include reduced postoperative recovery time and return to normal activities, decrease in the rate of cardiopulmonary complications, lower hypermetabolic response, and a decrease in complications related to the abdominal wall, including infections, herniae, and postoperative dehiscence. It also has the advantage of reducing adhesions and decreasing postoperative ileus.

Indications for laparoscopic surgery are the same as those for open surgery, and these benefits certainly are extensive in the obese population. Every bariatric surgical can conceivably be done by laparoscopic surgery.17

The presence of previous procedures is not a contraindication to laparoscopic surgery; actually, the mobilization of adhesions with delicate dissection and minimum mobilization of structures represents advantages in relation to conventional surgery—it may provide good exposure alternatives without compromising visualization.17

The proper positioning ...

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