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During the past decade, bariatric surgery has evolved into multiple forms characterized by restriction, limited absorption, or both. Roux-en-Y gastric bypass has become the “gold standard” for obesity surgery.1 MacLean, Sugerman, and their colleagues, however, have reported that construction of a small gastric pouch with proximal small-bowel bypass has not yielded comparable weight-loss results in patients in the higher end of the spectrum of obesity.2,3 These superobese (body mass index, BMI > 50) and super-superobese (BMI > 60) patients lose more weight, but stabilize at a BMI considered to be obese or even morbidly obese. Therefore, these proximal-bypass procedures may decrease the actuarial mortality risk in superobese patients.

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Biliopancreatic diversion with duodenal switch (BPD/DS) is often regarded as the most extreme obesity surgery practiced currently. A vertical, subtotal, laparoscopic sleeve gastrectomy (LSG) is fashioned along the lesser curvature, and with the pylorus preserved, the duodenum is transected to form the biliopancreatic limb. The distal ileum is transected 250 cm from the ileocecal valve and distal end is brought up to create a duodenoileostomy. This alimentary limb then joins the biliopancreatic limb in the distal ileum with a 100-cm common channel.4–6

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In one study, review of the historical cohort of open BPD–DS in the super super obese patients (N = 28) showed a 17.0% morbidity and 3.5% mortality rate.7 A minimally invasive approach could potentially offer better postoperative pulmonary function, earlier return of physical activity, better wound healing, and in turn, reduced morbidity and mortality, because this population of patients often has underlying cardiovascular, pulmonary, and metabolic diseases that put them at adversely increased surgical risks.8,9

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The authors began performing laparoscopic BPD–DS (LBPD–DS) in 1999.10,11 The following year, the technical approach was reported and results of the early series of 25 and 40 patients with a mean BMI of 60 kg/m2 were noted. An overall 15.0% major morbidity and 2.5% mortality rates were achieved. When the data were stratified to patients with BMI greater than 65 kg/m2, a 38.0% versus 8.3% complication rate was noted in patients with BMI less than 65 kg/m2. More recent review of the unpublished 138 LBPD–DS experience (mean BMI: 54 kg/m2) showed excellent excess body weight loss (EBWL) of 68.0% at 6 months. Overall 13.0% major morbidity and 1.4% mortality rates were noted. In the super super morbidly obese patients with BMI > 60 kg/m2 (N = 31), the morbidity (23.0%) and mortality (6.5%) rates of LBPD–DS were significantly higher.

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For the surgeons, LBPD–DS is technically difficult, physically demanding, and requires advanced laparoscopic skills. For the super-superobese patients who carry much of their weight in the neck, torso, and abdomen, the various positions of the operative table to facilitate exposure may compromise their ventilation and preclude them from extended anesthesia. At times, increased pneumoperitoneum to 20 mm Hg may be necessary to ...

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