Traditionally, biliopancreatic diversion with lateral “sleeve” gastrectomy and biliopancreatic diversion has been performed as a single or staged procedure for patients categorized as “superobese.” The technical challenges of performing the procedure laparoscopically combined with the associated severe nutritional deficiencies have made this combined procedure less popular in recent years. Initially offered as the first part of the staged procedure prior to weight loss, the sleeve gastrectomy has become increasingly popular as a stand-alone procedure. Reports of excellent weight reduction have become increasingly common in the literature, resulting in the acceptance of the procedure by the American Society of Metabolic and Bariatric Surgery as a surgical option in select patients. Although many minimally invasive surgeons consider it to be technically less challenging to perform, the risk of leak from the long gastric staple line, gastric dysmotility, and treatment failure due to delayed dilation of the stomach should warrant caution among inexperienced bariatric surgeons.
The biliary pancreatic diversion creates a malabsorptive state in which bile and digestive enzymes within a long afferent intestinal limb contact food within a “common channel” measuring only 100 cm. The alimentary limb of the Roux-en-Y measures only 250 cm from its anastomosis with the duodenum to the cecum. The small intestine is normally 600 cm long (with some variation), so in this operation, the total length of the small intestine is shortened to about 40% of normal, but the length of the “common channel,” where digestion of complex fats and proteins occurs, is only 1/6 or 16% of normal. When combined with the lateral gastrectomy, the procedure accomplishes dramatic weight loss by creating both severe restrictive and malabsorptive conditions.
Bariatric surgery patients require an extensive preoperative evaluation to determine their anesthetic risk, to define the severity of known comorbidities, and to identify occult comorbid conditions such as sleep apnea, obesity hypoventilation syndrome, and coronary artery disease. This evaluation requires a multidisciplinary approach. The bariatric team should include dieticians, psychologists, and medical subspecialists who can optimize the patient’s cardiovascular, pulmonary, and endocrine status before surgery. Patients with active substance abuse problems or uncontrolled psychiatric disorders are not candidates for bariatric surgery. Strong family and social support for the patient is important to achieving a successful outcome.
Patients who are preparing for bariatric surgery must be fully informed about all of the available surgical options. The choice of laparoscopic bariatric operations today include laparoscopic adjustable gastric banding, sleeve gastrectomy, gastric bypass, or a malabsorptive procedure such as biliopancreatic diversion (BPD) or BPD with duodenal switch (BPDS). The risks and benefits of lateral sleeve gastrectomy and duodenal switch should be discussed in detail with the patient and put into context with the other available bariatric procedures and other major laparoscopic operations performed today.
Laparoscopic sleeve gastrectomy with or without duodenal switch requires a general anesthetic. The anesthesiologist must be ...