title: Two-stage laparoscopic biliopancreatic diversion with duodenal switch as treatment of high-risk super-obese patients: analysis of complications.
abstract: BACKGROUND
  The aim of this study is to retrospectively analyze the incidence of complications after two-stage laparoscopic biliopancreatic diversion with duodenal switch (Lap BPD-DS) in high-risk super-obese patients and explore the possible predictive factors of specific complications after laparoscopic sleeve gastrectomy (SG).
  
  
  METHODS
  High-risk patients--body mass index (BMI) > 50 kg/m(2) with at least two major comorbidities: type 2 diabetes, obstructive sleep apnea syndrome (OSAS), hypertension--undergoing two-stage laparoscopic BPD-DS were retrospectively analysed. The SG pouch volume was 100-150 ml; in the second stage, the common channel and the alimentary loop were 100 cm and 150 cm, respectively.
  
  
  RESULTS
  Eighty-seven patients (50 female, 57.5%) underwent SG (two open). The mean age was 41.8 +/- 10.22 years with BMI of 55.2 +/- 6.69 kg/m(2). Four patients had Prader-Willy syndrome. Fourteen (16.46%) patients (6 female, 42.8%) had postoperative complications such as bleeding, fistula, pulmonary embolism, transitory acute renal failure, and abdominal abscess. One patient died at postoperative day 5 of pulmonary embolism. One patient was reoperated for hemoperitoneum by laparoscopy. The risk of complications after SG was lower in patients where reinforcement of the suture line was used (0.492), while it was higher in men (1.780). Neither difference was statistically significant [p = not significant (NS)]. After 9-24 months, 27 patients (BMI 43 +/- 8 kg/m(2)) underwent a second stage of BPD-DS (two open). Major postoperative complications were registered in eight patients (29.6%): three bleeding, four duodeno-ileal stenosis and one rhabdomyolysis. Two cases of internal hernia required laparoscopic reoperation. The reoperation rate was 1/85 (1.2%) after SG and 2/27 (7.4%) after second stage.
  
  
  CONCLUSIONS
  Complications after SG greatly decrease after the learning curve period and can be successfully managed without need of reoperation. Suture-line reinforcement, at least selectively in the middle-upper portion of the staple line and in super-super-obese patients, is recommended to decrease the incidence of specific complications.
authors.affiliation: Department of Surgery Paride Stefanini, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy. gianfranco.silecchia@uniroma1.it
authors.forename: G
authors.initials: G
authors.lastname: Silecchia
authors.forename: M
authors.initials: M
authors.lastname: Rizzello
authors.forename: G
authors.initials: G
authors.lastname: Casella
authors.forename: M
authors.initials: M
authors.lastname: Fioriti
authors.forename: E
authors.initials: E
authors.lastname: Soricelli
authors.forename: N
authors.initials: N
authors.lastname: Basso
mesh_terms: D000328:Adult; D015904:Biliopancreatic Diversion; D004386:Duodenum / Q000601:surgery*; D005260:Female; D005743:Gastrectomy; D006801:Humans; D015994:Incidence; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors