title: Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI > or = 50 kg/m2?
abstract: BACKGROUND
  Biliopancreatic diversion with or without the duodenal switch (BPD-DS) is a major bariatric procedure. The morbidity and mortality are likely to increase with an increasing body mass index (BMI), especially when > 50 kg/m(2). Controversy exists regarding the potentially increased risks of a single-stage procedure compared with the risks of sleeve gastrectomy first followed by the malabsorptive procedure after an initial weight loss.
  
  
  METHODS
  From March 2003 to October 2008, 90 patients with a BMI > or = 50 kg/m(2) were candidates for single-stage BPD-DS. Two study periods were identified: before and after February 2007, corresponding to the periods during and after the learning curve. The results were analyzed globally and by comparing the 2 periods using Fisher's exact test and the t test for unpaired values.
  
  
  RESULTS
  Of the 90 patients, 79 were women, the average BMI was 55.2 +/- 4.7 kg/m(2), 13 patients were super-super obese, and 4 patients underwent laparoscopic sleeve gastrectomy only. Of the 86 patients who underwent single-stage BPD-DS, 37 underwent surgery before (31 laparoscopically; group 1) and 49 after (48 laparoscopically; group 2) February 2007. BPD-DS was done as revision surgery for 14 patients with a failed restrictive procedure. The global rate of conversion to open surgery was 13.9%; 35.5% for group 1 versus 2% for group 2 (P = .0001). The morbidity decreased significantly between the 2 periods, with a rate of 16.3% for group 2 compared with 45.9% for group 1. Also, 1 postoperative death occurred in group 1.
  
  
  CONCLUSIONS
  Single-stage BPD-DS in the super obese appears to be a relatively safe procedure with a low rate of conversion when a laparoscopic approach is used. Although from the published data, the morbidity and mortality are increased for super obese patients, especially men, the BMI itself cannot be considered a contraindication for single-stage BPD-DS, because other factors such as surgical experience also influence the outcome. Despite these variables, performing a sleeve gastrectomy first should be considered for heavier, male, and at-risk patients.
authors.affiliation: Société de Chirurgie Viscérale, Clinique de l'Anjou, Angers, France. philippetopart@wanadoo.fr
authors.forename: Philippe
authors.initials: P
authors.lastname: Topart
authors.forename: Guillaume
authors.initials: G
authors.lastname: Becouarn
authors.forename: Patrick
authors.initials: P
authors.lastname: Ritz
mesh_terms: D000328:Adult; D015904:Biliopancreatic Diversion / Q000379:methods*; D015992:Body Mass Index; D005260:Female; D005743:Gastrectomy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies