Superobese and super-superobese patients: 2-step laparoscopic duodenal switch.
BACKGROUND
Morbidity and mortality after bariatric surgery in superobese (body mass index [BMI] >50 but <60 kg/m2) and super-superobese (BMI >60 kg/m2) patients can allegedly be reduced by performing surgery in 2 steps. We report a retrospective study gathered from a prospective database for superobese and super-superobese patients who underwent laparoscopic biliopancreatic diversion/duodenal switch (LBPD/DS) after laparoscopic sleeve gastrectomy (LSG) as the first step.


METHODS
From October 2004 to June 2010, 31 patients underwent LBPD/DS after LSG. The mean age was 45.8 ± 10.1 years (range 21-64). The mean interval between the 2 procedures was 13.9 ± 8.4 months (range 6-37). At LSG, the mean weight and BMI was 168.8 ± 35.4 kg (range 127-255) and 58.3 ± 6.7 kg/m2 (range 50-74.5). At LBPD/DS, the mean weight, BMI, and percentage of excess weight loss was 136.3 ± 32.6 kg (range 92-220), 47.1 ± 7.2 kg/m(2) (range 37.8-64.3), and 31.6% ± 12.2% (range -11.7 to +54.6). At LSG, 26 patients had 43 obesity co-morbidities. Three co-morbidities (6.9%) resolved in 3 patients before the second step of LBPD/DS was performed.


RESULTS
The mean operative time was 175.5 ± 60.6 minutes (range 75-285). There were no deaths or conversions to open surgery. Four patients had early complications (1 anastomotic leak, 1 small bowel perforation, 1 case of renal insufficiency, and 1 case of pneumonia). The mean hospital stay was 6.6 ± 8 days (range 3-35). All patients, with the exception of 3, were followed up for a mean of 28.8 ± 21.4 months (range 4-71). At follow-up, the mean weight, BMI, and percentage of excess weight loss (compared with the pre-LSG weight) was 99.4 ± 23.7 kg (range 62-150), 34.5 ± 5.8 kg/m2 (range 24.9-46.3), and 54.8% ± 16% (range 18.9-84.8). A total of 22 obesity co-morbidities (51.1%) resolved in 14 patients. Three patients presented with late complications (1 ventral hernia, 1 case of protein deficiency, 1 anastomotic stenosis).


CONCLUSIONS
In the treatment of superobese and super-superobese patients with 2-step LBPD/DS, we experienced no deaths and achieved acceptable morbidity, considering the high operative risk in this group. This procedure is effective for both weight loss and resolution of co-morbidities.
Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium. giovanni@dapri.net
Giovanni
G
Dapri
Guy Bernard
GB
Cadière
Jacques
J
Himpens
D000328:Adult; D000714:Anastomosis, Surgical; D050110:Bariatric Surgery / Q000379:methods*; D015904:Biliopancreatic Diversion / Q000379:methods*; D004386:Duodenum / Q000601:surgery*; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011446:Prospective Studies; D012189:Retrospective Studies; D016896:Treatment Outcome; D015431:Weight Loss; D055815:Young Adult