Wernicke Encephalopathy After Bariatric Surgery: a Literature Review.

Wernicke encephalopathy (WE) is an acute neurological disorder classically characterized by ataxia, ophthalmoplegia, and altered mental status. This is caused by thiamine deficiency and is usually seen in malnourished populations. However, with the advent and rise of bariatric surgery in the last 50 years, WE has become an increasingly recognized and potentially deadly complication. Here, we review the populations at risk, clinical presentation, and the incidence of WE in the bariatric surgery population from 1985 to 2023. While the predominant procedure shifts throughout the years, the overall incidence of WE per 100,000 cases for the following procedures are sleeve gastrectomy (1.06), gastric band (1.16), RYGB (4.29), and biliopancreatic diversion with duodenal switch (8.92). Thus, early intervention and post-operative supplementation is recommended to prevent WE.

Late complications of biliopancreatic diversion in an older patient: a case report.

BACKGROUND: In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications. CASE PRESENTATION: A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning. CONCLUSIONS: Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.

Sterile Corneal Perforation Occurring Several Years After Biliopancreatic Diversion.

BACKGROUND: To report the first two cases of sterile corneal perforation secondary to vitamin A deficiency after biliopancreatic diversion with duodenal switch (BPD/SW). METHODS: Observational case series. RESULTS: Two patients with a history of BPD/SW presented with corneal perforation associated with conjunctival xerosis and keratopathy. In both cases, serum vitamin A level dosage revealed a marked deficit, and the patients admitted poor compliance with vitamin supplementation. Oral therapy with vitamin A was started immediately, and in one case ocular surgery was performed to preserve the integrity of the globe. CONCLUSIONS: Ophthalmologists should carefully examine the ocular surface of patients undergone bariatric surgery in order to promptly recognize the signs of vitamin A deficiency and avoid serious sight-threatening complications.

Malnutrition in obesity before and after bariatric surgery.

Bariatric surgeries are considered the only effective way of weight loss therapy in morbidly obese patients, i.e. body mass index ≥ 35. However, micronutrient deficiencies and malnutrition are common after most bariatric procedures and thus, pre- and postoperative nutritional assessment and corrections are advised. The present review is presented in an effort to describe in some detail about prevalence, and mechanisms of macro- and micronutrient deficiencies in obese and post-bariatric surgery individuals. We also aimed to summarize the data on screening and supplementation of macro- and micronutrients before and after bariatric surgeries.

Treatment of Vitamin and Mineral Deficiencies After Biliopancreatic Diversion With or Without Duodenal Switch: a Major Challenge.

BACKGROUND: Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies. METHODS: Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS. RESULTS: Patients were introduced into the program 12-90 months after surgery. Vitamin B1, B6, B9, and B12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 µg, 600 µg, and 350 µg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies. CONCLUSION: Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.

Laparoscopic Reversal of the Biliopancreatic Diversion with Duodenal Switch: a Step by Step Video Case.

BACKGROUND: Despite the success of the Biliopancreatic Diversion with Duodenal Switch procedure (BPD-DS) in weight loss and comorbidities resolution, reversal of BPD-DS is necessary in 0.2-0.6% of BPD-DS cases for vitamin, protein, and other micronutrient deficiencies. Different techniques are available to reverse the malabsorptive component of the BPD-DS. METHODS: A retrospective chart review for a 37-year-old female patient who presented with lower leg edema and signs of malnutrition 5 years after a BPD/DS. The patient was not compliant with the required daily vitamin and protein intake. Thus, after extensive discussion with the patient, a decision was made to reverse the malabsorptive component of the BPD-DS. RESULTS: A laparoscopic reversal of the malabsorptive component of the BPD-DS was concluded by transecting the roux limb distally at the ileo-ileal anastomosis and reconnecting it to the proximal jejunum thus substantially lengthening the common channel for absorption. At 6 months follow-up, the patient normalized her vitamin deficiency and had a normal level of serum protein. Her weight, BMI, EWL%, and TBWL% were 72 kg, 27.5 kg/m2, 90%, and 45%, respectively. CONCLUSIONS: Proper nutrition and vitamin supplementation is essential to avoid nutritional complications. Different techniques are available to reverse the malabsorptive component of the BPD-DS. However, no standard approach is adopted by the surgical community. We demonstrate our preferred technique in reversing the malabsorptive component of the BPD-DS.

[Choice of bariatric and metabolic surgical procedures].

Bariatric and metabolic surgery has become the clinical hot topic of the treatment of metabolic syndromes including obesity and diabetes mellitus, but how to choose the appropriate surgical procedure remains the difficult problem in clinical practice. Clinical guidelines of American Society for Metabolic and Bariatric Surgery(ASMBS)(version 2013) introduced the procedures of bariatric and metabolic surgery mainly including biliopancreatic diversion with duodenal switch(BPD-DS), laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy(LSG). To choose the appropriate bariatric and metabolic procedure, the surgeons should firstly understand the indications and the contraindications of each procedure. Procedure choice should also consider personal condition (body mass index, comorbidities and severity of diabetes), family and socioeconomic status (postoperative follow-up attendance, understanding of potential surgical risk of gastrectomy and patient's will), family and disease history (patients with high risk of gastric cancer should avoid LRYGB; patients with gastroesophageal reflux disease should avoid LSG) and associated personal factors of surgeons. With the practice of bariatric and metabolic surgery, the defects, especially long-term complications, of different procedures were found. For example, LRYGB resulted in higher incidence of postoperative anemia and marginal ulcer, high risk of gastric cancer as well as the requirement of vitamin supplementation and regular follow-up. Though LSG has lower surgical risk, its efficacy of diabetes mellitus remission and long-term weight loss are inferior to the LRYGB. These results pose challenges to the surgeons to balance the benefits and risks of the bariatric procedures. A lot of factors can affect the choice of bariatric and metabolic procedure. Surgeons should choose the procedure according to patient's condition with the consideration of the choice of patients. The bariatric and metabolic surgery not only manages the diabetes mellitus and weight loss, but also results in the reconstruction of gastrointestinal tract and side effect. Postoperative surgical complications and nutritional deficiency should also be considered. Thereby, individualized bariatric procedure with the full consideration of each related factors is the ultimate objective of bariatric and metabolic surgery.

Nutrient Status 9 Years After Biliopancreatic Diversion with Duodenal Switch (BPD/DS): an Observational Study.

BACKGROUND: Since biliopancreatic diversion with duodenal switch (BPD/DS) produces hypoabsorption, evaluation of long-term nutrient changes is appropriate. METHODS: Measurements of micronutrients, trace elements, PTH, iron studies, and protein were completed for consented patients at baseline prior to surgery and at yearly intervals. The patients were advised and supplements were adjusted by blood studies with compliance checks. Independent t tests and ANOVAs compared changes between cross-sectional cohorts based on follow-up time from surgery. A p value of 0.05 was considered significant. RESULTS: Between 1999 and 2010, 284 patients had BPD/DS. At baseline, nutrient analysis was available for only 190 patients (70% women), age 42.7 ± 10.0 years, BMI 53.0 ± 11.9 kg/m2; at year 1, 189 were available; at year 3, 193; at year 5, 132; at year 7, 98; and at year 9, 68. Gender distribution was not significantly different between cohorts. Baseline vitamin D was low and PTH high. All of the patients took some supplements. Fat-soluble vitamins remained low. Protein deficiency appeared at year 3 and increased to 30% at year 9. Baseline zinc was normal, but at year 5, 45% were low. Over time, hematocrit was low for 40% and hemoglobin for 46%. Iron deficiency continued through year 9, more marked in males. Calcium deficiency increased from year 3 and remained steady. Half of the patients had abnormal PTH at baseline, and the percentage increased over time. Twenty percent had abnormal baseline magnesium values. Magnesium fluctuated during observation. CONCLUSIONS: Major deficits in nutrient status occurred and persisted after surgery although supplementation was prescribed. Interventions are mandated to avoid nutrient deficiency.

Weight Loss and Nutritional Outcomes 10 Years after Biliopancreatic Diversion with Duodenal Switch.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgical procedure, but major concerns exist about the nutritional consequences. OBJECTIVES: The study reported weight loss and nutritional outcomes of 80 patients with a follow-up of at least 10 years. SETTING: The follow-up was conducted at a university hospital as well as in a private practice institution in France. METHODS: Eighty patients operated on between February 2002 and May 2006 were reviewed. Weight outcomes were analyzed as well as complete biological status. Revisions were reported as well as the number of patients taking vitamin supplementation. RESULTS: A follow-up of 141 ± 16 months was available for 87.7% of the patients at least 10 years from surgery. Preoperative BMI decreased from 48.9 ± 7.3 to 31.2 ± 6.2 kg/m2 with an EWL of 73.4 ± 26.7% and a TWL of 35.9% ± 17.7%. Despite weight regain ≥10% of the weight loss in 61% of the cases, 78% of the patients maintained a BMI <35. Fourteen percent of the patients had a revision. Normal vitamin D levels were found in 35.4%. The overall PTH level was 91.9 ± 79.5 ng/mL, and 62% of the patients had hyperparathyroidism. Other deficiencies were less frequent but fat-soluble deficiencies as well as a PTH >100 ng/mL were significantly associated with the absence of vitamin supplementation. CONCLUSION: BPD/DS maintains a significant weight loss, but remains associated with side effects leading to revision and multiple vitamin deficiencies. The most severe deficiencies are related to the lack of supplementation compliance.

Micronutrient Supplementation after Biliopancreatic Diversion with Duodenal Switch in the Long Term.

BACKGROUND: Malabsorptive bariatric surgery requires life-long micronutrient supplementation. Based on the recommendations, we assessed the number of adjustments of micronutrient supplementation and the prevalence of vitamin and mineral deficiencies at a minimum follow-up of 5 years after biliopancreatic diversion with duodenal switch (BPD-DS). METHODS: Between October 2010 and December 2013, a total of 51 patients at a minimum follow-up of 5 years after BPD-DS were invited for a clinical check-up with a nutritional blood screening test for vitamins and minerals. RESULTS: Forty-three of fifty-one patients (84.3 %) completed the blood sampling with a median follow-up of 71.2 (range 60-102) months after BPD-DS. At that time, all patients were supplemented with at least one multivitamin. However, 35 patients (81.4 %) showed either a vitamin or a mineral deficiency or a combination of it. Nineteen patients (44.1 %) were anemic, and 17 patients (39.5 %) had an iron deficiency. High deficiency rates for fat-soluble vitamins were also present in 23.2 % for vitamin A, in 76.7 % for vitamin D, in 7.0 % for vitamin E, and in 11.6 % for vitamin K. CONCLUSIONS: The results of our study show that the prevalence of vitamin and mineral deficiencies after BPD-DS is 81.4 % at a minimum follow-up of 5 years. The initial prescription of micronutrient supplementation and further adjustments during the first follow-up were insufficient to avoid long-term micronutrient deficiencies. Life-long monitoring of micronutrients at a specialized bariatric center and possibly a better micronutrient supplementation, is crucial to avoid a deficient micronutrient status at every stage after malabsorptive bariatric surgery.

Management of vitamin K deficiency after biliopancreatic diversion with or without duodenal switch.

BACKGROUND: Reduced serum vitamin K levels are frequently observed after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). The criteria for treatment are not precisely defined. OBJECTIVES: To assess the effects of standardized vitamin K supplementation in patients who develop vitamin K deficiency after BPD or BPD/DS. SETTING: Teaching hospital specializing in bariatric surgery. METHODS: Serum vitamin K levels, clotting times, and vitamin K-dependent coagulation factors were measured after an overnight fast at baseline and then at 4 days and 1, 4, and 52 weeks after the start of vitamin K supplementation in 10 consecutive patients who had developed severe vitamin K deficiency after BPD or BPD/DS. Vitamin K was administered in a dose of 5 mg/d for 1 week, followed by a maintenance dose of 5 mg once a week. RESULTS: At baseline, all patients had serum vitamin K1 levels below the limit of detection, but none reported symptoms of easy bleeding. Minor prolongation of the prothrombin time and minimal decreases of some coagulation factors were observed in a minority of patients. During the first week of vitamin K loading, median serum vitamin K1 levels rose into the high normal range. During maintenance treatment, median vitamin K1 levels settled in the low normal range. CONCLUSION: Vitamin K1 deficiency in patients with BPD or BPD/DS is not commonly associated with bleeding or clinically relevant decreases in coagulation factor activity. We hypothesize that vitamin K2 production in the large intestine is usually sufficient to compensate for vitamin K1 deficiency and to maintain total liver vitamin K stores within the range required for (near) normal coagulation factor production.

Refeeding Syndrome: An Important Complication Following Obesity Surgery.

BACKGROUND: Refeeding syndrome (RFS) is an important and well-known complication in malnourished patients, but the incidence of RFS after obesity surgery is unknown and the awareness of RFS in obese patients as a postsurgical complication must be raised. We present a case of RFS subsequent to biliopancreatic diversion in a morbidly obese patient. CASE REPORT: A 48-year-old female patient with a BMI of 41.5 kg/m2 was transferred to our hospital due to Wernicke's Encephalopathy in a global malabsorptive syndrome after biliopancreatic diversion. Parenteral nutrition, vitamin supplementation and high-dosed intravenous thiamine supplementation were initiated. After 14 days, the patient started to develop acute respiratory failure, and neurological functions were impaired. Blood values showed significant electrolyte disturbances. RFS was diagnosed and managed according to the NICE guidelines. After 14 days, phosphate levels had returned to normal range, and neurological symptoms were improved. CONCLUSION: Extreme weight loss following obesity surgery has been shown to be associated with undernutrition. These patients are at high risk for evolving RFS, even though they may still be obese. Awareness of RFS as a postsurgical complication, the identification of patients at risk as well as prevention and correct management should be routinely performed at every bariatric center.

Twelve key nutritional issues in bariatric surgery.

In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

A clinical and nutritional comparison of biliopancreatic diversion performed with different common and alimentary channel lengths.

BACKGROUND: This retrospective study compares the clinical and nutritional outcomes of 100 morbidly obese patients who underwent biliopancreatic diversion (BPD) with common (CC) and alimentary channel (AC) length, respectively, 50/250 and 80/200 cm. METHODS: One hundred patients who received BPD from October 2006 to November 2011 were identified from a database of bariatric procedures performed at the University Hospital of Messina, and the outcomes in terms of weight loss and morbidity were compared. Forty morbidly obese patients underwent BPD with CC 80 cm and AC 200 cm (group 1) and 60 morbidly obese patients underwent BPD with CC 50 cm and AC 250 cm (group 2). RESULTS: A gradual weight loss was observed in both groups during the first 3 years after the operation without any significant difference between the two groups. Two cases of protein malnutrition occurred in the group 2 (3 %) due to poor patient compliance in terms of adequate dietary protein intake. Sideropenic anemia was found in 42 % of obese patients in group 2 versus 22.5 % in group 1 at third-year follow-up despite adequate supplementation (p = 0.047). Diarrhea occurred more frequently with a shorter CC. Lipophilic vitamin deficiencies occurred more frequently with a shorter CC despite adequate oral supplementation. CONCLUSIONS: In the medium term, our series showed that shorter CC was associated with no weight loss advantage but with higher morbidity rate, especially in young and fertile women. We recommend a longer CC (80 cm) to be performed especially in this sub-population of obese patients.

Pregnancy outcomes and nutritional indices after 3 types of bariatric surgery performed at a single institution.

BACKGROUND: Nutritional status during pregnancy and the effects of nutritional deficiencies on pregnancy outcomes after bariatric surgery is an important issue that warrants further study. The objective of this study was to investigate pregnancy outcomes and nutritional indices after restrictive and malabsorptive procedures. METHODS: We investigated pregnancy outcomes of 113 women who gave birth to 150 children after biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between June 1994 and December 2011. Biochemical indices and pregnancy outcomes were compared among the different types of surgery and to overall 20-year hospital data, as well as to 56 presurgery pregnancies in 36 women of the same group. RESULTS: Anemia was observed in 24.2% and 15.6% of pregnancies after BPD and RYGB, respectively. Vitamin B12 levels decreased postoperatively in all groups, with no further decrease during pregnancy; however, low levels were observed not only after BPD (11.7%) and RYGB (15.6%), but also after SG (13.3%). Folic acid levels increased. Serum albumin levels decreased in all groups during pregnancy, but hypoproteinemia was seen only after BPD. Neonates after BPD had significantly lower average birth weight without a higher frequency of low birth weight defined as<2500 g. A comparison of neonatal data between babies born before surgery and siblings born after surgery (AS) showed that AS newborns had lower average birth weight with no significant differences in body length or head circumference and no cases of macrosomia. CONCLUSION: Our study showed reasonably good pregnancy outcomes in this sample population after all types of bariatric surgery provided nutritional supplement guidelines are followed. Closer monitoring is required in pregnancies after malabsorptive procedures especially regarding protein nutrition.

Biliopancreatic diversion requires multiple vitamin and micronutrient adjustments within 2 years of surgery.

BACKGROUND: Malabsorptive bariatric procedures require multiple vitamin supplements, especially regarding fat-soluble vitamins. The exact amount required to maintain normal serum concentrations is still largely unknown. Based on the initial postoperative prescription, we assessed the number of adjustments and the amount of vitamins/micronutrients to normalize the biological markers 2 years after the biliopancreatic diversion with duodenal switch (BPD/DS). METHODS: A total of 112 consecutive patients had a laparoscopic BPD/DS between February 2007 and November 2010 for a body mass index of 53.1±5.9 kg/m² at a private hospital. Complete blood checks with vitamin status were obtained at each of the 3-month interval visits during the 1(st) postoperative year as well as twice during the 2(nd) year. RESULTS: Initially, all of the patients were prescribed daily 25,000 International units (IU) of vitamin A, 1000 mg of calcium, multivitamins, and 1900 IU of vitamin D3. Significant adjustments were necessary 3.6±1.1 times during this period. A total of 80% of the patients required added vitamin A, vitamin D, as well as calcium, zinc, and iron. After 2 years,≥20% of patients exhibited vitamin A and iron deficiency with low prealbumin or micropenic anemia. Seventy percent had vitamin D deficiency and 50% secondary hyperparathyroidism. CONCLUSION: The initial prescription was insufficient to cover the requirements after BPD/DS. At least 3000 mg of calcium with 7000 IU of vitamin D, 50,000 IU of vitamin A, 40 mg of zinc, and 200 mg of iron must be prescribed to start with. The trend toward a decrease in 25 OH vitamin D and hyperparathyroidism remains difficult to control although it can result from increased bone turnover during the early postoperative period.

Adrenal insufficiency following bariatric surgery.

A 35-year-old woman with morbid obesity and amenorrhoea underwent a bilo-pancreatic diversion (BPD). Surgery was successful with good weight loss, restoration of menstruation and almost immediately she conceived for the first time. She was commenced on routine vitamin supplements after surgery but failed to attend follow-up clinic. Five years later, she presented with limb girdle pains, lethargy, night blindness, skin pigmentation, amenorrhoea and dizziness. She had stopped taking supplements prescribed after the surgery. Investigations showed severe vitamin A and D deficiency along with iron and calcium deficiency. Her cholesterol was low at 3.5 mmol L⁻¹. Despite aggressive vitamin replacement, she continued to complain of lethargy and dizziness. Subsequently, three short adrenocorticotropic hormone-stimulation tests were suboptimal (basal cortisol: 196, 185 and 223 nmol L⁻¹; 30 min cortisol: 421, 453 and 435 nmol L⁻¹). She was subsequently commenced on adrenal replacement and her symptoms resolved and she conceived. We describe for the first time in the literature the unexpected finding of adrenal insufficiency following a BPD.

Phrynoderma: a rare dermatologic complication of bariatric surgery.

Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.

[Duodenal switch: a comprehensive view of a biliopancreatic diversion in metabolic surgery]. / Cruce duodenal: visión integral de una derivación biliopancreática en cirugía metabólica.

The duodenal switch is a technique of Bariatric Surgery that modifies the Scopinaro biliopancreatic diversion, described by Hess and Marceaux in 1988, supported by the original description that made De Meester for the treatment of gastroesophageal reflux recurrent disease. It is a complex technique, probably the most laborious of all bariatric procedures until now known, which can and must be done by laparoscopy and consisting of several surgical steps. It involves the performance of a vertical gastrectomy with bougies of different diameter and a bypass Roux-en-Y into the duodenum, with different lengths limbs. Duodenoileal anastomosis is the most difficult and different techniques are described. It must be accompanied by closure of the defects and in most of the cases of an appendectomy and cholecystectomy. There have been greater than the gastric bypass Roux-en-Y in operating time, hospitalization, morbidity and mortality. Reported complications are up a 24% of the cases, early or late, these are metabolic one and easily controllable, so a good index of satisfaction with low percentage of review and no more than 1.5% mortality. Achieved a decrease of 70% of excess weight in the long term, with improvement in all co-morbidities reaching around a 95% diabetes and metabolic control of the dyslipidemias. Given the good results it should be seen as a technique of choice for the treatment of the obese patient with metabolical disorder.