Revisional Malabsorptive Bariatric Surgery: 29-Year Follow-up in a Brazilian Public Hospital.

BACKGROUND: This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. METHODS: The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. RESULTS: Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. CONCLUSIONS: Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Glucagon-Like Peptides 1 and 2 Are Involved in Satiety Modulation After Modified Biliopancreatic Diversion: Results of a Pilot Study.

BACKGROUND: This paper aimed to evaluate the influence of modified biliopancreatic diversion (BPD) on the levels of GLP-1 and GLP-2 and correlate them with satiety regulation. METHODS: This is a pilot prospective cohort study that evaluated six mildly obese individuals with type 2 diabetes mellitus, which underwent modified BPD and were followed-up for 12 months. Levels of GLP-1 and GLP-2 after a standard meal tolerance test were determined and correlated with satiety scores obtained by means of a visual analogue scale (VAS). RESULTS: There were significant changes in BMI (33 ± 2.2 versus 26.3 ± 2.2 kg/m2; p < 0.001), HbA1c (7.9 ± 1.6 versus 5.8 ± 1.2%; p = 0.026), total cholesterol (172.3 ± 11.1 versus 134.7 ± 16.1 mg/dL; p < 0.001), LDL-c (103.3 ± 13 versus 64.6 ± 12.2 mg/dL; p < 0.001), and postprandial GLP-2 (972.7 ± 326.2 versus 1993.2 ± 1024.7; p = 0. 044). None of the scores obtained in the VAS significantly changed after surgery. After surgery, there were significant correlations of VAS scores and GLP-1 levels in question 01 ("how hungry do you feel?"; R = -0.928; p = .008) and GLP-2 levels in questions 02 ("how full do you feel?" R = 0.943; p = 0.005) and 04 ("how much do you think you can eat now? R = -0.829; p = 0.042). CONCLUSIONS: Modified BPD does not lead to significant changes in satiety evaluated by the VAS; different aspects of satiety regulation are correlated with the postprandial levels of GLP-1 (hunger feeling) and GLP-2 (satiation feeling and desire to eat) 1 year after modified BPD, signaling a specific postoperative gut hormone-related modulation of appetite.

Bone turnover after bariatric surgery

ABSTRACT Objective The aim of the present study was to evaluate parameters of bone and mineral metabolism after bariatric surgery. Subjects and methods This sectional study included data from medical records from 61 bariatric surgery (BS) patients (minimum period of 6 months after the procedure) and from 30 class II and III obese patients as a control group (Cont), consisting of daily dietary intake of macronutrients, calcium and sodium, serum 25(OH)D and parathyroid hormone (PTH) and other biochemical serum and urinary parameters. Bone alkaline phosphatase (BAP), leptin, fibroblast growth factor-23 (FGF-23) and deoxypyridinoline (DPYD) were determined from available banked serum and urinary samples. Results Mean body mass index (BMI), median energy, carbohydrate, protein and sodium chloride consumption were significantly lower in the BS versus Cont, but calcium and lipids were not. No significant differences were found in ionized calcium, 25(OH)D, PTH and fibroblast growth factor 23 (FGF-23) between groups. Mean serum BAP was significantly higher for BS versus Cont and had a positive correlation with time after the surgical procedure. Mean serum leptin was significantly lower and median urinary DPYD higher in BS versus Cont. Conclusion The present study showed an increase in bone markers of both bone formation and resorption among bariatric patients up to more than 7 years after the surgical procedure, suggesting that an increased bone turnover persists even at a very long-term follow-up in such patients.

Bone turnover after bariatric surgery.

OBJECTIVE: The aim of the present study was to evaluate parameters of bone and mineral metabolism after bariatric surgery. SUBJECTS AND METHODS: This sectional study included data from medical records from 61 bariatric surgery (BS) patients (minimum period of 6 months after the procedure) and from 30 class II and III obese patients as a control group (Cont), consisting of daily dietary intake of macronutrients, calcium and sodium, serum 25(OH)D and parathyroid hormone (PTH) and other biochemical serum and urinary parameters. Bone alkaline phosphatase (BAP), leptin, fibroblast growth factor-23 (FGF-23) and deoxypyridinoline (DPYD) were determined from available banked serum and urinary samples. RESULTS: Mean body mass index (BMI), median energy, carbohydrate, protein and sodium chloride consumption were significantly lower in the BS versus Cont, but calcium and lipids were not. No significant differences were found in ionized calcium, 25(OH)D, PTH and fibroblast growth factor 23 (FGF-23) between groups. Mean serum BAP was significantly higher for BS versus Cont and had a positive correlation with time after the surgical procedure. Mean serum leptin was significantly lower and median urinary DPYD higher in BS versus Cont. CONCLUSION: The present study showed an increase in bone markers of both bone formation and resorption among bariatric patients up to more than 7 years after the surgical procedure, suggesting that an increased bone turnover persists even at a very long-term follow-up in such patients.

Transenteric ERCP for Treatment of Choledocholithiasis After Duodenal Switch.

This article aims to describe step-by-step technique performed with the aid of a video. We report the performance of an endoscopic approach to the biliary tract on 2 patients who had previously undergone duodenal switch (DS). It was successfully performed a laparoscopic-assisted transenteric endoscopic retrograde cholangiopancreatography (ERCP) in both the patients. Although successful experiences with ERCP after Roux-en-Y gastric bypass have been found, few cases of ERCP after DS have been reported. Nevertheless, this is the first study to include a multimedia video with description of details and all technical steps of the transenteric ERCP performed on 2 patients who had previously undergone DS. Transenteric access is a feasible technique for reaching the biliary tract through endoscopy after DS. This technique could avoid most invasive and risky procedures. However, it requires a high level of therapeutic endoscopic training.

Liver failure following biliopancreatic diversions: a narrative review.

CONTEXT AND OBJECTIVE:: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING:: Narrative review; bariatric surgery service of a public university hospital. METHODS:: A review of the literature was conducted through an online search of medical databases. RESULTS:: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS:: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

Liver failure following biliopancreatic diversions: a narrative review / Falência hepática após derivações biliopancreáticas: uma revisão narrativa

ABSTRACT CONTEXT AND OBJECTIVE: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING: Narrative review; bariatric surgery service of a public university hospital. METHODS: A review of the literature was conducted through an online search of medical databases. RESULTS: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

RESUMO CONTEXTO E OBJETIVO: A ocorrência de falência hepática após a derivação jejunoileal foi extensivamente descrita no passado e foi um dos principais fatores que levaram ao abandono do procedimento. Os procedimentos predominantemente malabsortivos mais modernos, chamados de derivações biliopancreáticas, também já foram implicados em diversos casos de falência hepática aguda e subaguda. O objetivo foi revisar a atual evidência disponível sobre a ocorrência de insuficiência hepática após derivações biliopancreáticas. TIPO DE ESTUDO E LOCAL: Revisão narrativa; Serviço de Cirurgia Bariátrica de hospital universitário. MÉTODOS: Revisão da literatura conduzida por meio de pesquisa online de bancos de dados médicos. RESULTADOS: A associação entre derivações biliopancreáticas e falência hepática na literatura é infrequente. Entretanto, ela aparenta ser mais do que meramente anedótica. Os mecanismos fisiopatológicos continuam pouco compreendidos, mas parecem estar relacionados à rápida perda de peso, desnutrição proteica e déficit de fatores hepatotróficos, altos níveis circulantes de ácidos graxos livres e supercrescimento bacteriano em segmentos intestinais excluídos do trânsito. A reversão da cirurgia pode melhorar o comprometimento hepático. CONCLUSÕES: Embora infrequente, a falência hepática continua sendo preocupante após as derivações biliopancreáticas. Seguimento cuidadoso é mandatório em indivíduos submetidos a essas cirurgias.

IMPACT ON QUALITY OF LIFE, WEIGHT LOSS AND COMORBIDITIES: a study comparing the biliopancreatic diversion with duodenal switch and the banded Roux-en-Y gastric bypass / Impacto na qualidade de vida, perda de peso e comorbidades: estudo comparativo entre as intervenções cirúrgicas derivação biliopancreática tipo “duodenal switch” e derivação gástrica em Y de Roux com anel

Context Few studies have evaluated the results of different types of bariatric surgery using the Medical Outcome Study 36 - Health Survey Short-Form (SF-36) quality of life questionnaire, the Bariatric and Reporting Outcome System (BAROS) and the reviewed Moorehead-Ardelt Quality of Life II Questionnaire (M-A QoLQ II) that is part of BAROS. The Roux-en-Y gastric bypass (RYGB) is the most common morbid obesity surgery worldwide. However, there is evidence indicating that a biliopancreatic diversion with duodenal switch (DS) is more effective than RYGB in weight loss terms. Objectives To evaluate the impact of different types of bariatric surgery on quality of life, comorbidities and weight loss. Methods Two groups of patients who underwent bariatric surgery conventional Banded Roux-en-Y gastric bypass (BRYGB) or DS were evaluated through monitoring at 12 to 36 months after surgery, as well as a control group of obese patients who had not undergone surgery. The tools used for this were SF-36, BAROS and M-A QoLQ II. The DS group consisted of 17 patients and the BRYGB group consisted of 20. The control group comprised 20 independent, morbidly obese individuals. Results The mean age of the patients in the groups was 45.18 in the DS group, 49.75 in the BRYGB group and 44.25 in the control group, with no significant difference. There was no difference in the ratio of men to women in the groups. The patients that had surgery showed a significant improvement in all domains of quality of life vs the control group. Comparing the two groups that underwent surgery, the DS group achieved better quality of life results in terms of “general state of health” and “pain”, according to responses to the SF-36 tool, and in terms of “sexual interest”, according to responses to the M-A QoLQ II tool. There was no significant difference among the three groups regarding the ratio of occurrence of comorbidities. In the ...

Contexto Poucos estudos avaliaram os resultados de diferentes cirurgias bariátricas utilizando o questionário de qualidade de vida Medical Outcome Study 36 - Item Health Survey Short-Form (SF - 36), o Bariatric and Reporting Outcome System (BAROS) e o Moorehead-Ardelt Quality of Life II (M-A QoLQ II) revisado, que compõem o BAROS. A derivação gástrica em Y de Roux é a operação mais realizada em todo o mundo para tratamento da obesidade mórbida. Há evidencias sugerindo maior efetividade da operação derivação biliopancreática tipo “duodenal switch” (DS) em relação a derivação gástrica em Y de Roux quanto à perda de peso Objetivos Avaliar o impacto de diferentes intervenções cirúrgicas na qualidade de vida, comorbidades e perda de peso. Métodos Foram avaliados dois grupos de doentes submetidos à cirurgia bariátrica de derivação gástrica em Y-de-Roux com anel (BRYGB) ou “duodenal switch” após seguimento de 12 a 36 meses e, um grupo controle de doentes obesos não operados, utilizando o SF-36, o BAROS e o M-A QoLQ II. O grupo DS foi constituído por 17 doentes e, o BRYGB convencional, por 20. O grupo controle foi formado por 20 doentes obesos mórbidos independentes. Resultados A média de idade dos doentes nos grupos foi respectivamente 45,18 anos no grupo DS, 49,75 anos no grupo BRYGB e, 44,25 anos no grupo controle, sem diferença significante. Não foi observada diferença entre as proporções de sexo nos grupos. O grupo de pacientes operados apresentou melhora significante em todos os domínios de qualidade de vida, em relação ao grupo controle. Na comparação entre os grupos cirúrgicos, o grupo DS apresentou resultados de qualidade de vida melhores nos domínios “estado geral ...

Impact on quality of life, weight loss and comorbidities: a study comparing the biliopancreatic diversion with duodenal switch and the banded Roux-en-Y gastric bypass.

CONTEXT: Few studies have evaluated the results of different types of bariatric surgery using the Medical Outcome Study 36 - Health Survey Short-Form (SF-36) quality of life questionnaire, the Bariatric and Reporting Outcome System (BAROS) and the reviewed Moorehead-Ardelt Quality of Life II Questionnaire (M-A QoLQ II) that is part of BAROS. The Roux-en-Y gastric bypass (RYGB) is the most common morbid obesity surgery worldwide. However, there is evidence indicating that a biliopancreatic diversion with duodenal switch (DS) is more effective than RYGB in weight loss terms. OBJECTIVES: To evaluate the impact of different types of bariatric surgery on quality of life, comorbidities and weight loss. METHODS: Two groups of patients who underwent bariatric surgery conventional Banded Roux-en-Y gastric bypass (BRYGB) or DS were evaluated through monitoring at 12 to 36 months after surgery, as well as a control group of obese patients who had not undergone surgery. The tools used for this were SF-36, BAROS and M-A QoLQ II. The DS group consisted of 17 patients and the BRYGB group consisted of 20. The control group comprised 20 independent, morbidly obese individuals. RESULTS: The mean age of the patients in the groups was 45.18 in the DS group, 49.75 in the BRYGB group and 44.25 in the control group, with no significant difference. There was no difference in the ratio of men to women in the groups. The patients that had surgery showed a significant improvement in all domains of quality of life vs the control group. Comparing the two groups that underwent surgery, the DS group achieved better quality of life results in terms of "general state of health" and "pain", according to responses to the SF-36 tool, and in terms of "sexual interest", according to responses to the M-A QoLQ II tool. There was no significant difference among the three groups regarding the ratio of occurrence of comorbidities. In the groups that had surgery, the resolution of comorbidities was similar. The final classification according to the BAROS Protocol was excellent for the DS group and very good for the BRYGB group, with a statistical difference in favor of the DS group (P = 0.044*). There was no difference in the percentages of excess weight loss between the DS group (82.1%) and the BRYGB group (89.4%) (P = 0.376). CONCLUSIONS: A comparison of the performance of the groups, which were monitored from 12 to 36 months after surgery, showed that the two types of surgery are effective to improve quality of life, comorbidities and weight loss. The DS surgery produced better results in the quality of life evaluations regarding 2 of 8 domains according to the SF-36, and "sexual interest" according to the M-A QoLQ II. In the groups that had surgery, the patients showed high rates of comorbidity resolution. Weight loss was similar for the two surgical groups.

Efeito da derivação biliopancreática na função da célula-beta de mulheres obesas grau I e II portadoras de diabetes mellitus tipo 2 / Effect of biliopancreatic diversion in the beta-cell function of grade I and II obese women with type 2 diabetes mellitus

Objetivo: avaliar o efeito da cirurgia de derivação biliopancreática (DBP) na função da célula-beta de mulheres obesas grau I e II portadoras de diabetes mellitus tipo 2 (DM2), utilizando estímulos com glicose oral e intravenosa. Material e métodos: foram avaliadas 68 mulheres na menacme que compuseram três grupos: Controle magro - CMagro (n = 19, IMC = 23,0 ± 2,2 kg/m²), Controle obeso - CObeso: 18 mulheres obesas (IMC = 35,0 ± 4,8 kg/m²), ambos normotolerante à glicose; e Obeso com DM2 - ObesoDM2 (n = 31; IMC: 36,3 ± 3,7 kg/m²). No grupo ObesoDM2, 64% das mulheres foram submetidas à cirurgia de DBP (n = 20, IMC: 36,5 ± 3,7 kg/m²). Os 68 pacientes passaram por todas as avaliações uma única vez. Os pacientes submetidos à DBP foram reavaliados um mês após a cirurgia. A avaliação da célula-beta foi realizada por testes dinâmicos com estímulo oral (teste de tolerância à glicose oral) e intravenoso (clamp hiperglicêmico). Foram dosados glicose, insulina e peptídeo-C plasmáticos. A aplicação das técnicas de modelagem matemática aos dados possibilitou avaliar as secreções de insulina basal, dinâmica e estática (estímulo oral); a primeira e a segunda fase de secreção de insulina (estímulo intravenoso); a secreção de insulina total; a sensibilidade à insulina (SI), a extração hepática de insulina (EH) e o tempo de atraso ou tempo de atraso para a célula-beta recrutar novos grânulos de insulina para compor o reservatório de grânulos prontamente liberáveis em resposta a determinada glicemia. Resultados: após a DBP houve melhora substancial na SI no TTOG e no teste de clamp, com o grupo cirúrgico alcançando níveis semelhantes aos do grupo CMagro e mais elevados que do grupo CObeso (p < 0,05). A EH de insulina apresentou aumento significante após a DBP, com o grupo cirúrgico mantendo-se semelhante ao CMagro e com níveis aumentados em relação ao CObeso (p < 0,05)...

Objective: to assess the effect of biliopancreatic diversion surgery (BPD) in beta-cell function of obese grade I and II women with type 2 diabetes mellitus (T2DM), using an oral and an intravenous stimuli with glucose. Research Design and Methods: sixty eight premenopausal women were assessed and divided into three groups: lean control - LeanC (n = 19; BMI: 23.0 ± 2.2 kg/m²), obese control - ObeseC (n = 18; BMI: 35.0 ± 4.8kg/m²), both with normal glucose tolerance; and obese with type 2 diabetes - ObeseT2DM (n = 31; BMI: 36.3 ± 3.7 kg/m²). In ObeseDM2 group, 64% of women underwent BPD (n = 20, BMI: 36.5 ± 3.7 kg/m²). The 68 volunteers underwent all assessments once. The volunteers those underwent BPD were reassessed one month after surgery. The assessment of beta-cell function was performed by dynamic tests with an oral (oral glucose tolerance test) and an intravenous stimulation test (hyperglycemic clamp). Serum glucose, insulin and C-peptide were determined. The application of mathematical modeling techniques to data allowed to evaluate basal, dynamic and static (oral stimulus) insulin secretion; the first and second phase of insulin secretion (intravenous stimulus); the total insulin secretion; the insulin sensitivity (IS); the hepatic extraction of insulin (EH) and the delay time for the beta-cell to recruit new insulin granules to form the pool of readily releasable granules in response to a given plasma glucose. Results: after BPD, there was a dramatic improvement on IS during the OGTT and during the clamp test, with the surgical group reaching normalized levels compared to those observed in LeanC group and higher levels than ObeseC group (p < 0.05). The EH of insulin showed significant improvement after BPD, with the surgical group reaching similar levels to LeanC and with increased levels in comparison to ObeseC (p < 0.05)...

[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.

Nutrient deficiencies secondary to bariatric surgery.

PURPOSE OF REVIEW: The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention. RECENT FINDINGS: Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition. SUMMARY: Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.

Laparoscopic biliopancreatic diversion: technique and initial results.

BACKGROUND: Biliopancreatic diversion (BPD) is an efficient method for treating morbid obesity. We present the BPD technique by laparoscopy and the 1st year follow-up. METHODS: From July 2000 to April 2001, 40 patients underwent laparoscopic BPD (29 women, 11 men), with average age 39 (17-60). Average BMI was 43.6 kg/m2 (38-65). All operations were completed successfuly by laparoscopy. The technique followed strictly the operation of Scopinaro. 7 of these patients had removal of an adjustable gastric band and were converted to BPD. All underwent cholecystectomy. RESULTS: Mean loss of initial excess weight at 3, 6 and 10 months was approximately 30%, 50% and 90%. Mortality was 2.5% (1 patient) due to massive pulmonary embolism. Average operating time was 210 minutes (130-480), and average hospital stay was 4.3 days (3-21). There were 5 postoperative complications (12.5%): 2 pulmonary emboli, 2 GI bleeding from the staple-line, and 1 fistula. There have been 5 late complications (12.5%): 3 cases of diarrhea, 2 elevated PTH with normal calcium, and hypothyroidism that was difficult to control. CONCLUSION: BPD may be performed by laparoscopy without changes in the original technique or in the early results.