Biliopancreatic Diversion (BPD) and Duodenal Switch (DS): what should you expect after surgery?

Firstly, being obese makes any surgery riskier. Anaesthetics are more difficult, and any obesity-related diseases patients may have can add further complications.

Statistics show the death rate associated with BPD/DS surgery to be about 1 in 100 operations. The most common cause of death is a blood clot in the lung (pulmonary embolism) or problems arising from a leak in one of the joins made during the surgery.

The greatest short-term hazard after BPD/DS surgery is developing a leak from the join between the stomach and the small intestine. If it were to occur, a second operation would be required immediately as otherwise sepsis is likely to occur.

Also, as with any operation there is a small risk of an infection in the lungs, in the stomach, or in one of the wounds.

The greatest long-term risk is malnutrition in general and protein-calorie malnutrition in particular.

Other long-term risks include development of strictures or hernia at the junction of the stomach and the small bowel.

Finally, whilst it is not a sign that something has gone wrong, people who lose weight rapidly are more prone to developing gallstones. So, to avoid potential further surgery, some surgeons will propose that they remove the gallbladder at the same time.

How does a BPD or DS work?

Primarily on malabsorption.

Digestion and absorption of fat depends on it mixing with bile (from the liver and normally entering the duodenum). As this mixing does not occur until much further on in the intestine after a BPD or DS, the body’s ability to digest and absorb calories from fat is severely reduced. As a result weight drops, even when eating quite normally.

How long will I be in hospital?

The operations can be performed as an open operation through a midline incision from the base of the breastbone, or laparoscopically. Technically they are both complex operations which can take 5–7 hours to complete, and will usually require a post–op hospital stay of 4–6 days.

What can I expect following BPD or DS surgery?

Generally speaking, the patient is less restricted in their eating than after a RNY gastric bypass because fats and sugars are not absorbed by the intestine.

However, about 30% of patients experience major problems with offensive wind and diarrhoea, resulting from the undigested fat and the upset to the normal balance of bacteria in the intestines. This can be minimised by following a low-fat diet.

As well as preventing the absorption of fat and calories, the DS also hampers absorption of protein and essential minerals and vitamins such as iron, zinc and Vitamins A, D E and K. This can lead to a life-threatening condition called protein–calorie malnutrition. Unfortunately, without regular follow up this condition can creep up and overwhelm the patient before anything can be done to correct it.

To avoid this happening, as well as taking vitamin and mineral supplements, DS patients need to take double the normal intake of protein in their diet for the rest of their life. For this reason a good multi–disciplinary team, and a patient committed to complying with diet, supplement instructions and to attending appointments are both vital ingredients to successful outcomes with this surgery.

Of all the operations, DS is associated with the greatest weight loss (after 2 years 80% of patients have achieved normal weight). However, the risks and side effects are also higher with a DS than with other operations.

How do I know something has gone wrong?

1- Blood clots

Common places for clots to develop are in the lower leg (deep vein thrombosis) or lungs (pulmonary embolism).

Symptoms can include:

  • your lower leg becoming painful, achy and tender
  • swelling, redness or warmth in your lower leg
  • a sharp, stabbing chest pain that may be worse when breathing in
  • shortness of breath or a cough
  • feeling faint or dizzy

2 – Wound infection

Sometimes the wounds from your surgery can become infected while they’re healing.

Signs of a wound infection can include:

  • pain in or around the wound
  • red, hot and swollen skin
  • pus coming from the wound

3 – A leak

In the days or weeks after a BPD or DS, there’s a small chance of a leak.

Symptoms of a leak can include:

  • a fever
  • a fast heartbeat
  • stomach pain
  • chills and shivering
  • fast breathing

4 – A blockage

Sometimes the stomach or small intestine can become narrower (a stricture) or blocked after weight loss surgery.

Symptoms of a blockage can include:

5 – Malnourishment

Symptoms of malnourishment following BPD or DS  can include:

6 – Gallstones

The main symptom of gallstones is episodes of severe tummy pain that come on suddenly and typically last a few minutes to a few hours.

In a few cases, they can also cause:

  • a high temperature (fever) of 38C (100.4F) or above
  • a fast heartbeat
  • yellowing of the skin and eyes (jaundice)
  • itchy skin
  • chills or shivering
  • confusion

What is a Biliopancreatic Diversion (BPD)?

This is a malabsorptive operation that can be done as either an open operation through a midline incision from the base of the breastbone, or laparoscopically.

Most of the stomach (about 75%) is removed and the small pouch that remains is connected directly to the final segment of the small intestine, totally bypassing the duodenum and jejunum (first and second sections of the small intestine). Bile and pancreatic juices are also diverted to enter the intestine lower down, closer to the middle or end of the small intestine.

Some patients who would have, in the past, been offered a BPD may now be offered a duodenal switch operation instead. Both of these operations are best in the hands of very experienced surgeons.

What is a Duodenal Switch (DS)?

The duodenal switch (DS) is a variation of the biliopancreatic diversion and also works primarily by malabsorption.

A large portion of the stomach is removed by dividing it lengthways along the inner curve (called a sleeve gastrectomy) and the pyloric valve at the bottom of the stomach (which regulates how quickly to stomach contents empty into the small intestine) is left intact. This means that although the food holding capacity of the stomach is reduced, its function remains intact.

A short segment of the duodenum at the base of the stomach is left, but the remainder cut and the second half of the small intestine bought up and joined to the duodenum (this part of the operation is very similar to a RNY gastric bypass but is slightly lower down in the digestive tract).

Then, as in the BPD operation, the bypassed section of small intestine is then rejoined to carry bile and pancreatic juices to the latter part of the small intestine near where it joins the large intestine (colon).