Biliopancreatic diversion for obesity at eighteen years

Background. Surgical attempts to treat obesity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their long-term efficacy in weight maintenance have arisen. Methods. Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the last consecutive 1217 underwent the 'ad hoc stomach' type of diversion with a 200 cm alimentary limb, a 50 cm common limb, and a gastric volume varying between 200 and 500 ml. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow- up was 115 months with nearly 100% participation. Results. In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss of initial excess weight (IEW) at 2, 4, 6, and 8 years was 78 ± 16, 75 ± 16, 78 ± 18, and 77 ± 16 in the patients with IEW up to 120% and 74 ± 12, 73 ± 13, 73 ± 12, and 72 ± 10 in those with IEW more than 120%. A group of 40 patients who underwent the original 'half-half' biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term. Conclusions. Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.