Laparoscopic Billiopancreatic Diversion (Lap-BPD)

It is the operation with highest metabolic control among the surgical treatment options for morbid obesity. Systemic diseases such as Diabetes Mellitus (Type II DM), hyperlipidemia, hypertrigliceridemia, hypertension etc. frequently co-exist particularly in super obese patients with BMI>50. The tendencies of the patients to more severe heart and kidney diseases, due to such accompanying diseases, increase. The sufficient metabolic control of these patients cannot be reached only with methods that restrict the stomach volume and regaining of weight can be more than expected.

Laparoscopic Billiopancreatic Diversion Technique

The billiopancreatic diversion operation basically reduces the volume of the stomach and, as compared to the gastric by-pass, by passes a longer portion of the small intestine.

The lower part of the stomach is extracted with special tools as leaving 250-300 cc space. A large portion of small intestines is by passed. Thus, the nutrition is directly transferred to the middle parts of the small intestines. The early absorption of the nutrition in the beginning of the small intestines is prevented.

Metabolic Effects of the Laparoscopic Billiopancreatic Diversion Operation:

Billiopancreatic diversion operation gives metabolic actions through two main effects.

• Preventing the contact of duodenum and proximal jejunum with nutrition
• Providing early contact of nutrition with distal ileum.

This new physiological route causes an increase in the number and function of β-cells of pancreas due to several hormonal changes in small intestines. β-cells are responsible for insulin secretion of pancreas. Any decrease in number and function of these cells causes Diabetes Mellitus. The billiopancreatic diversion operation then increases the insulin secretion capacity of pancreas thanks to new-formed physiology.

Another effect of billiopancreatic diversion operation is its limiting effect on the maximum fat level that the body may absorb. Thus, the excess fat may not be absorbed but discharged with excretion.

The two main sources used by muscles for energy are fats and sugar. After billiopancreatic diversion, the free fat in the body is decreased and the muscles prefer the sugar, which is in higher amounts. The fast and permanent result of this cycle is recovery of Diabetes diseases as normalized blood sugar without any medicine or insulin support.

Morbid Obesity and Type 2 Diabetes Mellitus

Diabetes Mellitus condition is simply the blood sugar self-digestion disorder. It is seen in two types:

• Type 1 Diabetes Mellitus (Mainly due to pancreas disorder and β-cells failure)
• Type 2 Diabetes Mellitus (Mainly due to over weight and increased fat mass as related to insulin resistance)

Type 1 DM generally seen in early ages and is more resistant to treatment. This is related to the underlying pancreas failure, which is the basic reason of the condition.

Type 2 DM is much more related to extra weights.

The effect of obesity on diabetes

Particularly in morbid obese patients, the fatty mass in body is in quite more than normal. This muscles than may easily access to fat molecules, together with sugar, to transform to energy. The energy per unit is higher when fat is used and accordingly the muscles tend to use the fat molecules increasingly.  Thus, the blood sugar happens to increase. The pancreas, which is normal in its functions, but starts to increase insulin secretion. However, this blind cycle continues to the advantage of the fats and insulin resistance is then seen in the muscles. The formed insulin resistance prevents the matching of the formed insulin in the muscles. This causes a permanent “hyperinsulinemia”.

The muscles preferring fats for production of energy gives the idea, roughly, of lessening fat mass in the body. However, as the blood sugar tends to increase the body transforms the sugar to fat and stores. This system then feeds itself and causes permanent diabetes.

The Effect of Surgery for Morbid Obese Patients on Diabetes Mellitus

All the bariatric initiatives, even only volume restriction is the case, cause positive effects for Type II Diabetes Mellitus due to loss of weight. Malabsorptive initiatives have stronger and more permanent effects on the other hand.

The morbid obese patients who have undergone laparoscopic billiopancreatic diversion operation can recover from Type II Diabetes Mellitus nearly in total. Nicola Scopinaro states that all the patients with Type II DM and hypertrigliceridemia have fully recovered after billiopancreatic diversion.

This strong metabolic effect provides very effective control of over weights and long-term permanency. The positive metabolic effects then increase the expected lifetime and quality.

For detailed information:

• 2004 ASBS Consensus Conference; Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers Henry Buchwald, M.D., Ph.D., F.A.C.S. Surgery for Obesity and Related Diseases 1 (2005) 371–381
• Türkiye Obezite (Şişmanlık) ile Mücadele ve Kontrol Programı (Turkey's Program for Struggle Against Obesity) Obesity (2010-2014), Ankara 2010 T.C. Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü (Ministry of Health, General Directorate for Basic Public Health)
• WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO technical report series 894.Geneva: World Health Organistion, 2000.
• Gastrointestinal surgery for severe obesity: National Institutes of Health Concensus Developement Conference Statement March 25-27,1991. Published: Am J Clin Nutr 1992:55:615S-9S.
• Biliopancreatic diversion: mechanisms of action and long-term results. Nicola Scopinaro. Obes Surg. 2006 Jun; 16(6):683-9.