Techniques and perioperative management of laparoscopic bile duct and duodenal transposition

Laparoscopic bile-pancreatic diversion and duodenal transposition

The jejunal-ileal bypass was the first surgical procedure to restrict nutrient absorption, and in the early days, it was the only weight loss procedure available.

This technique was first proposed by Varco and Kremen in 1953 and dominated the field of bariatric surgery for over 20 years.

The procedure includes end-to-end jejunoileal anastomosis and ileocecolic anastomosis to drain the bypassed intestinal segment.

Postoperative weight loss is effective, but there are serious complications such as bloating syndrome, diarrhea, electrolyte changes, impaired mental state, kidney stones, rash skin lesions, liver fibrosis and failure.

Due to these serious complications, this procedure is not used routinely.

In 1963, Payne et al. published a report on bypass surgery of the large part of the intestine, in which almost the entire small intestine, right ascending colon and the anterior half of transverse colon were bypassed.

This case series included 10 female patients with morbid obesity. The proximal 37.5 cm of the intestine was located in the middle part of the transverse colon and was anastomosed end-to-end with the transverse colon in a T-shape to restore intestinal continuity.

Clinical outcomes showed uncontrollable severe diarrhea, electrolyte imbalance, and liver failure.

The procedure was initially designed as a two-stage operation: the first step was to cause uncontrolled weight loss, and after reaching the ideal weight, the second step was to restore the original anatomical structure.

However, all patients returned to their pre-operative weight after undergoing the second surgery.

In 1969, Payne and DeWind abandoned the radical approach of anastomosing at the colon and proposed establishing intestinal continuity by performing a jejunoileal end-to-side anastomosis proximal to the ileocecolic junction.

The main goal of this modified surgery is to achieve a balance between the body's calorie intake and needs, avoiding the need for a second surgery to restore the original anatomical structure of the intestines after weight loss.

In the following years, some less radical surgical approaches were designed to avoid major complications.

Payne and DeWind completely abandoned the direct bypass from the intestine to the colon.

In 1969, they reported a surgery performed on 80 patients with morbid obesity, anastomosing the proximal 35cm of jejunum to the terminal ileum to create a 10cm common passage.

This surgery can be completed in one procedure, resulting in significant postoperative weight loss and a significant reduction in medium- and long-term adverse reactions.

In the years that followed, this procedure became the most commonly used procedure in the United States.

This classic jejunoileal bypass procedure has been widely used, but nearly 10% of patients have not achieved the expected weight loss results, most likely due to the reflux of nutrients into the bypassed ileum.

Therefore, to avoid this situation, some teams have revived the technique previously proposed by Varco and Kremen and restarted the end-to-end anastomosis, connecting the jejunal stump to the transverse colon or cecum to avoid intussusception.

In this case, the ileocecal valve is preserved to reduce postoperative diarrhea and avoid electrolyte loss.

Later, different modifications were made to the procedure, especially to the length of the remaining ileum.

In 1971, Buchwald and Varco reported an anastomosis of 40 cm of jejunum to the ileum at 4 cm from the end of the ileum, with the bypass segment draining into the cecum.

This improvement resulted in a significant weight loss effect.

In addition, cholesterol and triglyceride levels also decreased significantly.

To avoid nutrient reflux, some surgical teams tried different jejunoileal anastomosis methods, such as performing ileogastric anastomosis to drain the bypass portion of the intestine, or shortening the proximal jejunum to the ligament of Treitz.

However, these techniques were not recognized and were only used by the surgeons who invented them.

The experience gained from years of practice is to avoid some major complications, such as the fact that no part of the small intestine should be completely disused without any substance passing through it.

Therefore, surgical techniques have been continuously improved, such as creating functional intestinal loops through which chyme passes; and creating bile-pancreatic loops to allow bile or bile and pancreatic juice to pass through.

In 1978, Lavorato et al. performed a standard end-to-side jejunostomy and anastomosed the proximal small bowel bypass segment to the gallbladder, with the aim of diverting bile to the bypass loop.

In 1981, another similar procedure was reported, but it was not widely used.

Modern surgical methods for restricting nutrient absorption in the intestines originated in Italy, marked by the classic bile-pancreatic diversion (BPD) procedure performed by Scopinaro et al.

They reported the initial case study in 1979.

This procedure involves a partial transverse resection of the distal stomach, preserving 200-500 ml of the proximal gastric pouch, closing the proximal duodenum, establishing a gastroileoileal anastomosis 250 cm distal to the ileum, and anastomosing the biliary-pancreatic loop to the ileum 50 cm from the ileocecal valve to create a very short common passage.

In 1993, Marceau et al. improved this original BPD into duodenal transposition.

By performing a greater curvature gastrectomy, a tubular stomach is created along the lesser curvature of the stomach, preserving the pylorus. The functional intestinal tract is anastomosed to the duodenum at the proximal end, and the distal end of the duodenum is closed laterally without cutting the duodenum.

However, all of these patients experienced suture breakage because the duodenum cannot tolerate this type of intestinal closure.

In 1998, Hess and Hess modified this procedure by separating the duodenum distal to the pylorus and transecting it, with the functional intestinal loop anastomosed to the duodenum distal to the pylorus.

This procedure, known as "Biliary-Pancreatic Diversion with Duodenal Rotation (BPD-DS)," has rapidly gained widespread acceptance worldwide.

After the advent of this surgical method, which mainly restricts nutrient absorption in the intestines, the most significant innovation was the use of laparoscopy to perform the surgery. In this way, the advantages of laparoscopy and this type of surgery were well combined.

The first laparoscopic BPD-DS surgery was performed by Dr. Gagner in early July 1999 and was officially published in 2001.