Biliopancreatic Diversion is More Effective Than Sleeve Gastrectomy

The study by Sucandy and coworkers[1] deals with a frequently neglected topic in bariatric surgery, related to the importance of the results in terms of weight loss in the selection of the procedure to be performed. The recently developed and highly fashionable sleeve gastrectomy (SG) is compared to the time honored and successful biliopancreatic diversion in the duodenal switch version (BPD-DS).. The article presents two series each of 100 obese patients submitted to SG or BPD-DS. A significant percentage of patients have been lost to the follow-up; nevertheless data show that BPD-DS attains greater success in terms of body mass index (BMI) reduction 18 months after surgery. The effects of malabsorption appear very early, with differences between the two procedures already evident after 6 months. The great diffusion of SG is mainly due to its technical ease and to its “natural” ending in patients with inadequate weight loss: being SG the first step of BPD-DS, an eventual failure can be corrected performing the duodenal switch.

Several papers deal with the failure in weight loss after SG and disclose the related statistics. Patients in these reports often show young age and relatively low BMI values, and thus the results are quite good.[2] In the present paper[1] both group showed mean age and BMI values around 50. The treatment of the more severe cases of obesity actually emphasizes the more successful procedure.

A second relevant point concerns the presentation of the results. Bariatric surgery is expected to bring obese patients towards a condition of lower morbidity and mortality and possibly of a lower healthcare expenditure.[3,4] reaching BMI values <30 or <35, that means absence of obesity or slight obesity, according to the definition of success of the surgical treatment.[5,6] In the present article.[1] The authors show the percentage of patients reaching BMI < 35 after surgery. They found values of 60% after SG and 85% after BPD-DS. This allows a more readily understandable comparison of the results between the two different procedures.

It is very unusual to find in the literature universally accepted criteria to define success of bariatric operations and this paper shows the role of BMI, not only in selecting patients for surgery, as generally practiced, but also in checking the results of the treatment.[7] Moreover, the distribution of the BMI is not of the Gaussian type and thus the variations of mean values do not reflect the real clinical results. Generally, in presenting data, it is more significant the number of patients reaching a specific BMI during the follow-up, as the authors actually did.

This study[1] confirms the superiority of BPD-DS in dealing with obese patients with high BMI values. The role of SG has to be further investigated, particularly to identify in advance the population with low risk of weight loss failure to avoid reoperative surgery. It is highly desirable that, in clinical papers, authors present their data referring success of surgical procedures to the percentage of patients reaching a specific value of BMI during the follow - up.