Malabsorptive procedures

According to SASSO, malabsorptive procedures lead to the best long term outcomes. There are two acceptable procedures; the biliopancreatic bypass procedure (BPD) which is usually performed on patients with a body mass index (BMI) of 50 or more, and the biliopancreatic bypass with duodenal switch operation (BPD-DS).

All malabsorptive procedures are surgically challenging, particularly when performed laparoscopically. If one rates a laparoscopic cholecystectomy as being at level 1 difficulty, an AGB would be at level 2, a gastric bypass at level 5, and a BPD-DS at level 10 difficulty.

SASSO therefore recommends that these complex procedures should only be attempted by experienced surgeons at an accredited centre when they have performed at least 300 gastric bypass procedures.

The bariatric centres at Netcare Waterfall City, Netcare N1 City and Netcare St Augustine's hospitals are accredited by SASSO to perform BPD-DS surgery, reflecting the skill and experience of the surgeons who perform bariatric surgery at these Netcare hospitals.

Biliopancreatic diversion with duodenal switch (BPD-DS)

The BPD-DS procedure is not suitable for everyone. Patients who stand to benefit most from it are morbidly obese individuals with comorbidities and long standing diabetes. In addition, more comprehensive, multidisciplinary post-operative care, as well as ongoing monitoring of vitamin levels and supportive infusions are required. In the hands of practised surgeons, the procedure takes about four hours.

This uncommon, complex procedure involves the surgical removal of about 60 to 70% of the stomach, leaving the patient with a smaller, tube shaped stomach. Thereafter, the end portion of the small intestine is divided much lower down than in the case of a gastric bypass. In this way, two thirds or more of the intestine is bypassed so that the end portion of the intestine can be connected to the duodenum near the stomach. The BPD-DS controls how much can be eaten and lowers the absorption of proteins, fats and nutrients.

Stringent requirements:

For patients' safety, SASSO has set very strict requirements for surgeons to be accredited to perform the BPD-DS procedure.

Combination of restrictive and malabsorptive procedures

Roux-en-Y gastric bypass procedure (GBP)

The Roux-en-Y gastric bypass surgery is the most commonly performed bariatric procedure and is used for some 80% of patients. The GBP procedure is usually performed on patients with a BMI of 35 or more. The decision on which procedure is appropriate for individual patients is, however, also based on various physiologically relevant factors.

The Roux-en-Y gastric bypass procedure (gastric bypass) is a predominantly restrictive procedure with a longer Roux limb (> 150 cm), adding a malabsorptive component to the procedure. The better long term success achieved by the GBP over the purely restrictive options is largely due to the hormonal changes that occur in the bypassed stomach and duodenum which, in turn, regulate the appetite and satiety centres of the brain.