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B28 Bariatric Times • November 2016 • Supplement B FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH process enteral supplementation. Bowel side effects. Most BPD- D S patients have 2 to 3 soft bowel movements a day. If patients have excessive bowel movements or flatus, intestinal infections including Clostridium difficile c olitis should be ruled out. If infections are excluded, intake of lactose should be curtailed as many patients will be lactose intolerant after the BPD-DS. Carbohydrates will predispose patients to more flatus and simple sugars will still be absorbed resulting in inadequate weight loss. Fatty meals on the other hand will cause more steatorrhea. Many of these bowel related side-effects can be managed with appropriate dietary discretion. If these side effects continue to be excessive or intolerable despite dietary discretion, the cause may be bacterial overgrowth, and a course of metronidazole can be prescribed for 10 to 14 days along with a probiotic to help recolonize the gut with more normal bacterial flora. Foul flatus can also be managed with activated charcoal such as Devrom ® (The Parthenon Co., Salt Lake City, Utah). If patients are experiencing excessive bowel movements despite the above measures, a trial of antidiarrheal agents such as diphenoxylate HCl/atropine sulfate (Lomotil) or loperamide (Imodium), can be tried. In addition, anticholinergic agents such as amitriptyline can often be helpful and in rare instances codeine can also be tried. The bowel disturbance is often temporary and will resolve by these measures. Additional measures such as cholestyramine that bind bile salts can also be beneficial. The use of pancreatic enzymes with each meal may also aid in digestion and help reduce malabsorption and can also improve nutritional status of the patient. If patients are compliant with these remedies, it is very rare f or a patient to need a reoperation to correct excessive diarrhea but elongating the common channel by disconnecting the Roux limb at the distal anastomosis and r econnecting it more proximally on the biliary limb will help treat excessive diarrhea. There is no set formula as to how long the common channel should be. Our practice is to reconnect the alimentary limb about 50 to 60 cm distal to the ligament of Treitz so that the patients have a bypass that more closely approximates that of a Roux-en-Y operation. The quality of life with regards to bowel dysfunction between patients undergoing Roux-en-Y gastric bypass has been compared to the BPD-DS patients and even though the BPD-DS patients had more stools, overall, the quality of life was equivalent. 8 Protein malnutrition. Patients who are compliant with their nutritional recommendations have low chances of protein malnutrition because the alimentary limb has adequate proteolytic enzymes in the stomach and in the brush border of the small bowel to digest proteins. Initial measures to treat protein deficiency include oral pancreatic enzymes supplements to the diet. If this is not adequate, a nasojejunal feeding tube can be placed endoscopically in the alimentary limb, for enteral nutrition. It is best to use an elemental formula as this does not require pancreatic enzymes or bile for digestion. This is a temporary measure but can provide high- quality nutrition before resorting to a surgical feeding tube or using total parenteral nutrition. If the patients need longer-term enteral nutrition, a laparoscopic feeding jejunostomy catheter is placed in the biliary limb where bile and pancreatic enzymes facilitate d igestion and absorption of tube feeds. If these measures fail, it is only then that we consider other surgical options, to address malnutrition. A kissing-X a nastomosis can be performed laparoscopically by performing a side-to-side anastomosis between the proximal alimentary limb and the proximal biliary limb. Another option is to elongate the common channel. Vitamin and mineral deficiencies. Because the BPD-DS is a fat malabsorptive operation, fat-soluble vitamins are also poorly absorbed. Water-soluble analogues of the fat-soluble vitamins are available and along with other vitamins and minerals should be prescribed per ASMBS guidelines (Table 1). 5 It is unusual to suffer deficiencies of vitamin A, E, or K. However, vitamin D deficiency with a concomitant increase in parathormone level is more common. Such patients are given high dose vitamin D3 orally to aid in normalizing their vitamin D 25- OH and parathormone levels. The help of an endocrinologist can often be utilized for managing these patients. It is typically not necessary to resort to parenteral vitamin D or reoperate for vitamin D deficiency. In a study of bone biopsies of the ileal crest, no significant histological evidence of osteoporosis was noted in long- term studies. 9 Vitamin B, folate, vitamin C deficiencies are uncommon and are managed by supplemental oral vitamins and occasionally parenterally. Patients who are malnourished or have excessive nausea and vomiting should be treated with parenteral vitamin B1 to prevent Korsakoff psychosis or Wernicke's encephalopathy. To