Background <p>Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective weight loss procedure, albeit with a risk of malnutrition and side effects. Sleeve gastrectomy with transit bipartition (TB) has been performed for over 20 years with promising results; however, there is a limited number of publications.</p> Methods <p>The most recent 99 primary BPD-DS and the first 141&#xa0;TB in patients with a BMI ≥ 50&#xa0;kg/m2 operated on between 2017 and 2023 were compared. The postoperative course, side effects, need for revision, and weight outcomes were reviewed.</p> Results <p>TB was faster (92 ± 15 vs. 149 ± 30&#xa0;min, <i>p</i> &lt; 0.0001), and patients stayed less longer (2.5 ± 1 vs. 4.5 ± 3.3 days, <i>p</i> &lt; 0.0001) with comparable early complication rates of 7% and 5.7% between BPD-DS and TB. There was significantly more weight loss after BPD-DS compared to TB at 2 years (%EBMIL: 93.6 ± 11.9 vs. 84.9 ± 17.3% and %TWL: 50.2 ± 6.7 vs. 45.7 ± 9.6%) and 4 years but not at 5 years after surgery (%EBMIL: 85 ± 12.7 vs. 80.8 ± 21% and %TWL: 45.4 ± 7.4 vs. 42.6 ± 11.4%) (88 and 72.6% follow-up). More patients required surgical reintervention for malnutrition or side effects after BPDS-DS (10%) compared to TB (4.2%). Twice as many patients reported loose stools after BPD-DS compared to TB.</p> Conclusions <p>For patients with a BMI ≥ 50, TB yielded slightly less weight loss 5 years after surgery, but with fewer side effects and risk of malnutrition.</p> Graphical Abstract <p></p>