ΜΕΤΑΠΤΥΧΙΑΚΟ ΠΡΟΓΡΑΜΜΑ ΣΠΟΥΔΩΝ:
‘‘ΕΛΑΧΙΣΤΑ ΕΠΕΜΒΑΤΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ, ΡΟΜΠΟΤΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ ΚΑΙ ΤΗΛΕΧΕΙΡΟΥΡΓΙΚΗ’’
ΕΘΝΙΚΟ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ ΙΑΤΡΙΚΗ ΣΧΟΛΗ
ΔΙΠΛΩΜΑΤΙΚΗ ΕΡΓΑΣΙΑ
ΘΕΜΑ : THE SINGLE ANASTOMOSIS DUODENAL SWITCH WITH SLEEVE GASTRECTOMY FOR
MORBID OBESITY. CURRENT STATUS.
ΜΕΤΑΠΤΥΧΙΑΚΟΣΦΟΙΤΗΤΗΣ: ΣΑΚΑΡΕΛΛΟΣΠΑΝΑΓΙΩΤΗΣ
Α.Μ.: 20120732
ΑΘΗΝΑ, ΙΑΝΟΥΑΡΙΟΣ 2016
2 ΠΡΑΚΤΙΚΟ ΚΡΙΣΕΩΣ
ΤΗΣ ΣΥΝΕΔΡΙΑΣΗΣ ΤΗΣ ΤΡΙΜΕΛΟΥΣΕΞΕΤΑΣΤΙΚΗΣ ΕΠΙΤΡΟΠΗΣ ΓΙΑ ΤΗΝ ΑΞΙΟΛΟΓΗΣΗ ΤΗΣ ΔΙΠΛΩΜΑΤΙΚΗΣ ΕΡΓΑΣΙΑΣ
Του Μεταπτυχιακού Φοιτητή Σακαρέλλου Παναγιώτη Εξεταστική Επιτροπή
Ανδρέας Αλεξάνδρου, Λέκτορας Χειρουργικής, Επιβλέπων
Χρήστος Π. Τσιγκρής, Καθηγητής Χειρουργικής & Επιστημονικός Υπεύθυνος τουΠ.Μ.Σ.
Θεόδωρος Διαμαντής, Καθηγητής Χειρουργικής
H Tριμελής Εξεταστική Επιτροπή η οποία ορίσθηκε από την ΓΣΕΣ της Ιατρικής Σχολής του Παν. Αθηνών Συνεδρίαση της ...ης ... 20.... για την αξιολόγηση και εξέταση του υποψηφίου Κου Σακαρέλλου Παναγιώτη, συνεδρίασε σήμερα .../.../....
H Eπιτροπή διαπίστωσε ότι η Διπλωματική Εργασία του Κου Σακαρέλλου Παναγιώτη με τίτλο: “The single anastomosis duodenal switch with sleeve
gastrectomy for morbid obesity. Current status.” , είναι πρωτότυπη, επιστημονικά και τεχνικά άρτια και η βιβλιογραφική πληροφορία ολοκληρωμένη και εμπεριστατωμένη.
Η εξεταστική επιτροπή αφού έλαβε υπ’ όψιν το περιεχόμενο της εργασίας και τη συμβολή της στην επιστήμη, με ψήφους ... προτείνει την απονομή του Μεταπτυχιακού Διπλώματος Ειδίκευσης (Μaster's Degree), στον παραπάνω Μεταπτυχιακό Φοιτητή.
Στην ψηφοφορία για την βαθμολογία ο υποψήφιος έλαβε για τον βαθμό «ΑΡΙΣΤΑ»
ψήφους ..., για τον βαθμό «ΛΙΑΝ ΚΑΛΩΣ» ψήφους ..., και για τον βαθμό «ΚΑΛΩΣ» ψήφους ... Κατά συνέπεια, απονέμεται ο βαθμός
«...».
Tα Μέλη της Εξεταστικής Επιτροπής
Ανδρέας Αλεξάνδρου, Επιβλέπων (Υπογραφή)
Χρήστος Π. Τσιγκρής, (Υπογραφή)
Θεόδωρος Διαμαντής, (Υπογραφή)
3 CONTENTS Page
1. Introduction 5
2. Materials and Methods 6
2.1 Literature search 6
2.2 Inclusion and Exclusion criteria 6
2.3 Results of the literature search 6
3. Results 7
3.1 Indications and contraindications for the surgical procedure 7
3.2 Patients’ demographics 7
3.2.1 Number 7
3.2.2 Age 8
3.2.3 Gender 8
3.2.4 Body mass index (BMI) - Weight - Excess weight 8
3.2.5 Prior abdominal operations 9
3.3 Intraoperative metrics 9
3.3.1 Operative time (OT) 9
3.3.2 Estimated Blood Loss (EBL) 9
3.3.3 Conversion rate 9
3.4 Postoperative metrics 9
3.4.1 Length of Stay (LOS) 9
3.4.2 Morbidity 10
3.4.3 Mortality 10
3.4.4 Re-operation 10
3.4.5 Pain 10
4
3.4.6 Bowel movement - Flatus passage 11
3.4.7 Early postoperative following/Early postoperative diet 11
3.5 Surgical technique 11
3.6.1 Patient’s position 11
3.6.2 Approach/Laparoscopic instruments/Anastomosis 12
3.6.3 Postoperative follow-up 14
4. Tables 16
5. Figures 17
6. Discussion 18
7. Conclusions 22
ABSTRACT 23
ΠΕΡΙΛΗΨΗ 24
REFERENCES 25
5 INTRODUCTION
Bariatric operations have proven their value as an effective treatment for long- term weight loss and metabolic rebalancing in obese patients(1–3). Although they are currently safe surgical procedures and are followed by very few surgically related complications, they should be considered technically complex operations(4–7).
Consequently the types of operation are evolving. Most procedures combine a restrictive and a malabsorvative component(5,6,8). Trying to simplify the surgical procedure, three different groups modified the duodenal switch (DS)(6), in an attempt to perform only one anastomosis. Τhe “single anastomosis duodeno-ileal bypass with sleeve gastrectomy” or SADI-S was introduced by Sanchez et al(4,9,10), the “single- anastomosis duodeno-jejunal bypass with sleeve gastrectomy” or SADJB-SG was introduced by Lee et al(11) and the “loop duodeno-jejunostomy with sleeve gastrectomy” or DJOS and the “loop duodeno-ileostomy with sleeve gastrectomy” or DIOS were introduced by Grueneberger et al(12,13). The elimination of one anastomosis may have some advantages over previous procedures, i.e., less probability of postoperative leaks or anastomotic strictures, a decrease in the operative time and consequently less anesthetic-derived complications, and as the mesentery is not opened there may be a lower probability of postoperative obstructions(9,11,13). The purpose of this study is to review all cases of ‘‘single anastomosis duodenal switch with sleeve gastrectomy’’ in the literature and analyze its feasibility, safety and potential benefits.
6 MATERIALS AND METHODS
Literature search
The MEDLINE, Cochrane and Embase databases were searched for publications with the medical subject heading “single anastomosis duodeno-enteral (duodenojejunal/duodenoileal) bypass with sleeve gastrectomy” and keywords “single anastomosis”, “duodenal switch”, “biliopancreatic diversion”, “duodenojejunal bypass”, “duodenoileal bypass”, “sleeve gastrectomy”, “morbid obesity”, “metabolic surgery”. All the retrieved articles were hand searched for relevant references. We set our analysis starting date on November 2007, when Sanchez et al(10) first proposed the above technique and the end date of the review was December 2014.
Inclusion and exclusion criteria
All the references from the identified articles were hand searched for relevant information. We focused on studies in adults that reported the application of the
“single anastomosis duodenojejunal/duodenoileal bypass with sleeve gastrectomy”
technique in the treatment of morbid obesity and metabolic disorders associated with morbid obesity. We excluded articles that were not written in English language. We include in our review those who combined the sleeve gastrectomy with bypass of different lenghth of duodenum and small intestine performing one single anastomosis and configuring a pylorous preserving Billroth II follow of the alimentary canal. After applying the above inclusion and exclusion criteria, 6 articles were deemed appropriate for our analysis.
Results of the literature search
After applying the above inclusion and exclusion criteria, the experience of these three research groups was deemed appropriate for our analysis.
7 RESULTS
Indications and contraindications for the surgical procedure
The indications for “single anastomosis duodenal switch with sleeve gastrectomy” arising from meticulous literature search are the same as for the other operations for morbid obesity and associate metabolic disorders. Explicit written informed consent for operation and data was obtained from all patients of all research groups. Sanchez et al(4,9,10) excluded patients with previous bariatric operations, except for seven (n=7/100) that had a previous laparoscopic sleeve gastrectomy (LSG). Lee et al(11) excluded patients with previous bariatric operation.
Grueneberger et al(12,13), while constructing a DJOS, performed (n=3/7) a gastric plicature instead of a sleeve gastrectomy, in case of previous gastric banding and relevant perigastric scar tissue to minimize operative risk. Additionaly two-step DIOS was performed as revisionary surgery after failed Roux-en-Y gastric bypass (RYGB) due to dumping syndrome (n=2/9)(14) or after LSG with insufficient weight loss alone (n=3/9)(3) or in combination with persisting type 2 diabetes (n=4/9)(2). Below we will present only the data resulting from the contribution of the method in reducing the excess weight of the patients.
Patients’ demographics
Number
In Sanchez et al(9) study 100 patients underwent SADI-S, 50 of whom received a 200 cm common limb and 50, a 250 cm common limb. In Lee et al(11) study 50 patients underwent SADJB-SG. In Grueneberger et al(13) study 16 patients underwent DJOS/DIOS, 7 of whom received a combined single step operation with a
8 proximal duodeno-jejunostomy (DJOS) and 9 a two-step LSG with a distal loop DIOS.
Age
All patients were adults. Ages ranged between 22 and 71 years old in Sanchez et al(9) study. Ages ranged between 32.4 and 44.4 years old in Lee et al(11) study and 44 and 52 years old in Grueneberger et al(13) study.
Gender
There were 63 males and 37 females in Sanchez et al(9) study. There were 19 males and 31 females in Lee et al(11) study. There were 4 males and 12 females in Grueneberger et al(13) study.
Body mass index (BMI) - Weight - Excess weight
The patients who underwent SADI-S as their first procedure had a mean weight of 119.5kg (range 72-164), a mean BMI of 44.6kg/m2 (range 33-67), and a mean excess weight of 53kg (range 28-99). The patients who underwent SADI-S as a second step had a mean preoperative weight of 127kg (range 94-160), a mean BMI of 48.5kg/m2 (range37.6-54.6) and a mean excess weight of 62kg (range 31.5-84)(4,9).
The patients who underwent SADJB-SG had a mean preoperative BMI of 38.4kg/m2 (range 32.4-44.4). There were some poorly controlled type 2 diabetes patients (Hba1c>7.5%) with BMI>28kg/m2 who underwent SADJB-SG as well(11). The patients who underwent DJOS had a mean preoperative weight of 117.4kg (range 103-145) and a mean BMI of 41.6kg/m2 (range 35.74-47.9). The patients who underwent DIOS had a mean preoperative weight of 114.2kg (range 85-145) and a mean BMI of 40.63kg/m2 (range 33.2-55.94)(13).
9 Prior abdominal operations
In Sanchez et al(4,9) study 7 out of 100 patients underwent SADI-S as a second step after previous LSG. There were 4 patients with previous abdominal operations for another medical issue in Sanchez et al(4,9) study. In Grueneberger et al(13) study 9 out of 16 underwent a two-step LSG with a distal loop doudeno- ileostomy (DIOS).
Intraoperative metrics
Operative time (OT)
Operative time ranged between 100min to 240min for Sanchez et al(9).
Operative time ranged between 143.3min to 220.1min for Lee et al(11). A mean operative time of 147min for DJOS and 120.6min for DIOS for Grueneberger et al(13).
Estimated Blood Loss (EBL)
EBL ranged from 10.9ml to 55.7ml in Lee et al(11) study.
Conversion rate
In Sanchez et al study(9), 4 of the patients received an open laparotomy because of previous abdominal operations and in 1 case, laparoscopy was converted to open laparotomy because of technical difficulties in performing the anastomosis(4,9). Therefore overall conversion rate from laparoscopic procedure to open laparotomy was 0.61% (1/162)(9,11,13).
Postoperative metrics
Length of Stay (LOS)
10 LOS was from 2.3 to 5.3 days in Lee et al(11) study.
Morbidity
In Sanchez et al(4,9) study, three postoperative leaks developed, two from the gastric tube and one from the duodenoileal anastomosis. All were successfully treated conservatively. One patient developed a gastric hemorrhage and underwent endoscopic coagulation. One patient developed an acute trocar site herniation and underwent reoperation and prosthetic repair. Concerning Lee et al(11), no major complication occured. Three patients had minor complication including wound infection, gastric stasis, and prolonged intubation, each in one patient, and all recovered uneventfully. Finally concerning Grueneberger et al(13), one intestinal perforation occurred upon insertion of the first trocar in a patient with previous gastric banding and subsequent adhesions to the abdominal wall. No complications specific to the duodeno-enterostomy were noted.
Mortality
No deaths relative to surgery were reported or during the early postoperative period.
Re-operation
No re-operations were reported for intraoperative or postoperative major complications. Two conversions to a standard duodenal switch with a longer alimentary channel were required because of recurrent hypoproteinemia in Sanchez et al(9,15) study.
Pain
11 Analgesic dosage of morphine after SADJB-SG was between 0 to 4.7mg during the whole hospital stay in Lee et al(13) study.
Bowel movement - Flatus passage
Sanchez et al(4,9) study provides data regarding time of bowel return. They had a median of 2.5 days.
Early postoperative following/Early postoperative diet
In Sanchez et al(4,9) study, initially, a barium swallow X-ray study was routinely performed between the fourth and seventh postoperative day, and if the study was normal, patients were started on liquids and discharged on the sixth to the eighth postoperative day. Currently, no barium sallow is performed; patients start liquid diet on the second postoperative day and they are discharged on the fifth to the seventh postoperative day. In Lee et al(11) study a gastrografin swallow X-ray study was performed after surgery showing “sleeve-like” appearance of stomach and loop anastomosis at duodenum. A proton pump inhibitor was administered for 1 day postoperatively. Nasogastric tube was removed the second post operative day. The patient was allowed to drink water if flatus passage started, and the patients were discharged later, if they did not exhibit vomiting or specific discomfort.
Surgical technique
Patient’s position
All three studies provided data regarding patient’s position. The patient is placed in the split-leg position (French potision) with the operating surgeon standing between the legs.
12 Approach/Laparoscopic instruments/Anastomosis
In Sanchez et al(4,9) study the technique begins with the devascularization of the greater curvature of the stomach with the harmonic scalpel. The stomach is then tubularized over a 54 French oral bougie, with a linear stapler charged with a gold cartridge, commencing 6 to 8 cm proximal to the pylorus. Occasionally the staple line has been reinforced with Seamguard bioabsorbable strips. Nowadays, they systematically perform a running invaginating suture protected with TachoSil patches.
The dissection of the greater curvature is prolonged through the first portion of the duodenum down to the gastroduodenal artery. At this point the duodenum is divided with a linear blue cartridge stapler, preserving all the vascularization to the lesser curvature, i.e., the right gastric artery and the supraduodenal artery. This first part of the operation is performed with the operating table under anti-Trendelenburg position and the surgeon positioned between the legs of the patient; when finished, the table is rotated to the horizontal position and the surgeon moves to the left-hand side of the patient to perform the second part of the operation. The ileocecal junction is identified. In the first 50 cases, the duodenoileal anastomosis was performed at 200 cm from the ileocecal valve (SADI-S 200). In the last 50 cases, this length was enlarged to 250 cm (SADI-S 250). The intestinal measurement is performed after infusion of 20 mg of Buscapine®, to get the maximum possible relaxation of the smooth muscle and perform the most accurate calculation of the common limb’s length. The selected loop is ascended ante-colically without division of the greater omentum, and a stapled isoperistaltic side-to-side duodeno–ileal anastomosis is completed using a 30-mm linear stapler. The staple defect is closed with a two-layer suture. The anastomosis is tested for tightness with oral methylene blue instillation and covered with fibrin glue. One 19-French suction drainage is systematically left
13 until the patient resumed an oral diet. In Lee et al(11) study the procedure begins again with the mobilization of the greater curvature from the omentum. Sleeve gastrectomy with 45 French boogie was performed with a linear stapler, commencing from 6 cm proximal to the pylorus. The stapler line was routinely reinforced by a running invaginating suture using nonabsorbable suture. The dissection is then prolonged through the lower part and posterior wall of the duodenum above the gastroduodenal artery. The duodenum was divided with preserving the right gastric artery and supra-duodenal vessels. The ligament of Treitz is identified and measured downward. The length of the alimentary limb is decided according to the BMI value with a 150 cm biliopancreatic limb for patients with BMI<35 kg/m2 and a 200 cm alimentary limb for patients with BMI>35 kg/m2. The selected loop is ascended antecolically without division of the omentum and a stapler isoperistaltic side-to-side duodeno-jejunal anastomosis is performed. The stapler defect is closed with two-layer running suture using an absorbable one. An air leak test was done, and a drain is routinely left. In Grueneberger et al(13) study sleeve gastrectomy is conducted as described earlier. In case of a stomach plication, they use a modified technique described by Talebpour et al applying at least two rows of plication using a 3-0 V-Loc TM sutures. The second part of the operation (second step, when performing a two- step procedure) begins with separation of the duodenum with an endostapling device under preservation of the right gastric artery. Before performing the duodeno- enterostomy, the length of the small bowel is determined to account for inter- individual differences. After measurement, the omega loop should be placed near the postpyloric duodenum with special attention to intestinal alignment to avoid mesenteric malrotation. The position of the duodeno-enterostomy is determined to be aboral to the Treitz ligament, 1/3 of total small bowel length for DJOS, and 2/3 for
14 DIOS. The duodeno-enterostomy is performed as an antecolic, continuous end-to-side handsewn anastomosis using 3-0 V-loc TM sutures. Diluted half-strength methylene blue dye (150-200 ml) is used for leak testing. Finally, a drain is put towards the duodenal stump. In case of a two-step procedure, the second part of the operation is conducted separately, then sparing the top left 5 mm trocar needed for sleeve gastrectomy.
Postoperative follow-up
In Sanchez et al(4,9) study excess weight loss (calculated from an ideal BMI of 25 kg/m2) reached 95% in the first 12 months and was maintained throughout the following years, with no significant differences between SADI-S 200 and SADI-S 250. Only one, a 55-year-old male diabetic patient failed to achieve a 50% excess weight loss. He reached a 64% excess weight loss at 10 months from surgery (SADI- S 200). However, he experienced a myocardial infarction and was advised to reduce physical activity, which presumably contributed to his weight regain. In Lee et(11) al study the percentage of excess weight loss (%EWL) was 80% during the first 6 postoperative months and had reached a mean value of 100% at 18 months postoperatively. These data were maintained during the whole follow-up period. The protein and starch absorption were similar for SADI-S 250 as for biliopancreatic diversion with duodenal switch (BPD-DS), because the length of the alimentary limb is exactly the same. A greater rate of fat absorption may be expected with SADI-S, because the common channel is longer. This has not yet been observed; however, their patients have had a lower number of daily bowel move- ments (2.3 versus 3.2), which could be explained by the lower amount of bile salts reaching the colon. During follow-up of SADJB-SG, the mean BMI dropped to 32.9 ± 4.8 kg/m2 at 1 month, 29.9
15
± 6.8 kg/m2 at 3 months, 27.6 ± 5.4 kg/m2 at 6 months, and 25.9 ± 4.6 kg/m2 at 12 months. The percentage of weight loss at 1, 3, 6, and 12 months were 15.1, 20.3, 25.0 and 32.7 %. No revision surgery was required during the follow-up. In Grueneberger et al(13) study the mean preoperative BMI was 40.63 kg/m2 for patients who underwent DIOS and 41.60 kg/m2 for patients who underwent DJOS. Patients after primary DJOS operation presented with an excess weight loss (%EWL) of 19.75%
and 46.53% at 1 and 6 months. The overall %EWL of the combined DIOS procedure was 38.31% and 49.60%. Mean weight loss through LSG alone was 31.73% (range 2.67-69.54). Further %EWL came to 18.73% at 1 and 33.03% at 6 months following the second step operation. In this early follow-up, 1 patient did not lose any additional weight after the second step operation despite bypassing 520 cm of small intestine and clinical signs of malabsorption. Furthermore, control CT sleeve volumetry revealed a small volume of 142 ml at 10 months postoperatively indicating sustained restriction.
For the first postoperative month, the patients were maintained on a low-caloric diet.
Multivitamin supplements, calcium, vitamin D3, folic acid and iron were initially prescribed and maintained, depending on the results of the blood analyses(9,11,13,15).
16 TABLES
Author Patients
Mean preoperative weight(kg)
Mean preoperative BMI(kg/m2) First
procedure
Second Procedure
First procedure
Second procedure
Sanchez et al(4,9)
2012 100* 119.5 127 44.6 48.5
Lee et al(11)
2013 50** N/A† 38.4
Grueneberger et al(12,13)
2014 16***
117.4 41.6
114.2 40.63
*50 operated with SADIS -200 and 50 operated with SADIS-250
**SADJB-SG operation
*** 9 with DJOS and 7 with DIOS operation
†N/A: Not Available
Author Operation EWL
% 1m
EWL
% 3m
EWL
% 6m
EWL
% 9m
EWL
% 12m
EWL
% 2y
EWL
% 3y Sanchez et
al(4,9), 2012*
SADIS N/A** 53.6 81.6 87.8 94.7 114 >100
Lee et al(11), 2013
SADJB-SG N/A N/A N/A N/A 80.3 N/A N/A
Grueneberger et al(12,13), 2014
DJOS 19.75 N/A 46.53 N/A N/A N/A N/A
DIOS 38.31 N/A 49.60 N/A N/A N/A N/A
*50 operated with SADIS – 200 and 50 operated with SADIS – 250
** Not available
17 FIGURES
Figure 1: Anatomy of SADI-S
Figure 2: Physiological characteristics of SADI-S
18 DISCUSSION
Various procedures have been developed by different study groups so to improve the results and reduce associated complications. These procedures combine a restrictive and a malabsorvative component. The present review aims to describe novel surgical procedures and to present their early results. Those procedures, conducted by three different study groups, may have a place in the armentarium of the bariatric surgeon. Sanchez et al(4,9,10) named their technique “single-anastomosis duodeno-ileal bypass with sleeve gastrectomy” (SADI-S). Lee et al(11) named their technique “single-anastomosis duodeno-jejunal bypass with sleeve gastrectomy”
(SADJB-SG). Grueneberger et al(12,13) named their technique “loop duodeno- jejunostomy with sleeve gastrectomy” (DJOS) and “loop duodeno-ileostomy with sleeve gastrectomy” (DIOS). They all combined the restrictive component created by sleeve gastrectomy with the malabsorptive component created by bypass of different length of duodenum and small intestine. Associated advantages are performance of one single anastomosis and configuration of a pylorous preserving Billroth II (BII) follow of the alimentary canal.
Laparoscopic sleeve gastrectomy (LSG) is now a stand-alone bariatric surgery worldwide. LSG was originally introduced as the first step of a two-step BPD-DS by Regan et al, yet only about one-third of the LSG patients needed BPD-DS as a second step 3 years after the primary operation(16,17). Several randomized trials have shown that LSG has a comparable effect on weight reduction comparing to RYGB(18,19).
Therefore, LSG has been accepted by more and more bariatric surgeons as a first choice of bariatric procedure(20). LSG preserves the gastric antrum and the pylorus maintaining hydrochloric acid and intrinsic factor secretion, thus preserving normal
19 iron, calcium, vitamin B12
In bariatric surgery, the Roux-en-Y reconstruction is commonly used for RYGB or DS operations. The BII gastroenterostomy reconstruction after distal stomach resection was first introduced by Mason with the first gastric bypass in 1967(8). Alden, modified the procedure 10 years later(21). In 1980, Scopinaro described a BII reconstruction in the bilio-pancreato-jejuno-ileal bypass(22). Rutledge again used a BII reconstruction when developing the mini gastric bypass (MGB)(23).
The BII reconstruction leads to biliary reflux into the stomach. The idea of preserving the pylorus and performing an omega duodeno-enterostomy originates from Watson who introduced a pylorus-preserving alternative to the classic Whipple procedure in performing a pancreatic head resection(24). The preservation of the pylorus and the first 4 cm of the duodenum avoid this problem: pancreatobiliary secretions are the natural environment of the duodenum. It is very important to assure that the anastomosis is performed on duodenal mucosa and that the pylorus is not damaged during the procedure. The omega switch was introduced into bariatric surgery by Sanchez et al as SADI-S, as an evolution of BPD-DS(10).
and protein absorption. Grueneberger et al(12,13) performed a gastric plicature instead of a LSG in case of previous gastric banding and relevant perigastric scar tissue, to minimize operative risk.
The BII-like procedure has two major advantages; first, it reduces to the half the number of performed anastomoses, and second, there is no mesentery opening. It is important to reduce operating time, even for the most skillful surgeons, as this variable is directly related to surgical complications. On the other hand, the number of anastomotic leaks is nowadays very low in experienced hands(25), but it may be even lower if one anastomosis is performed instead of two. In bariatric operations,
20 mesenteric openings are normally short, and most surgeons suture them after performing the intestinal anastomoses. Even so, these mesenteric openings have been related to postoperative short and long term complications, i.e., bleeding and intestinal obstruction.
Answer to the question of the proper length of the common limb has been attempted by every study group. This is yet unanswered, although we can find some clues from similar procedures performed over the history of bariatric surgery. The limbs’ length should dictate the patient’s weight reduction after the operation.
Sanchez et al introduced SADI-S in 2007(10). Three years later in 2010, they reported the first clinical results on a consecutive series of 50 patients(4). For the first 50 patients they chose a common loop of 200 cm, from the cecum to the duodenoileostomy. Some patients developed clinical complications secondary to excessive malabsorption, so for the next 50 patients the length of this limb was changed to 250 cm. In the study of 2012, they report the results in weight loss and metabolic improvement obtained with SADI-S in the first 100 patients, 50 of whom received a 200 cm common limb and 50, a 250 cm common limb(9). EWL% reached 95% in the first 12 months and was maintained throughout the following years (table), with no significant differences between SADI-S 200 and SADI-S 250.
Lee et al introduced SADJB-SG as a novel metabolic surgery in 2013(11).
They compared SADJB-SG with other gastric bypass procedures such as RYGB and MGB. A total of 50 morbid obese Asian patients received SADJB-SG for the treatment of their obesity and accompanying comorbidities. The length of the alimentary limb was analogous to the preoperative BMI with a 150-cm biliopancreatic limb for patients with BMI<35 kg/m2 and a 200-cm alimentary limb for patients with
21 BMI>35 kg/ m2
Grueneberger et al present results of a smaller group of patients, 16 in number, who underwent either a two-step LSG with a distal DIOS as revisional bariatric surgery or a combined single step operation with a proximal DJOS(12,13). Total small intestinal length was determined to account for inter-individual differences. The overall intestinal length was 750.8 cm (range 600-900 cm) with a bypassed limb length of 235.7 cm in DJOS patients. The mean length of the common channel in DIOS patients measured 245.6 cm. %EWL of the two-step DIOS procedure came to 38.31% and 49.60%, DJOS patients experienced an %EWL of 19.75% and 46.53% at 1 and 6 months, resp. No complication related to the duodeno-enterostomy occurred.
(26). The mean BMI decreased from 38.4 to 25.4 at 1 year after surgery with a mean weight loss of 32.7 %, comparable to gastric bypass. According to them one major advantage of SADJB-SG compared to RYGB or MGB is diminution of the risk of gastric cancer arising from gastric remnant(27–30).
Although the risk of remnant gastric cancer may be low, it is not negligible. SADJB- SG may avoid this risk by leaving no excluded stomach.
22 CONCLUSIONS
Bariatric surgery is currently the most effective treatment for morbid obesity and its related comorbidities. Research on surgical technique is ongoing with modifications of older techniques and invention of new ones. Potential surgical benefits of this group of operations are a single anastomosis, less surgical time, less blood loss, reduced hospital stay and probably less morbidity and mortality. In terms of weight loss, preliminary results seem at least as good as those of standardized procedures and potentially better. Yet those results have to be evaluated in the context of large clinical prospective randomized studies. Also long term results remain yet unexplored. Nevertheless constant research remains necessary for clinicians so to ensure the best for their patients’ interests.
23 ABSTRACT
Obesity surgery is a fundamental element in treatment of morbid obese patients. Various surgical procedures have developed through time. Single anastomosis duodenal switch with sleeve gastrectomy is a promising new strategy in evolution of surgical techniques. This technique combines a sleeve gastrectomy with a Billroth II gastro–entero anastomosis. Certain technical issues remain unanswered such as best common limb length. Three different study groups have developed this surgical technique and have shown promising results. Main technical advantages are existence of a single anastomosis diminishing surgical risk, less surgical time and less blood loss. Main physiological benefits are combination of both a malabsorptive and a restrictive element. Current results show an one year excess weight loss of 80-90%
and satisfactory control of diabetes and other obesity related co-morbidities.
Morbidity and mortality have shown to be minimum. Yet those results have to be studied in the context of large clinical prospective randomized trials to verify their efficacy and constancy.
24 ΠΕΡΙΛΗΨΗ
Η βαρϊατρική χειρουργική είναι βασικό στοιχείο της θεραπείας των νοσηρά παχύσαρκων ασθενών. Ποικίλες χειρουργικές επεμβάσεις έχουν αναπτυχθεί. Η δωδεκαδακτυλική παράκαμψημε μία αναστόμωση και επιμήκη γαστρεκτομή (single anastomosis duodenal switch with sleeve gastrectomy) είναι μια ελπιδοφόρα στρατηγική και συνέχεια της εξέλιξης των χειρουργικών τεχνικών. Συνδυάζει την επιμήκη γαστρεκτομή με μια Billroth II γάστρο-έντερο αναστόμωση. Σε αυτήν διάφορα τεχνικά θέματα είναι ακόμη αναπάντητα όπως το βέλτιστο μήκος της κοινής έλικας. Τρεις διαφορετικές ερευνητικές ομάδες έχουν αναπτύξει την τεχνική και έχουν δείξει ελπιδοφόρα αποτελέσματα. Κύρια τεχνικά πλεονεκτήματα είναι η ύπαρξη μιας μόνο αναστόμωσης και η συνεπακόλουθη μείωση του χειρουργικού κινδύνου, η μείωση του χειρουργικού χρόνου και η μειωμένη απώλεια αίματος. Τα κυριότερα πλεονεκτήματα που άπτονται της φυσιολογίας της επέμβασης είναι ο συνδυασμός τόσο του δυσαπορροφητικού όσο και του περιοριστικού στοιχείου. Τα έωςτώρααποτελέσματαδείχνουναπώλειαυπερβάλλοντοςβάρουςστονπρώτοχρόνο της τάξης του 80-90% και ικανοποιητικό έλεγχο του διαβήτη και των άλλων συν- νοσηροτήτων που σχετίζονται με την παχυσαρκία. Η νοσηρότητα και η θνητότητα φαίνονται ελάχιστες. Ωστόσο αυτά τα αποτελέσματα πρέπει να μελετηθούν και στο πλαίσιο μεγάλων προοπτικών τυχαιοποιημένων μελετών ώστε να αποδειχθεί η αποτελεσματικότητα και η σταθερότητά τους.
25 REFERENCES
1. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Leccesi L, et al.
Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Apr 26;366(17):1577–85.
2. Sjöström L, Lindroos A-K, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004 Dec 23;351(26):2683–93.
3. Topart P, Becouarn G, Ritz P. Comparative early outcomes of three laparoscopic bariatric procedures: sleeve gastrectomy, Roux-en-Y gastric bypass, and
biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012 Jun;8(3):250–4.
4. Sánchez-Pernaute A, Herrera MAR, Pérez-Aguirre ME, Talavera P, Cabrerizo L, Matía P, et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg. 2010 Dec;20(12):1720–6.
5. Scopinaro N, Adami GF, Marinari GM, Gianetta E, Traverso E, Friedman D, et al. Biliopancreatic diversion. World J Surg. 1998 Sep;22(9):936–46.
6. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998 Jun;8(3):267–82.
7. Hess DS, Hess DW, Oakley RS. The biliopancreatic diversion with the duodenal switch: results beyond 10 years. Obes Surg. 2005 Mar;15(3):408–16.
8. Mason EE, Ito C. Gastric bypass. Ann Surg. 1969 Sep;170(3):329–39.
9. Sánchez-Pernaute A, Rubio MÁ, Pérez Aguirre E, Barabash A, Cabrerizo L, Torres A. Single-anastomosis duodenoileal bypass with sleeve gastrectomy:
metabolic improvement and weight loss in first 100 patients. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013 Oct;9(5):731–5.
10. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García Pérez JC, Cabrerizo L, Díez Valladares L, et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007 Dec;17(12):1614–8.
11. Lee W-J, Lee K-T, Kasama K, Seiki Y, Ser K-H, Chun S-C, et al. Laparoscopic single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB- SG): short-term result and comparison with gastric bypass. Obes Surg. 2014 Jan;24(1):109–13.
12. Karcz WK, Kuesters S, Marjanovic G, Grueneberger JM. Duodeno-enteral omega switches - more physiological techniques in metabolic surgery.
Wideochirurgia Inne Tech Małoinwazyjne Videosurgery Miniinvasive Tech Kwart Pod Patronatem Sekc Wideochirurgii TChP Oraz Sekc Chir Bariatrycznej TChP. 2013 Dec;8(4):273–9.
26 13. Grueneberger JM, Karcz-Socha I, Marjanovic G, Kuesters S, Zwirska-Korczala
K, Schmidt K, et al. Pylorus preserving loop duodeno-enterostomy with sleeve gastrectomy - preliminary results. BMC Surg. 2014;14:20.
14. Swartz DE, Mobley E, Felix EL. Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2009 Feb;5(1):27–30.
15. Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al.
Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009 Jul;90(1):15–22.
16. Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003 Dec;13(6):861–4.
17. Nocca D, Krawczykowsky D, Bomans B, Noël P, Picot MC, Blanc PM, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg. 2008 May;18(5):560–5.
18. Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008 Mar;247(3):401–7.
19. Peterli R, Wölnerhanssen B, Peters T, Devaux N, Kern B, Christoffel-Courtin C, et al. Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial. Ann Surg. 2009 Aug;250(2):234–41.
20. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg.
2013 Apr;23(4):427–36.
21. Alden JF. Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch Surg Chic Ill 1960. 1977 Jul;112(7):799–806.
22. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Two years of clinical experience with biliopancreatic bypass for obesity. Am J Clin Nutr. 1980 Feb;33(2 Suppl):506–14.
23. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg. 2001 Jun;11(3):276–80.
24. Watson K. Carcinoma of ampulla of vater successful radical resection. Br J Surg. 1944 Apr;31(124):368–73.
25. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Obes Surg. 2000 Dec;10(6):509–13.
26. Wang W, Wei P-L, Lee Y-C, Huang M-T, Chiu C-C, Lee W-J. Short-term results of laparoscopic mini-gastric bypass. Obes Surg. 2005 May;15(5):648–54.
27 27. Khitin L, Roses RE, Birkett DH. Cancer in the gastric remnant after gastric
bypass: a case report. Curr Surg. 2003 Oct;60(5):521–3.
28. Escalona A, Guzmán S, Ibáñez L, Meneses L, Huete A, Solar A. Gastric cancer after Roux-en-Y gastric bypass. Obes Surg. 2005 Mar;15(3):423–7.
29. Corsini DA, Simoneti CAM, Moreira G, Lima SE, Garrido AB. Cancer in the excluded stomach 4 years after gastric bypass. Obes Surg. 2006 Jul;16(7):932–4.
30. Harper JL, Beech D, Tichansky DS, Madan AK. Cancer in the bypassed stomach presenting early after gastric bypass. Obes Surg. 2007 Sep;17(9):1268–71.
