Duodenal Switch Procedure Research Articles

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and or endoscopic interventions in treating adiposity-based chronic diseases. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is also called the one anastomosis duodenal switch (OADS). This is a relatively new procedure that has been proposed as an alternative to the currently accepted duodenal switch (DS) procedure. The IFSO commissioned a task force (Appendix 1) to determine if SADI-S/OADS is an effective and safe procedure and if it should be considered a surgical option for the treatment of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO SADI-S/OADS task force and approved by the IFSO Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed in 2years.

Laparoscopic SADI-S as a salvage procedure for failed gastric bypass and sleeve gastrectomy: How I do it

Malabsorptive procedures such as duodenal switch (DS) and biliopancreatic diversion are extremely effective bariatric operations, yet account for<1.5% of all bariatric procedures performed worldwide at present [ [1] Angrisani L. Santonicola A. Iovino P. Formisano G. Buchwald H. Scopinaro N. Bariatric Surgery Worldwide 2013. Obes Surg. 2015; 25: 1822-1832 Crossref PubMed Scopus (1063) Google Scholar ]. Reasons for such low volume include perceived technical complexity of these operations and concerns for major postoperative complications including severe nutritional deficiencies. The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the standard DS procedure, which can achieve equivalent clinical benefit but with less associated risk of postoperative nutritional complications [ 2 Sanchez-Pernaute A. Herrera M.A. Perez-Aguirre M.E. et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg. 2010; 20: 1720-1726 Crossref PubMed Scopus (146) Google Scholar , 3 Sanchez-Pernaute A. Rubio Herrera M.A. Perez-Aguirre E. et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007; 17: 1614-1618 Crossref PubMed Scopus (132) Google Scholar , 4 Sanchez-Pernaute A. Rubio M.A. Cabrerizo L. Ramos-Levi A. Perez-Aguirre E. Torres A. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015; 11: 1092-1098 Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar , 5 Gebelli J.P. Gordejuela A.G. Ramos A.C. et al. Sadi-S with right gastric artery ligation: technical systematization and early results. Arq Bras Cir Dig. 2016; 29: 85-90 Crossref Google Scholar ].

The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience

BackgroundThe single-anastomosis duodenal switch procedure is a type of duodenal switch that involves a loop anastomosis rather than traditional Roux-en-Y reconstruction. To date, there have been no multicenter studies looking at the complications associated with post-pyloric loop reconstruction. ObjectivesThe aim of the study was to report the incidence of complications associated with loop duodeno-ileostomy (DI) following single-anastomosis duodenal switch (SADS) procedures. SettingMixed of private and teaching facilities. MethodsThe medical records of 1328 patients who underwent primary SADS procedure (single-anastomosis duodeno–ileal bypass with sleeve gastrectomy or stomach intestinal pylorus-sparing surgery) by 17 surgeons from 3 countries (United States, Spain, and Australia) at 9 centers over a 6-year period were retrospectively reviewed, and their results were compared with articles in the literature. ResultsMean preoperative body mass index was 51.6 kg/m2. Of 1328 patients, 123 patients received a linear stapled duodeno-ileostomy (DI) and 1205 patients a hand-sewn DI. In the overall series, the anastomotic leak, ulcer, and bile reflux occurred in .6% (9/1328), .1% (2/1328), and .1% (2/1328), respectively. None of our patients experienced volvulus at the DI or an internal hernia. Overall, 5 patients (.3%) (3/123 [2.4%] with linear stapled DI versus 2/1205 [.1%] with hand-sewn DI [P<.05]) experienced stricture at the DI in this series. ConclusionsThe overall incidence of complications associated with loop DI was lower than the reported incidence of anastomotic complications after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. SADS procedures may cause much fewer anastomotic complications compared with Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch.

Safety and Effectiveness of Single-Anastomosis Duodenal Switch Procedure: 2-Year Result from a Single US Institution.

Single-anastomosis duodenal switch (DS) was introduced by Sanchez-Pernaute et al. as a modification of the biliopancreatic diversion with duodenal switch. We have published preliminary results of the loop DS as the first report of the procedure in the USA. This study aims to evaluate the loop DS procedures again, in terms of weight loss, comorbidity resolution, complication rate, and address the nutritional concerns. A retrospective chart review was performed on initial 128 patients who underwent laparoscopic or robot-assisted laparoscopic single-stage loop DS between December 17, 2013 and September 23, 2016. Sixteen additional patients were prospectively enrolled from September 24, 2016 to May 4, 2017. A total of 102 female and 38 male patients were included in this study with a mean age of 41.2 ± 9.6years. The mean body mass index (BMI) at the time of procedure was 57.3 ± 9.2kg/m2. Percentage of total weight loss was 23.1, 37.1, 42.9, and 44.7% at 6, 12, 18, and 24months, respectively. Percentage of excess BMI loss was 41.9, 68.1, 76.6, and 80.8% at 6, 12, 18, and 24months, respectively. Mean levels of HbA1c, triglyceride, and LDL-cholesterol decreased significantly after the loop DS. Regarding the fat-soluble vitamins, majority of patients had vitamin A and E levels in the normal range. However, 42 to 56% of the patients had low levels of vitamin D at 6, 12, and 24months following the procedure. Mean length of hospital stay was 4.1 ± 2.7days. Thirty-day readmission rate was 7.6% (n = 11), and 30-day reoperation rate was 6.9% (n = 10). Loop DS seems to be effective in weight loss and is a feasible operation in the super-obese population. However, close monitoring of liver enzymes is warranted in addition to nutritional follow-up.

American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016

BackgroundBariatric surgery, despite being the most successful long-lasting treatment for morbid obesity, remains underused as only approximately 1% of all patients who qualify for surgery actually undergo surgery. To determine if patients in need are receiving appropriate therapy, the American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of use for obesity treatment interventions. ObjectivesThe objective of this study was to determine metabolic and bariatric procedure trends since 2011 and to provide the best estimate of the number of procedures performed in the United States in 2016. SettingUnited States. MethodsWe reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2016 were compared with the previous 5 years of data. ResultsCompared with 2015, the total number of metabolic and bariatric procedures performed in 2016 increased from approximately 196,000 to 216,000. The sleeve gastrectomy trend is increasing, and it continues to be the most common procedure. The gastric bypass and gastric band trends continued to decrease as seen in previous years. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement emerged as a significant contributor to the cumulative total number of procedures performed. ConclusionsThere is increasing use of metabolic and bariatric procedures performed in the United States from 2011 to 2016, with a nearly 10% increase noted from 2015 to 2016.

A508 - Complications associated with the Two-stage Approach to Single Anastomosis Duodenal Switch Procedure: Is it really safer?

A508 - Complications associated with the Two-stage Approach to Single Anastomosis Duodenal Switch Procedure: Is it really safer?

A retrospective comparison of biliopancreatic diversion with duodenal switch with single anastomosis duodenal switch (SIPS-stomach intestinal pylorus sparing surgery) at a single institution with two year follow-up

BackgroundThe traditional duodenal switch is performed using a Roux-en-Y configuration. This procedure has proven to be the most effective procedure for long-term weight loss and co-morbidity reduction.Recently, stomach intestinal pylorus sparing surgery (SIPS) has been introduced as a simpler and potentially safer variation of the duodenal switch (DS). It is a single anastomosis end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. In this study, we compare our outcomes between biliopancreatic diversion with duodenal switch (BPD-DS) and SIPS at 2 years. SettingThis is a retrospective analysis from a single surgeon at a single private institution. MethodsWe analyzed data from 182 patients retrospectively, 62 patients underwent BPD-DS while 120 other patients underwent SIPS between September 2011 and March 2015. A subset analysis was performed comparing data from both procedures to evaluate weight loss and complications. ResultsOf 182 patients, 156 patients were beyond 1 year postoperative mark and 99 patients were beyond 2 year postoperative mark. Five patients were lost to follow-up. None of our patients had complications resulting in death. BPD-DS and SIPS had statistically similar weight loss at 3 months but percent excess weight loss (%EWL) was more with BPD-DS than SIPS at 6, 9, 12, 18, and 24 months. Patient lost a mean body mass index (BMI) of 23.3 (follow-up: 69%) and 20.3 kg/m2 (follow-up: 71%) at 2 years from the BPD-DS and SIPS surgery, respectively. However, patients who had undergone SIPS procedure had significantly shorter operative time, shorter length of stay, fewer perioperative and postoperative complications than BPD-DS (P<.001). Interestingly, even though BPD-DS patients lost slightly more weight, the actual final BMI for SIPS group was lower than BPD-DS group (25.6 versus 26.9) (P<.05). There was no statistical difference between 2 groups for postoperative nutritional data such as vitamins D, B1, B12, serum calcium, fasting blood glucose, glycosylated hemoglobin (HbA1C), insulin, serum albumin, serum total protein, and lipid panel. ConclusionThe SIPS is a simplified DS procedure. The SIPS eliminates one anastomosis and compared with BPD-DS has fewer perioperative and postoperative complications, shorter operative time and length of stay, and similar nutritional results at 2 years. However, weight loss was more with BPD-DS. A fair criticism is that the vast majority of BPD-DS cases were done before the SIPS cases. As a result, experience and learning curve cannot be completely dismissed when viewing postoperative complications.

The Swedish laparoscopic duodenal switch—from omega-loop to Roux-en-Y

The biliopancreatic diversion with duodenal switch (BPDDS) is considered to be the most effective bariatric procedure for introduction and maintenance of weight loss and resolution of obesity-related co-morbidities [1]. Scopinaro described the biliopancreatic diversion (BPD) in 1979 with a partial distal gastrectomy, closure of the duodenal stump, a Roux-en-Y gastroenterostomy, and an anastomosis between the biliary and the alimentary limb 50 cm proximal to ileocecal valve [2]. To gain control of complications related to Scopinaro’s procedure, the common channel was lengthened and the duodenal switch (DS) was added. The latter comprises a vertical sleeve gastrectomy with preservation of the pylorus and a duodenoileostomy [3]. In 1999 a laparoscopic approach for the DS procedure was introduced [4]. Study results concerning postoperative complication rates comparing open and laparoscopic DS are inconsistent [5,6]. This might be a result of the complexity of the surgery and the relatively small number of procedures performed worldwide. Internal herniation (IH) is a common complication after bariatric surgery. It has been shown that the closure of the mesenteric defects reduces the risk of IH and ileus. Closure of the mesenteric defects is technically challenging during standard laparoscopic DS with the entero-entero-anastomosis (EA) in the lower part of the abdomen. For successful advancement of the laparoscopic DS, the following 3 aims were defined that the novel procedure had to fulfill: (1) enhancement of the surgical workflow, (2) better overview of the correct positioning of the different limbs, and (3) facilitation of the closure of the mesenteric defects. The presented procedure accomplishes these targets.

Review of contemporary role of robotics in bariatric surgery.

With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery.

Nutritional Markers after Loop Duodenal Switch (SADI-S) for Morbid Obesity: A Technique with Favorable Nutritional Outcome

Background: A reduction of body weight can be achieved after Biliopancreatic diversion, but there is a risk ofmalnutritionanddiarrhea. This risk may be reduced by pyloric preservation with duodenalswitch. Loop duodenal switch (Single anastomosis duodeno-ileal bypass with sleeve gastrectomy=SADI-S) is hybrid operation combining moderate intake restriction with moderate malabsorption for treatment of morbid obesity. It is considered a modified version of the original duodenal switch operation in which after the sleeve gastrectomy, the duodenum is anastomosed in end to side, ante colic and isoperistaltic manner to the selected ileal loop with a length of 2 meters from ileocacal valve. Objective: To evaluate the nutritional outcomes as well as to determine weight loss success of Loop duodenal switch Procedure as surgical treatment for morbid obesity on a series of 37 consecutively operated patients in Endocrine surgery Unit, Mansoura University hospital, Mansoura University, Mansoura, Egypt. Patients and methods: A prospective study conducted during the period from July 2010 to January 2013. The mean age was 35.37 ± 7.78years. The mean BMI was 56.25 ± 8.43 kg/m². All patients were subjected to Loop Duodenal Switch after preoperative preparation and laboratory investigations including: Haemoglobin, serum iron, serum ferritin, serum vitamin B12, serum folic acid, serum albumen, serum calcium, serum magnesium, serum phosphorus, serum alkaline phosphatase, serum cupper, serum zinc, serum sodium, serum potassium, serum albumen, Aspartate Aminotransferase (AST), Alanine Transaminase (ALT) and serum bilirubin were followed up over 1 year. Results: Most of the patients had smooth postoperative course with no major morbidity and single mortality. The BMI decreased significantly, from: 56.52 ± 8.47, to 33.21 ± 3.91, with decrease of the amount of food ingested. Both hemoglobin and calcium in Loop DS readilyreturned to within the reference range followingsupplementation with iron and calcium respectively. The mean serum iron,serum ferritin, serum vitamin B12, serum folic acid, , serum calcium, serum magnesium, serum phosphorus,serum Alkaline phosphatase,serum cupper, serum zinc, serum sodium, serum potassium, serum albumen, Aspartate Aminotransferase (AST), Alanine Transaminase (ALT) and serum bilirubinremained within the normal range with no significant nutritional deficiency. Conclusion: LoopDS is not associated with broad nutritional deficiencies and does not appear to pose a threat to nutritional status. It provides excellent weight loss with preservation of good alimentation, even in the super obese. Postoperative supplementation with iron, multivitamins, calcium and vitamin D may be required continuously to prevent nutritional deficiency especially for adults and females in the Child bearing period.

Effects on GLP-1, PYY, and leptin by direct stimulation of terminal ileum and cecum in humans: implications for ileal transposition

BackgroundWe do not have a unified, scientifically tested theory of causation for obesity and its co-morbidities, nor do we have explanations for the mechanics of the metabolic/bariatric surgery procedures. Integral to proffered hypotheses are the actions of the hormones glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and leptin. The objective of this study was to obtain blood levels of GLP-1, PYY, and leptin after stimulation of the terminal ileum and cecum by a static infusion of a food hydrolysate in morbidly obese patients undergoing a duodenal switch procedure. SettingUniversity Hospital. MethodsPlasma levels of GLP-1, PYY, and leptin were obtained at 0, 30, 60, 90, and 120 minutes after instillation of 240 mL of a food hydrolysate into the ileum or cecum. ResultsThe mean±SD GLP-1 values by cecal stimulation for 0, 30, 60, 90, and 120 minutes were: 41.3±23.2; 39.6±21.8; 38.9±19.1; 47.4±22.3; 51.7±27.3 pM, and by ileal stimulation: 55.0±32.8; 83.4±16.1; 78.7±23.8; 84.7±23.5; 76.4±25.6. The mean±SD PYY values by cecal stimulation were: 62.1±24.8; 91.1±32.8; 102.1±39.6; 119.6±37.5; 130.3±36.7, and by ileal stimulation: 73.8±41.6; 138.1±17.7; 149.5±23.3; 165.7±24.3; 155.5±29.1. Percent change in PYY levels increased ~150%, GLP-1 increased ~50%, and leptin decreased ~20%. ConclusionDirect stimulation of the human terminal ileum and cecum by a food hydrolysate elicits significant plasma GLP-1 and PYY elevations and leptin decreases, peaking at 90–120 minutes. The ileal GLP-1 and PYY responses exceed those of the cecum, and the PYY effect is about 3-fold that of GLP-1. The results of this study question the satiety premise for ileal transposition.

Five-year Changes in Health-Related Quality of Life after Biliopancreatic Diversion with Duodenal Switch

BackgroundLong-term data of health-related quality of life (HRQL) after biliopancreatic diversion with duodenal switch (BPDDS) procedure are lacking. The aim of this study was to evaluate changes in HRQL from baseline to 5 years after BPDDS.MethodsFifty morbidly obese patients were followed for 5 years after BPDDS procedure. The sample consisted of 27 women and 23 men, the mean age was 37.8 years, and the mean body mass index (BMI) was 51.7 units. HRQL was measured with the Short Form 36 questionnaire (SF-36). Anxiety and depression were measured with the Hospital Anxiety and Depression Scale (HADS). Linear mixed model was used to investigate the change scores. The SF-36 scores and HADS scores of the sample were also compared with a Norwegian population norm, adjusted for age, gender, and BMI.ResultsMental summary scores (MCS) and physical summary scores (PCS) were very low preoperatively but significantly improved (P < 0.05) 5 years after surgery. The PCS was comparable to the population norm, while MCS was lower. Depression improved significantly from baseline to the 5-year follow-up (P = 0.004), but anxiety did not (P = 0.595).ConclusionsThis study demonstrates a sustained weight loss and improved, although somewhat fading, HRQL scores 5 years after BPDDS. The study also shows that BPDDS is associated with a sustained reduction in depression symptoms but not in anxiety symptoms.

Pressure tolerance of newly constructed staple lines in sleeve gastrectomy and duodenal switch

BackgroundMany bariatric surgeons elect to pressure test the newly constructed staple lines in sleeve gastrectomy and duodenal switch procedures as a means of intraoperatively detecting leaks. The pressure tolerance of these fresh staple lines has not been well studied in a clinical setting. MethodsThis is a retrospective institutional review board–approved study that analyzed resected stomachs immediately after resection during a bariatric operation performed using sleeve gastrectomy or biliopancreatic diversion with duodenal switch. Resected stomachs were connected to a normal saline infusion and manometric pressure device for determining the maximum stomach capacity, the leak pressure, and the location of the first leak. ResultsThirty patients (9 underwent biliopancreatic diversion with duodenal switch and 21 underwent sleeve gastrectomy) met the inclusion criteria (mean age of 44.7 years, 63.3% female) with a mean body mass index of 44.1 that was higher with biliopancreatic diversion (51.3 vs 41.0, P = .001) and a mean weight loss of 83 lb (a body mass index decrease of 13.4; median follow-up, 307 days). The leak volume of the resected stomach averaged 1,478 mL (range 1,100 to 2,200) with an average pressure of 25.6 cm H2O (range 12 to 60). The volume and leak pressures were equivalent despite the operative approach (P = .79 and .32, respectively), and there was no difference in the location of the leak (staple line or intrinsic stomach) based on volume or pressure (P = .246 and .131, respectively), with 50% of leaks occurring on the staple lines. ConclusionsThe fresh staple lines in vertical sleeve gastrectomy and duodenal switch show burst strength well in excess of any intragastric pressures likely to be created by brief intraoperative leak checks via air instilled by an orogastric tube or intraoperative endoscopy. Leak testing is not likely to create iatrogenic damage to properly constructed fresh staple lines in these procedures.

Oxalate nephropathy: An important cause of renal failure after bariatric surgery

Obesity is a major public health issue all over the world. Bariatric surgery is increasingly becoming popular as a surgical treatment for morbid obesity. Nephrologists need to be aware of possible renal complications after bariatric surgery. We report a 54-year-old male patient who presented with progressive worsening of renal function following a duodenal switch procedure for morbid obesity, and he was found to have oxalate nephropathy on renal biopsy.

Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients

BackgroundSingle-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified 1-loop duodenal switch with a 200–250 common channel. Our objective was to analyze the weight loss and metabolic results of the technique on a series of 100 consecutively operated patients at a tertiary center university hospital. MethodsA total of 100 patients consecutively underwent surgery. The criteria of inclusion were morbid obesity or metabolic disease. In the first 50 cases, the common/efferent limb measured 200 cm. The length was changed to 250 cm to reduce the hypoproteinemia rate. ResultsNo mortality and no severe complications developed. The mean excess weight loss was >95% maintained during the follow-up period. More than 90% of the patients experimented complete remission of type 2 diabetes mellitus. Two conversions to a standard duodenal switch with a longer alimentary channel were required because of recurrent hypoproteinemia. Hypertension was controlled in 98% of the patients, with a 58% remission rate. The mean number of bowel movements was 2.5/d. ConclusionSingle-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified duodenal switch procedure that is safe and quicker to perform and offers good results for the treatment of both morbid obesity and its metabolic complications.

The duodenal switch for morbid obesity: modification of cardiovascular risk markers compared with standard bariatric surgeries

BackgroundObesity is associated with cardiovascular risk factors such as lipid levels and increased levels of C-reactive peptide (CRP). We hypothesized that duodenal switch (DS) would show equivalent or superior risk reduction compared with standard bariatric surgeries. MethodsPatients underwent DS, sleeve gastrectomy (SG), or gastric bypass (GB) over a 2-year period. Body mass index (BMI), lipid panel, and CRP were measured preoperatively and then 3, 6, and 12 months postoperatively. ResultsA total of 130 patients were identified; 42 underwent DS, 40 underwent SG, and 48 underwent GB. All groups had similar sex and comorbidity profiles, but the mean preoperative BMI was greatest in the DS group (mean = 52). At all intervals weight loss was greater in the DS group (P < .01), with a final BMI of 31 for the DS group, 31 for the SG group, and 28 for the GB group. Cholesterol and low-density lipoprotein showed significantly greater improvement at all time points with DS compared with SG and GB (P < .01). Baseline CRP levels among DS patients were double that of SG and GB, but rapidly declined to equivalent levels by 3 months and normalized in 79%. ConclusionsThe DS procedure resulted in a superior reduction in cardiovascular and proinflammatory risk markers compared with GB and SG.

Successful Management of a Gastric Sleeve Leak with an Endoscopic Stent

Laparoscopic sleeve gastrectomy has been a recently developed technique for treating morbid obesity. Gagner and Patterson performed the first laparoscopic sleeve gastrectomy as part of a duodenal switch procedure at Mount Sinai Hospital in New York in 1999. Since then many surgeons and institutions have adopted this technique. One of the most dreaded complications of sleeve gastrectomy is a leak along the staple line. We present the case of a 23-year-old female with gastric sleeve leak managed successfully with a fully covered wall flex stent. Our aim is to examine the incidence, causes, classification, and presentation of gastric sleeve leaks and to evaluate the use of endoscopic stents in its management.

Petersen hernia complicating laparoscopic duodenal switch

l p t b Petersen type hernias have become increasingly recognized with the worldwide adoption of laparoscopic gastric bypass. So-called Petersen’s hernia (PH) is contemporarily defined as an internal hernia through the space between the mesentery of the alimentary limb and the transverse mesocolon. PH can be classified by type and symptoms [1]. No level I data are available to inform surgeons whether Petersen’s space should be closed at primary surgery, and this has led to a lively debate in published studies [2–6]. However, it is clear that PH can present nonspecifically, is diagnostically challenging, and can rapidly cause fatal complications. Our unit policy is to close Petersen’s space at gastric bypass. Similar to gastric bypass, Petersen’s space is created during laparoscopic biliopancreatic diversion and duodenal switch (BPD/DS) procedure (Fig. 1). A paucity of data is available regarding PH and laparoscopic BPD/DS. We present 4 cases of symptomatic PH complicating laparoscopic BPD/DS (Table 1).

Abstract 8543: Ectopic Fat Mobilization Following a Bariatric Surgery-Induced Weight Loss; Association with Insulin Resistance

Severe obesity is associated with increased cardiovascular morbidity and mortality and is increasing in prevalence. The purpose of the study was to measure the impact of weight loss and changes in insulin resistance following biliopancreatic diversion with duodenal switch (BPD-DS) procedure on adiposity and skeletal muscle. Anthropometric measures, mid-thigh computed tomography (CT) and fasting plasma glucose and insulin were measured at baseline, at 6 and 12 months in severely obese subjects who underwent BPD-DS (n=43) and in a severely obese control group (n=24). At baseline, the two groups were similar for age, sex, weight (128.3±23.3 vs. 117.6±19.1 kg; p=0.059, BPD-DS vs. control respectively) and mid-thigh CT composition but not for body mass index (BMI) (47.6±5.9 vs. 43.5±4.8 kg/m2; p=0.004). At 6 months, in the BPD-DS group, there were a significant decrement in weight (-26.7±7.4%), BMI (-26.7±5.6%), as well as in mid-thigh CT composition: total adipose tissue (-34.7±10.5%), deep adipose tissue (-36.1±15.4%), subcutaneous adipose tissue (-34.7±10.5%), total skeletal muscle (-19.2±8.8%), fat infiltrated muscle (-54.4±29.4%) and non-fat infiltrated muscle (-17.7±11.4%); all p&lt;0.001. Between month 6 and 12, in the BDP-DS group, weight, BMI, total, deep and subcutaneous adipose tissue decrease significantly but to a lesser degree compared to the first 6 month; all p≤0.001. There was no change regarding total skeletal muscle, but a significant increment in non-fat infiltrated muscle (5.3±7.8%) and decrement in fat infiltrated muscle (-11.8±10.8%); all p≤0.001. A decreased in insulin resistance at 6 and 12 months was associated with a reduction of thigh deep adipose tissue (r=0.469, r=0.692, 6 and 12 months respectively) and fat infiltrated muscle (r=0.469, r=0.526); all p≤0.001. There were no changes, in all these parameters in the control group. BPD-DS surgery-induced weight loss had major impact on muscle and fat mass. Mobilization of thigh ectopic fat; thigh deep adipose tissue and fat-infiltrated muscle, may be one mechanism that improves insulin resistance. Muscle regain at 12 months suggests that BPD-DS exerts a physiologic effect beyond that of nutrient restriction on the regulation of energy metabolism.

Neurologic Dysfunction and Pancytopenia Secondary to Acquired Copper Deficiency Following Duodenal Switch

The duodenal switch (DS) procedure is a type of restrictive-malabsorptive bariatric surgery that is typically reserved for severe morbidly obese people (body mass index >50 kg/m(2)) with obesity-related comorbidities, when diet, lifestyle changes, and pharmacologic therapy fail to achieve adequate weight loss. Patients who undergo the DS procedure are at risk for malabsorption, malnutrition, and nutrient deficiencies. Copper deficiency is a commonly reported long-term complication of Roux-en-Y gastric bypass (RYGB) surgery. However, data are limited on copper deficiency-associated complications and their treatment in DS patients. This article presents a case of a patient who developed hypocupremia with associated pancytopenia, myeloneuropathy, and leukoencephalopathy following DS and reviews the literature related to the pathophysiology of copper deficiency and copper replacement in bariatric surgery patients. When severe diarrhea was present, intravenous elemental copper 4 mg (as cupric chloride)/d in addition to daily oral copper gluconate was necessary to correct the hypocupremia and improve the hematologic indices and neurologic symptoms of copper deficiency. When diarrhea subsided, oral elemental copper 4 mg (as copper gluconate) 3 times daily maintained normal serum copper concentrations and avoided the relapse of severe neurologic dysfunction. Regular monitoring of serum copper and ceruloplasmin concentrations is recommended following DS surgery to detect any copper deficiency before irreversible neurologic damage occurs. Long-term copper supplementation is likely necessary to maintain normal copper status in DS patients.