Mid-term 4-Year Outcomes with Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy Surgery at a Single US Center

One-Anastomosis Gastric Bypass (OABG) vs. Single Anastomosis Duodeno-Ileal Bypass (SADI) as revisional procedure following Sleeve Gastrectomy: results of a multicenter study

PURPOSE

Sleeve Gastrectomy (SG) is the most performed bariatric surgery, but a considerable number of patients may require revisional procedures for suboptimal clinical response/recurrence of weight (SCR/RoW). Conversion options include One-Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Ileal Bypass (SADI). The study aims to compare SADI vs. OAGB as revisional procedures in terms of early and mid-term complications, operative time, postoperative hospital stay and clinical outcomes.

METHODS

All patients who underwent OAGB or SADI as revisional procedures following SG for SCR/RoW at three high-volume bariatric centers between January 2014 and April 2021 were included. Propensity score matching (PSM) analysis was performed. Demographic, operative, and postoperative outcomes of the two groups were compared.

RESULTS

One hundred and sixty-eight patients were identified. After PSM, the two groups included 42 OAGB and 42 SADI patients. Early (≤ 30 days) postoperative complications rate did not differ significantly between OAGB and SADI groups (3 bleedings vs. 0, p = 0.241). Mid-term (within 2 years) complications rate was significantly higher in the OAGB group (21.4% vs. 2.4%, p = 0.007), mainly anastomotic complications and reflux disease (12% of OAGBs). Seven OAGB patients required conversion to another procedure (Roux-en-Y Gastric Bypass-RYGB) vs. none among the SADI patients (p = 0.006).

CONCLUSIONS

SADI and OAGB are both effective as revisional procedures for SCR/RoW after SG. OAGB is associated with a significantly higher rate of mid-term complications and a not negligible rate of conversion (RYGB). Larger studies are necessary to draw definitive conclusions.

Single Anastomosis Duodeno-Ileal bypass (SADI-S) as Primary or Two-Stage Surgery: Mid-Term Outcomes of a Single Canadian Bariatric Center

PURPOSE

Compare primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and two-stage SADI after sleeve gastrectomy (SG) in terms of weight loss, reduction/remission of comorbidities, and morbidity.

METHODS

Retrospective study including 179 patients treated laparoscopically between 2016 and 2020. A 50Fr bougie was used for the SG in the primary SADI-S (group 1) and 36/40Fr for the two-stage procedure (group 2). The duodeno-ileal anastomosis was performed at 250 cm from the ileocecal valve and at least 2 cm after the pylorus.

RESULTS

Mean age was 44.1 years old, and there were 148 women and 31 men. There were 67 (37.4%) patients in group 1 and 112 (62.6%) in group 2, with 67% completing the 4-year follow-up. Mean preoperative body mass index (BMI) was 51.1 kg/m2 and 44.6 kg/m2 for groups 1 and 2, respectively. Preoperative comorbidities were obstructive sleep apnea, hypertension, type 2 diabetes, and dyslipidemia in 103 (57.5%), 93 (52%), 65 (36.3%), and 58 (32.4%) of cases. At 4 years postoperatively, excess weight loss (EWL) was 67.5% in group 1 and 67% in group 2 (p = 0.1005). Both groups had good comorbidity remission rates. Early postoperative morbidity rate was 10.4% in group 1 and 3.6% in group 2. In group1, there were mostly postoperative intra-abdominal hematomas managed conservatively (n = 4). Two revisional surgeries were needed for duodeno-ileal anastomosis leaks. Postoperative gastroesophageal reflux disease (GERD), daily diarrhea, vitamin, and protein levels were similar in both groups.

CONCLUSION

Both types of strategies are efficient at short and mid-term outcomes. Preoperative criteria will inform surgeon decision between a primary and a two-stage strategy.

Evaluation study of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of Chinese obese patients based on efficacy and nutrition

To evaluate the efficacy and nutrition of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in Chinese obese patients in the first postoperative year. Clinical data of 66 obese patients who underwent SADI-S surgery at China-Japan Union Hospital of Jilin University from November 2018 to May 2022 were retrospectively collected. The weight, body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of total weight loss (%TWL) were recorded at 3, 6, and 12 months after surgery. Moreover, metabolic disease remission and nutrient deficiencies were assessed at 1 year postoperatively. Overall, 66 patients (38 males and 28 females) were recruited, with a mean age of 35 (18-61) years and an average preoperative BMI of 42.94 kg/m2. Before surgery, 38 patients had type 2 diabetes mellitus (T2DM), 46 patients had hyperuricemia (HUA), 45 patients had hypertension (HTN), 35 patients had hyperlipidemia, 12 patients had hypercholesterolemia, 12 patients had hyper-low-density lipoproteinemia, and 14 patients had gastroesophageal reflux disease symptoms (GERD). All patients had undergone a DaVinci robotic or laparoscopic SADI-S surgery, and none converted to laparotomy or died. Four patients developed postoperative complications and were cured and discharged after conservative treatment or surgical treatment. At 3, 6 and 12 months, the average %EWL was 62.07 ± 26.56, 85.93 ± 27.92, and 106.65 ± 29.65%, %TWL was 22.67 ± 4.94, 32.10 ± 5.18, and 40.56 ± 7.89%, respectively. Fasting blood glucose (FBG), glycated hemoglobin (HbA1c), uric acid (UA), triglycerides (TG), blood pressure (BP), and other indexes were significantly lower after one year post-surgery compared with the preoperative period (P < 0.05). The remission rates of T2DM, HUA, HTN, hypertriglyceridemia, hypercholesterolemia, and hyper-low-density lipoproteinemia 1 year after surgery were 100, 65.2, 62.2, 94.3, 100, and100%, respectively. One year after surgery, the remission rate of GERD was 71.4% (10/14), the rate of new occurrence of GERD was 12.1% (8/66), and the overall incidence rate was 18.2% (12/66). Except for vitamin B12(vit B12), the other nutrient indexes were significantly decreased after 1 year of surgery relative to levels before surgery (P < 0.05). The deficiency rates for vitamin A (vit A), vitamin E (vit E), zinc ion (Zn), and folic acid (FA) were higher (45.5, 25.8, 24.2, and 16.7%, respectively); however, there were no related clinical symptoms. SADI-S had significant effects on weight loss and metabolic disease remission. The main nutrient deficiencies after SADI-S were vit A, vit E, Zn, and FA deficiencies. The long-term efficacy and safety of SADI-S warrant further follow-up.

Single Anastomosis Duodenoileostomy with Sleeve: A Comprehensive Review of Anatomy, Surgical Technique, and Outcomes

PURPOSE OF REVIEW

Single anastomosis duodenoileal bypass with sleeve (SADI-S) is a recently endorsed metabolic and bariatric surgery (MBS) procedure in the US. Despite its favorable characteristics, the utilization of SADI-S remains limited, accounting for a mere 0.25% of all MBS procedures performed. This review aims to offer an updated examination of the technique, while also presenting the safety and outcomes associated with SADI-S on both the short and long term.

RECENT FINDINGS

The safety of SADI-S is well-established, with short-term complication rates as low as 2.6%. A common channel length of 300 cm has consistently shown a lower incidence of malabsorption complications compared to shorter lengths. Bile reflux after SADI-S is relatively rare with an incidence of only 1.23%. SADI-S demonstrated sustained total weight loss (%TWL) at 5 years (37%) and 10 years (34%) postoperatively. Resolution of weight-related medical conditions was also significant after SADI-S, with remission rates of diabetes mellitus as high as 86.6% with over 5 years of follow-up. SADI-S is a safe and effective MBS procedure that has shown impressive and sustainable results in terms of weight loss and improvement in obesity-related medical conditions. Careful limb length selection is essential in minimizing the risk of nutritional deficiencies. SADI-S holds great promise as a valuable option for individuals seeking effective weight loss and improvement in associated health conditions.

Primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus sleeve gastrectomy to SADI conversions: a comparison study of prevalence and safety

BACKGROUND

Conversion from sleeve gastrectomy (SG) to single anastomosis duodeno-ileal bypass (SADI) is becoming increasingly common, but data regarding safety is of these conversions is scarce. As such, the objective of this study was to compare the 30-day rate of serious complications and mortality of primary SADI (p-SADI-S) with SG to SADI (SG-SADI) conversions.

METHODS

This retrospective cohort study analyzed the MBSAQIP database. Patients undergoing p-SADI-S and SG-SADI were included. Data collection was limited to 2020 and 2021. A multivariable logistic regression analysis was performed between groups to determine if SG-SADI was an independent predictor of 30-day serious complications or mortality.

RESULTS

A total of 783 patients were included in this study, 488 (62.3%) underwent p-SADI-S and 295 (37.6%) underwent SG-SADI. The mean body mass index (BMI) at the time of surgery was lower in the SG-SADI cohort (45.1 vs 51.4 kg/m2, p < 0.001). Indications for revision in the SG-SADI cohort included weight recurrence (50.8%), inadequate weight loss (41.0%), other (3.0%), GERD (2.7%), and persistent comorbidities (2.5%). SG-SADI had longer operative times (156.7 vs 142.1 min, p < 0.001) and was not associated with a higher rate of serious complications (5.7 vs 6.9%, p = 0.508) compared to p-SADI-S. p-SADI-S was associated with a higher rate of pneumonia (1.2 vs 0.0%, p < 0.001), and SG-SADI was not correlated with higher rates of reoperation (3.0 vs 3.2%, p = 0.861), readmission (5.4 vs 5.5%, p = 0.948) and death (0.0 vs 0.2%, p = 0.437). On multivariable analysis, SG-SADI was not independently predictive of serious complications (OR 0.81, 95% CI 0.43 to 1.52, p = 0.514) when adjusting for age, sex, BMI, comorbidities, and operative time.

CONCLUSIONS

The prevalence of SG-SADI is high, representing 37.6% of SADI-S procedures. Conversion from sleeve to SADI, is safe, and as opposed to other studies of revisional bariatric surgery, has similar 30-day complication rates to primary SADI-S.

Comparative analysis of 5-year efficacy and outcomes of single anastomosis procedures as revisional surgery for weight regain following sleeve gastrectomy

BACKGROUND

It is imperative to assess the results of revisional procedures following Sleeve Gastrectomy (SG), given the substantially growing population of patients who experience weight regain within a few years after undergoing this procedure.

OBJECTIVE

Examine the comparative effectiveness of the Single Anastomosis Duodeno-Ileal Bypass (SADI-S) and the One Anastomosis Gastric Bypass (OAGB-MGB) as revisional procedures, with respect to their impact on weight loss, resolution of comorbidities, incidence of complications, and rates of reoperation in patients who had weight regain after SG with up to or more than 5 years of follow-up.

SETTING

Hamad General Hospital, Academic tertiary referral center, Qatar.

METHODS

This study retrospectively analyzed a database of patients who underwent the Single Anastomosis Duodeno-Ileal Switch (SADI-S) or the One Anastomosis Gastric Bypass - Mini Gastric Bypass- (OAGB-MGB) as revisional procedures for weight recidivism after a primary Laparoscopic Sleeve Gastrectomy (LSG). The follow-up period was at least 5 years, during which the impact of both procedures on weight loss, comorbidities, nutritional deficiencies, complications, and outcomes were compared.

RESULTS

The study comprised 91 patients, with 42 and 49 in the SADI-S and OAGB-MGB groups, respectively. Significant weight loss (measured by total weight loss percentage, TWL%) was observed at the 5-year follow-up for the SADI-S group compared to the OAGB-MGB group (30.0 ± 18.4 vs. 19.4 ± 16.3, p = 0.008). Remission of comorbidities, specifically diabetes mellitus and hypertension, was more prevalent in the SADI-S group. Notably, the OAGB-MGB group had a higher incidence of complications (28.6% vs. 21.42%) and reoperations (5 patients vs. 1 in the SADI-S group). No mortality events were reported in either group.

CONCLUSION

While both the OAGB-MGB and SADI-S have demonstrated efficacy as revisional procedures for weight regain following SG, the SADI-S exhibits superior outcomes compared to the OAGB-MGB with regard to weight loss, resolution of comorbidities, complication rates, and reoperation rates.

Outcomes of single anastomosis duodeno ileal bypass and single anastomosis stomach ileal bypass for type II diabetes: a systematic review

INTRODUCTION

Bariatric surgery has demonstrated long-term effectiveness in inducing weight loss and improving metabolic parameters for obesity. Single anastomosis duodeno-ileal (SADI) bypass and single anastomosis sleeve-ileal (SASI) bypass have both emerged as new promising bariatric procedures. In this paper, we review the existing literature and compare the outcomes of SADI and SASI bypass procedures in regard to weight loss, complication rate, and improvement of type II diabetes (T2DM). This has not yet been done in the preexisting literature.

AREAS COVERED

We conducted a systematic literature search of electronic databases focusing on weight loss outcomes, rate of complications and remission, or improvement of T2DM and other obesity-related comorbidities. Seventeen studies on SADI and nine studies on SASI were included. Both are similar in terms of surgical technique and have demonstrated fewer complications when compared to other bariatric procedures. Mean preoperative BMI was similar in both study groups: 46.4 kg/m2 in SADI and 48.8 kg/m2 in SASI. Mean %EWL at 12 months in the SADI group was 74.1% compared to 77.4% in the SASI group. Preoperative severity of T2DM appeared to be higher in the SASI patient group, with a higher preoperative HbA1c and fasting blood glucose levels. T2DM resolution was achieved in a significant proportion of both SADI and SASI patient populations (78.5% in SADI and 89.0% in SASI). Complication rates were comparable for both procedures.

EXPERT OPINION

Both SADI and SASI are effective in inducing weight loss at 12 months, with a low rate of major complications and mortality. From the studies included in this review, the SASI procedure had a higher impact on T2DM resolution compared to SADI.

Single-anastomosis Sleeve Jejunal: a Mid-term Follow-up Report of a New Surgical Technique

INTRODUCTION

Single anastomosis sleeve ileal bypass (SASI) is a combined bariatric metabolic technique, in which few studies have shown its outcomes efficacy. However, this technique has a high risk of malnutrition due to long biliopancreatic limb. Single anastomosis sleeve jejunal bypass (SASJ) has a shorter limb. Therefore, it seems to have a lower risk of nutrient deficiency. Furthermore, this technique is relatively new, and little is known about the efficacy and safety of SASJ. We aim to report our mid-term follow-up of SASJ from a high-volume center for bariatric metabolic surgery in the Middle East region.

METHODS

For the current study, the 18-month follow-up data of 43 patients with severe obesity who underwent SASJ was collected. The primary outcome measures were demographic data, weight change variables according to ideal body mass index (BMI) of 25 kg/m² at 6, 12, and 18 months, laboratory assessments, remission of obesity-associated medical problems, and other potential bariatric metabolic complications after the surgery.

RESULTS

No patient was lost due to follow-up. After 18 months, patients lost 43.4 ± 11 kg of their weight and 68 ± 14% of their excess weight, and their BMI decreased from 44.9 ± 4.7 to 28.6 ± 3.8 kg/m² (p < 0.001). The percentage of total weight loss till 18 months was 36.3%. The T2D remission rate at 18 months was 100%. Patients neither faced deficiency in significant markers for nutrition state nor represented major bariatric metabolic surgery complications.

CONCLUSION

SASJ bypass achieved satisfactory weight loss and remissions in obesity-associated medical problems within 18 months after surgery without major complications and malnutrition.

Medium-Term Nutritional and Metabolic Outcome of Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S)

INTRODUCTION

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S), like other hypoabsorptive procedures, could be burdened by long-term nutritional deficiencies such as malnutrition, anemia, hypocalcemia, and hyperparathyroidism.

OBJECTIVES

We aimed to report our experience in terms of mid-term (2 years) bariatric, nutritional, and metabolic results in patients who underwent SADI-S both as a primary or revisional procedure.

METHODS

One hundred twenty-one patients were scheduled for SADI-S as a primary or revisional procedure from July 2016 to February 2020 and completed at least 2 years of follow-up. Demographic features, bariatric, nutritional, and metabolic results were analyzed during a stepped follow-up at 3 months, 6 months, 1 year and 2 years.

RESULTS

Sixty-six patients (47 female and 19 male) were included. The median preoperative BMI was 53 (48-58) kg/m². Comorbidities were reported in 48 (72.7%) patients. At 2 years, patients had a median BMI of 27 (27-31) kg/m² (p < 0.001) with a median %EWL of 85.3% (72.1-96.1), a TWL of 75 (49-100) kg, and a %TWL of 50.9% (40.7-56.9). The complete remission rate was 87.5% for type 2 diabetes mellitus, 83.3% for obstructive sleep apnea syndrome and 64.5% for hypertension. The main nutritional deficiencies post SADI-S were vitamin D (31.82%) and folic acid deficiencies (9.09%).

CONCLUSION

SADI-S could be considered as an efficient and safe procedure with regard to nutritional status, at least in mid-term (2 years) results. It represents a promising bariatric procedure because of the excellent metabolic and bariatric outcomes with acceptable nutritional deficiency rates. Nevertheless, larger studies with longer follow-ups are necessary to draw definitive conclusions.

Single-anastomosis duodenoileal bypass with sleeve in the United States: a first comparative safety analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BACKGROUND

The single-anastomosis duodenoileal bypass with sleeve (SADI-S) is a relatively new bariatric procedure. In 2020, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) started reporting outcomes for SADI-S.

OBJECTIVES

We aimed to study the perioperative safety of SADI-S and compare it with other established bariatric procedures utilizing the MBSAQIP database.

SETTING

Academic hospital, United States.

METHODS

The 2020 MBSAQIP Participant Use File was used to evaluate SADI-S outcomes. We included SADI-S primary cases and excluded revisions and concurrent operations. A 5:1 propensity matched analysis (PMA) for 20 variables was performed to compare the outcomes of the SADI-S with the Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and a 2:1 PMA to the biliopancreatic diversion with duodenal switch (BPD/DS).

RESULTS

There were 255 primary SADI-S reported in 2020. After PMA, the only significant complications between the RYGB and SADI-S cohorts were Clavien-Dindo grade IVa and IVb (.1% and 1.4% versus 1.6% and 7.1%, respectively). SADI-S had more Clavien-Dindo grade II, IVa, and IVb complications than the SG cohort (1.3% versus 3.5%, P = .03; .2% versus 1.6%, P = 0; 1.% versus 7.1%, P = 0). When compared with BPD/DS, outcomes including readmission, reoperation, and intervention were not statistically significant.

CONCLUSION

SADI-S, in its early adoption stage, has a higher incidence of perioperative complications than RYGB and SG. It has comparable 30-day outcomes to BPD/DS.

Single Versus Double Anastomosis Duodenal Switch in the Management of Obesity: A Meta-analysis and Systematic Review

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity.

METHODS

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521).

RESULTS

From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=-10.16%, 95% confidence interval: -11.80, -8.51, I2=0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=-1.36 d, 95% CI: -2.39, -0.33, I2=86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I2=20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I2=0%) values than the BPD-DS group.

CONCLUSIONS

SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Evaluation of Metabolic Outcomes Following SADI-S: a Systematic Review and Meta-analysis

PURPOSE

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) offers a novel bariatric procedure. This systematic review and meta-analysis evaluates observational and comparative studies evaluating SADI-S, with meta-analysis comparing outcomes to other malabsorptive procedures (MPs).

MATERIALS AND METHODS

Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in March 2021. The study followed PRISMA guidelines. Studies evaluating SADI-S with n > 5 were included. Primary outcome was diabetes (DM) remission, and secondary outcomes included perioperative outcomes, comorbidity resolution, and weight loss.

RESULTS

We reviewed 2285 studies with 16 included evaluating 3319 patients and 1704 (51.3%) undergoing SADI-S. SADI-S patients had increased BMI (49.6 kg/m² vs 48.8 kg/m²) and weight (139.7 kg vs 137.1 kg), were more likely to have DM (46.3% vs 42.1%), and dyslipidemia (36.6% SADI-S vs 32.7%). SADI-S had a shorter operative duration than MPs (MD - 36.74, p < 0.001), 0.85-day shorter post-operative stay (p < 0.001), and trended towards fewer complications (OR 0.69, p = 0.06). Rate of reoperation (OR 0.83, p = 0.59) was similar and DM remission was similar (OR 0.07, p = 0.1). Subgroup analysis suggested greater DM remission than Roux-en-Y gastric bypass (OR 4.42, p = 0.04). SADI-S had fewer malabsorptive complications, though follow-up was shorter. Weight loss was 37.3% compared to 35.6% total weight loss after SADI-S and MPs, respectively.

CONCLUSION

SADI-S demonstrates improved metabolic and weight loss outcomes with lower perioperative risks. SADI-S represents a promising bariatric procedure but long-term outcomes are needed to guide future uptake.

Retrospective Comparison of SADI-S Versus RYGB in Chinese with Diabetes and BMI< 35kg/m2: a Propensity Score Adjustment Analysis

BACKGROUND

As a modification of the duodenal switch (DS), single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) has recently become very popular and is successful for weight loss and T2DM remission. However, current studies have been mostly aimed at patients with severe obesity.

OBJECTIVES

In this study, we firstly compare primary SADI-S to the Roux-en-Y gastric bypass (RYGB) in Chinese with diabetes and BMI< 35 kg/m².

METHODS

Using a propensity score (PS) matching analysis, we analyzed all patients with diabetes and BMI< 35 kg/m² who underwent primary SADI-S or RYGB. All surgeries were conducted by a single surgeon at a Chinese center from June 2017 to January 2019.

RESULTS

Twenty-six patients who underwent SADI-S and 65 patients who underwent RYGB were included in our analysis. Of these, 26 (100%) of patients in the SADI-S group and 43 (66%) of patients in the RYGB group completed the 24-month follow-up. No severe perioperative complication was observed in either group. There was a statistically higher percentage of total weight loss with SADI-S at the 2-year follow-up when compared to RYGB (p = 0.017 after PS correction). After PS adjustment, 76.5% of patients in the SADI-S group and 82.4% of patients in the RYGB group achieved complete remission of T2DM (p = 1.000). Nutritional outcomes were similar in the two groups.

CONCLUSION

In Chinese with diabetes and BMI< 35 kg/m², with comparable T2DM remission and nutritional outcomes, primary SADI-S allows for better weight loss than RYGB. Compared with RYGB, SADI-S is also a safe, effective, and feasible treatment for these patients.

A safety study of laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication (SADI-GP) in the management of morbid obesity

Background

Bariatric surgery is more effective in the management of morbid obesity and related comorbidities than is conservative therapy. Pylorus-preserving single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-SG) is a modified duodenal switch technique. Gastric plication (GP) is an alternate to SG.

Methods

Morbidly obese (BMI of > 40, or > 35 in the presence of diabetes or prediabetes) patients were recruited and operated on to perform SADI with GP. Complications related to surgery were recorded to assess the feasibility of the procedure. Weight-loss outcomes were analysed to determine efficacy. Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was recorded after 1 year of follow-up, and test scales were used to describe physiological phenomena.

Results

Seventeen middle-aged (mean: 40 years) patients were involved in our study; 15 of them were females. The mean duration of surgery was 205 min. There were no complications of conversion, death, bleeding, VTE or 30-day readmission to hospital. We did experience CD4a (pulmonary insufficiency due to chronic lung disease) and a CD3b (anastomosis leakage treated laparoscopically) complications. Vomiting occurred in three cases (CD1). Obesity-related comorbidities showed favourable resolution rates (77.8% for hypertension, 81.2% for dyslipidaemia, 100% for diabetes at the 1-year follow-up). Weight-loss outcomes were favourable (53.20 EWL%, and 35.58 TWL% at 1-year follow-up). Greater weight loss caused significantly higher levels of Depression (t(13.958) =  − 2.373; p = 0.00; p < 0.05) and Low Positive Emotions (t(13.301) =  − 2.954; p = 0.00; p < 0.05) and Introversion/Low Positive Emotionality (t(13.408) =  − 1.914; p = 0.02; p < 0.05) in MMPI-2 data.

Conclusion

According to our safety study, SADI-GP is a promising malabsorptive procedure, but a long-term high-volume case series or a randomised controlled trial is necessary to evaluate complication rates and weight-loss outcomes. Emotional dysregulation is common among bariatric surgery patients according to personality inventory data; therefore, psychological follow-up and psychotherapeutic support are necessary for weight-loss maintenance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02276-9.

Single-Anastomosis Duodenal Switch: Conceptual Difference between East and West

Single-anastomosis duodenal switch (SADS) has become increasingly popular. This review compared the conceptual difference between Eastern (SADS-E) and Western (SADS-W) countries. After searching for SADS through PubMed and high-impact journals, 19 articles with 2280 patients were included for analysis. We found SADS-W was reserved for patients with a high body mass index (BMI) without type 2 diabetes mellitus (T2DM). Surgeons performing SADS-W used larger bougies and preferred shorter common channels. However, SADS-E was mainly preferred in T2DM patients with a low BMI. SADS-E bypassed less bowel and used smaller bougies. The spectra of major postoperative complications, nutritional deficiencies, and gastrointestinal disorders were different between SADS-E and SADS-W. SADS-W yielded better weight loss and better T2DM remission than SADS-E. SADS are effective bariatric and metabolic procedures with promising therapeutic outcomes and acceptable safety.

Efficacy and Drawbacks of Single-Anastomosis Duodeno-Ileal Bypass After Sleeve Gastrectomy in a Tertiary Referral Bariatric Center

Background

The need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18–36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery.

Materials and Methods

Data of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal.

Conclusion

SADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05323-y.

Primary SADI-S in Chinese with Diabetes and BMI < 35 kg/m2: a Retrospective Study with 2-Year Follow-up

BACKGROUND

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a bariatric procedure based on the standard duodenal switch surgery. It was first introduced in 2007 as a procedure for individuals with clinically severe obesity. Till date, primary SADI-S has not been used on Chinese with diabetes and body mass index (BMI) < 35 kg/m².

OBJECTIVES

Here, we account the use of this novel surgery in Chinese with diabetes and BMI < 35 kg/m².

METHODS

All relevant medical information, involving patients with diabetes and BMI < 35 kg/m², who received primary SADI-S at Beijing Shijitan Hospital from June 2017 to December 2018, was retrospectively assessed.

RESULTS

Twenty-six patients were selected for evaluation, and all of them completed a 2-year follow-up. The age, diabetic duration, and preoperative BMI were 35.5 (range 20-63) years, 3.5 (range 0.5-18) years, and 34.40 (range 28.74-34.96) kg/m², respectively. At 24 months, the percentage of total body weight loss (%TWL) and BMI were 26.26 (range 13.33-43.88) and 24.72 (range 17.96-29.07) kg/m², respectively. There were no serious complications or sequelae within a 2-year follow-up. In addition, for diabetes, 20/23 people achieved complete remission, whereas 3 achieved partial remission.

CONCLUSION

SADI-S is a highly effective and feasible bariatric surgery for Chinese having diabetes and BMI < 35 kg/m². However, care must be taken to follow a strict criteria for patient selection and to monitor patients carefully for the detection of postoperative nutritional sequelae.

Laparoscopic Vertical Sleeve Gastrectomy

Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.

Is duodeno-jejunal bypass liner superior to pylorus preserving bariatric surgery in terms of complications and efficacy?

PURPOSE

Based on recent scientific evidence, bariatric surgery is more effective in the management of morbid obesity and related comorbidities than conservative therapy. Pylorus preserving surgical procedures (PPBS) such as laparoscopic single-anastomosis duodeno-jejunal or duodeno-ileal bypass with sleeve gastrectomy are modified duodenal switch (DS) surgical techniques. The duodeno-jejunal bypass liner (DJBL) is a novel surgical method in the inventory of metabolism focused manual interventions that excludes duodeno-jejunal mucosa from digestion, mimicking DS procedures without the risk of surgical intervention. The aim of this article is to summarize and compare differences between safety-related features and weight loss outcomes of DJBL and PPBS.

METHODS

A literature search was conducted in the PubMed database. Records of DJBL-related adverse events (AEs), occurrence of PPBS-related complications and reintervention rates were collected. Mean weight, mean body mass index (BMI), percent of excess of weight loss (EWL%), percent of total weight loss (TWL%) and BMI value alterations were recorded for weight loss outcomes.

RESULTS

A total of 11 publications on DJBL and 6 publications on PPBS were included, involving 800 and 1462 patients, respectively. The baseline characteristics of the patients were matched. Comparison of DJBL-related AEs and PPBS-related severe complications showed an almost equal risk (risk difference (RD): -0.03 and confidence interval (CI): -0.27 to 0.21), despite higher rates among patients having received endoscopic treatment. Overall AE and complication rates classified by Clavien-Dindo showed that PPBS was superior to DJBL due to an excess risk level of 25% (RD: 0.25, CI: 0.01-0.49). Reintervention rates were more favourable in the PPBS group, without significant differences in risk (RD: -0.03, CI: -0.27 to 0.20). However, PPBS seemed more efficient regarding weight loss outcomes at 1-year follow-up according to raw data, while meta-analysis did not reveal any significant difference (odds ratio (OR): 1.08, CI: 0.74-1.59 for BMI changes).

CONCLUSION

Only limited conclusions can be made based on our findings. PPBS was superior to DJBL with regard to safety outcomes (GRADE IIB), which failed to support the authors' hypothesis. Surgical procedures showed lower complication rates than the incidence of DJBL-related AEs, although it should be emphasized that the low number of PPBS-related mild to moderate complications reported could be the result of incomplete data recording from the analysed publications. Weight loss outcomes favoured bariatric surgery (GRADE IIB). As the DJBL is implanted into the upper gastrointestinal tract for 6 to 12 months, it seems a promising additional method in the inventory of metabolic interventions.

Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.

The Effectiveness of Single-Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS): an Updated Systematic Review

Single-anastomosis duodenoileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) was developed as a bariatric operation with reduced overall morbidity and lasting weight loss results. We performed a systematic review of the literature, including 14 studies reporting on weight loss, comorbidity resolution, postoperative complications, and nutritional deficiencies following SADI-S. Twelve months after SADI-S, the mean total body weight lost ranged from 21.5 to 41.2%, with no weight regain being observed after 24 months. The comorbidity resolution rate was 72.6% for diabetes, 77.2% for dyslipidemia, and 59.0% for hypertension cases. The need for reoperation was the most common postoperative complication. While several patients developed nutrient deficiencies, SADI-S seems to be an overall safe and effective bariatric operation.

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement-Update 2020

PreambleThe 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 communities 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/one anastomosis duodenal switch (SADI-S/OADS) is a relatively new procedure that has been proposed as an alternative to the conventional duodenal switch (DS) procedure. The IFSO published a position paper on SADI-S/OADS in 2018 with which concluded that this procedure was likely to be a safe and efficacious treatment for adiposity and its related diseases. However, it noted that there was insufficient long-term data and minimal high-level evidence available. The position statement called for patients to be enrolled in long-term multidisciplinary care encouraged the registration of patients in national registries, and called for more randomized controlled trials (RCT) (Obes Surg 28:1207-16, 2018) involving the procedure. The following position statement is an update of the previous position statement. It is issued by the IFSO SADI-S/OADS task force and has been reviewed and approved by both the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed again in 2 years.

Management of Leak after Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

Vitamin E status among bariatric surgery patients: a systematic review

Vitamin E, a fat-soluble vitamin with antioxidant properties, is thought to modulate enzymes involved in signal transduction, affect gene expression, and have immunomodulatory capabilities. Severe vitamin E deficiency is associated with neuronal disorders, impaired immune response, hemolytic anemia, and oxidative-based disorders. Patients who undergo bariatric surgery (BS), especially malabsorptive procedures, are at greater risk of developing fat-soluble vitamin deficiencies. Current data on vitamin E statuses among BS patients are limited. Therefore, this systematic review has summarized the scientific literature on vitamin E and examined its status among patients following different types of BS. Searches of the MEDLINE and Embase databases were performed, followed by hand-searching of reference lists from all relevant papers. Of the 671 initially identified articles, 24 met the inclusion criteria: 1 study on adjustable gastric banding patients (n = 21), 4 studies on sleeve gastrectomy patients (n = 173), 12 studies on Roux-en-Y gastric bypass patients (n = 689) and 12 studies on biliopancreatic diversion with or without duodenal switch (n = 799) or single anastomosis duodeno-ileal bypass with sleeve gastrectomy patients (n = 163). Results suggest that patients who undergo malabsorptive procedures are at higher risk of developing vitamin E deficiency, although clinical manifestations of vitamin E deficits following BS are rarely documented. The optimal dose of vitamin E supplementation required for prevention of deficiency or for treatment following BS has yet to be established. Future observational and intervention studies are needed to bridge the gaps in existing knowledge.

Third bariatric procedure for insufficient weight loss or weight regain: how far should we go?

BACKGROUND

Revisional procedures in bariatric surgery are increasing with several debated failure risk factors, such as super obesity and old age. No study has yet evaluated the outcomes and risks of a third bariatric procedure indicated for weight loss failure or weight regain.

OBJECTIVES

To assess failure risks of a third bariatric procedure according to Reinhold's criteria (percentage excess weight loss [%EWL] ≤50% and/or body mass index [BMI] ≥35 kg/m²).

SETTING

A university-affiliated tertiary care center, France.

METHODS

From 2009 to 2019, clinical data and weight loss results of patients who benefited from 3 bariatric procedures for weight loss failure or weight regain were collected prospectively and analyzed using a binary logistic regression. Weight loss failure was defined according to Reinhold's criteria.

RESULTS

Among 1401 bariatric procedures performed, 336 patients benefited from 2 or more procedures, and 45 had a third surgery. Eleven patients that were reoperated on because of malnutrition or gastroesophageal reflux disease were excluded from the final analysis. Among 34 patients with 3 procedures because of weight loss failure or regain, mean BMI was 48.3 ± 8.3 kg/m², and mean age was 30 ± 10.7 years. Three out of 34 patients (9%) presented a severe complication (Dindo-Clavien IIIb) and 2 (6%) had a minor one. Achieving Reinhold's weight loss criteria after the second bariatric procedure was a significant predictor of success of the third procedure (β = 2.9 ± 1.3 S.E.).

CONCLUSION

Not reaching Reinhold's criteria after a second bariatric procedure was identified as a significant risk factor of failure of a third procedure. A third surgery should be carefully discussed especially in case of primary failure of previous procedures.

SADI-S 250 vs Roux-en-Y Duodenal Switch (RY-DS): Results of 5-Year Observational Study

PURPOSE

There are only a small number of studies providing a comparison between SADI-S and Hess-Marceau's BPD/Duodenal Switch (RY-DS) operations. We aimed to compare 5-year results of SADI-S 250 (common limb 250 cm) with RY-DS.

MATERIAL AND METHODS

Data of patients who underwent open SADI-S (n 226) and RY-DS (n 528) were retrospectively studied. EWL(%), EBMIL(%), TWL(%), antidiabetic effect, complications, and revision rate were compared between the two groups.

RESULTS

After the first 12 months, EWL% (77.0% vs 73.3%) and TWL% (39.4% vs 38.9%) were statistically significantly better after SADI-S (p < 0.01, and p < 0.05 respectively), but not EBMIL% (p > 0.05). At nadir to 24-36 months, EWL, TBWL, and EBMIL after SADI-S was comparable to the RY-DS group. Up to the fourth and fifth year, better weight loss (TBWL, EBMIL, EWL) was observed after RY-DS than after SADI-S. Early complication rate was less (2.65%) in the SADI-S group vs 5.1% in the RY-DS. Protein deficiency and small bowel obstruction rates were also lower after SADI-S. 93.4% of patients achieved total remission of their diabetes. 7.5% of patients in the SADI-S group had symptoms of bile reflux, which was a main indication for revisions.

CONCLUSION

SADI-S has many advantages over RY-DS. However, weight loss and antidiabetic effects after the third year were marginally lower after SADI-S compared to RY-DS. SADI-S is less dangerous in terms of malabsorption and looks to be a reasonable alternative to RY-DS as a metabolic operation. RY-DS could be implemented for weight regain and/or bile reflux after SADI-S.

Single Anastomosis Duodeno-ileostomy (SADI-S) Versus One Anastomosis Gastric Bypass (OAGB-MGB) as Revisional Procedures for Patients with Weight Recidivism After Sleeve Gastrectomy: a Comparative Analysis of Efficacy and Outcomes

Purpose

Many revisional procedures are available for unsuccessful laparoscopic sleeve gastrectomy (LSG) in patients with complications or weight recidivism. Single anastomosis duodeno-ileal bypass (SADI-S) and one anastomosis gastric bypass (OAGB-MGB) are two revisional procedures to address the problem of weight recidivism. We aimed to evaluate the efficacy and outcomes of the 2 revisional approaches (SADI-S vs. OAGB-MGB).

Materials and Methods

A retrospective analysis of prospectively collected database of patients who underwent SADI-S or OAGB-MGB as a revisional procedure for weight recidivism after primary LSG with a minimum 1-year follow-up. Weight loss, comorbidities, nutritional deficiencies, complications, and outcomes were compared in the 2 procedures.

Results

Ninety-one patients were included in the study (42 SADI-S and 49 OAGB-MGB). There was a significant weight loss (total weight loss percentage, TWL%) at 1-year follow-up observed for SADI-S when compared to OAGB-MGB (23.7 ± 5.7 vs. 18.7 ± 8.5, p = 0.02). However, this difference was not statistically significant at 18 months (26.4 ± 7.3 vs. 21.2 ± 11.0, p = 0.25). Remission of comorbidities (diabetes mellitus and hypertension) was comparable. Although OAGB-MGB had higher complication rate than SADI-S, the difference was not statistically significant (p = 0.39). No mortality was reported in the study groups.

Conclusion

Both SADI-S and OAGB-MGB are effective and safe revisional procedures for weight regain after LSG. The short-term outcomes are comparable; however, SADI-S is associated with less upper gastrointestinal complications and could be a better option for patients suffering from GERD post-LSG. Moreover, the underlying bile reflux may get worse with OAGB-MGB. However, further prospective larger studies are needed.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04933-2) contains supplementary material, which is available to authorized users.

Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures

PURPOSE

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss.

MATERIALS AND METHODS

Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1 years earlier.

RESULTS

Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids-leucine, isoleucine, and valine-were higher after SADI-S as compared with BPD-DS.

CONCLUSION

Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

A Multi-institutional Study on the Mid-Term Outcomes of Single Anastomosis Duodeno-Ileal Bypass as a Surgical Revision Option After Sleeve Gastrectomy

INTRODUCTION

Recently, a single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has become increasingly popular for patients with BMI > 50 as a primary or staged surgery. Staging allows surgeons to do the sleeve gastrectomy (SG) first with the conversion only happening when a failure or technical challenge is identified.

PURPOSE

We present the mid-term outcomes of SADI bypass surgery after SG.

METHOD

A retrospective analysis was performed on a prospective database from four institutions. Ninety-six patients were identified from 2013 to 2018. Patients were divided into two groups: one had two-stage SADI because of insufficient weight loss, the second had planned two-stage SADI because of super obesity (BMI > 50 kg/m²). Incidence of complications was divided into < 30 days and > 30 days.

RESULT

Of 96 patients, 3 patients were completely lost to follow-up. The mean age was 44.8 ± 11.3 years. There were no deaths or conversion to open surgery. The postoperative early complication and late complication rate was 5.3% and 6.4% respectively. At 24 months, group 2 had higher %weight loss (WL) and change in BMI units compared to group 1 with statistically significant difference. The average WL and change in BMI for entire patient's population at 24 months after 2nd stage SADI was 20.5% and 9.4 units respectively. The remission rate for DM was 93.7% with or without the use of medication.

CONCLUSION

The two-stage approach to SADI-S appears technically simpler than a single compromised operation. However, this approach needs more patients to understand its limitations.

Vitamin K-what is known regarding bariatric surgery patients: a systematic review

Vitamin K, a fat-soluble vitamin, is involved in blood coagulation, bone mineralization, inhibition of vascular calcification, and regulation of numerous enzyme systems. Patients who undergo bariatric surgery (BS), especially procedures that involve a malabsorptive component, are prone to develop vitamin K deficiency (VKD). The causes of VKD include decreased absorptive surface areas, steatorrhea, bacterial overgrowth, marked reduction of carriers of vitamin K, decrease in vitamin K intake, and modifications of gut microbiota. Data on vitamin K status among BS patients are scarce and the strength of evidence supporting vitamin K supplementation is weak. Thus, this systematic review summarized the scientific literature on vitamin K and examined the status among patients before and after BS, as well as among pregnant women with a history of BS. A MEDLINE/Pubmed and Embase electronic search was performed. After a thorough screening of 204 titles, 19 articles were selected by 2 independent reviewers. Five studies on BS candidates (n = 750), 12 studies after BS (n = 1442), and 4 studies on pregnant woman after BS (n = 83, of them n = 7 from case reports) were included. Results of the current review suggest that patients who undergo major malabsorptive surgeries are at a higher risk of developing VKD and should be better monitored. At this point, it is still unclear whether supplementation of vitamin K is required, and what oral dose or vitamer type should be used to normalize serum levels after different types of bariatric procedures. It should be noted that the current protocols for VKD treatment are still experiential in these patients. It is also unknown at what intervals screening tests for vitamin K should be performed and what assay is most appropriate for screening purposes. Future studies are needed to answer these unresolved issues.

Comparison of Diabetes Remission and Micronutrient Deficiency in a Mildly Obese Diabetic Rat Model Undergoing SADI-S Versus RYGB

BACKGROUND

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has launched a huge challenge to classic Roux-en-Y gastric bypass (RYGB). Our objective was to compare diabetes remission and micronutrient deficiency in a mildly obese diabetic rat model undergoing SADI-S versus RYGB.

METHODS

Thirty adult male mildly obese diabetic rats were randomly assigned to sham (S), SADI-S, and RYGB groups. Body weight, food intake, fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), plasma insulin, GLP-1, and ghrelin levels were measured at indicated time points. Meanwhile, insulin sensitivity and pancreatic β cell function were assessed during OGTT. Finally, plasma micronutrient evaluation and islet β cell mass analysis were performed after all animals were sacrificed.

RESULTS

As compared to sham, the SADI-S and RYGB groups achieved almost equivalent efficacy in caloric restriction and FPG control without excessive weight loss. During OGTT, the SADI-S and RYGB groups also provided comparable effects on glycemic excursion, insulin sensitivity, and β cell function; however, only rats in the RYGB group showed significant changes in gut hormones, whereas the three groups were found to exhibit no significant difference in β cell mass. In addition, only vitamin E in the RYGB group was deficient as compared with the SADI-S and S groups.

CONCLUSION

In mildly obese diabetic rat, SADI-S and RYGB procedures have comparable efficacy in diabetes remission and risk of micronutrient deficiency. These data show that each of the surgery accomplishes diabetes improvements through both overlapping and distinct mechanisms requiring further investigation.

Current and future impact of clinical gastrointestinal research on patient care in diabetes mellitus

The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There have been a number of clinically-relevant advances in diabetes, obesity, and metabolic syndrome emanating from gastroenterological research. Gastric emptying is a significant factor in the development of upper gastrointestinal symptoms. However, it is not the only mechanism whereby such symptoms occur in patients with diabetes. Disorders of intrinsic pacing are involved in the control of stomach motility in patients with gastroparesis; on the other hand, there is limited impact of glycemic control on gastric emptying in patients with established diabetic gastroparesis. Upper gastrointestinal functions related to emptying and satiations are significantly associated with weight gain in obesity. Medications used in the treatment of diabetes or metabolic syndrome, particularly those related to pancreatic hormones and incretins affect upper gastrointestinal tract function and reduce hyperglycemia and facilitate weight loss. The degree of gastric emptying delay is significantly correlated with the weight loss in response to liraglutide, a glucagon-like peptide-1 analog. Network meta-analysis shows that liraglutide is one of the two most efficacious medical treatments of obesity, the other being the combination treatment phentermine-topiramate. Interventional therapies for the joint management of obesity and diabetes mellitus include newer endoscopic procedures, which require long-term follow-up and bariatric surgical procedure for which long-term follow up shows advantages for individuals with diabetes. Newer bariatric procedures are presently undergoing clinical evaluation. On the horizon, combination therapies, in part directed at gastrointestinal functions, appear promising for these indications. Ongoing and future gastroenterological research when translated to care of individuals with diabetes mellitus should provide additional options to improve their clinical outcomes.