Early Outcomes of Primary SADI-S: an Australian Experience

Hypoabsorption in Bariatric Surgery: Is the Benefit Worth the Risk?

Metabolic and bariatric surgery has been well described in the existing literature to be an effective and safe modality for weight loss in patients with obesity. Recently, hypoabsorptive procedures such as one-anastomosis gastric bypass (OAGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single-anastomosis duodenoileostomy with sleeve (SADI-S) have gained traction, particularly among patients with severe obesity. These procedures combine restrictive and hypoabsorptive mechanisms, resulting in significant and sustainable weight loss, especially in those with severe obesity and associated comorbidities. However, the risk of malnutrition and nutritional deficiency following these procedures has been a deterrent for surgeons in their adoption. This review evaluates the existing literature on the safety, efficacy, and long-term outcomes of OAGB, BPD-DS, and SADI-S. While these hypoabsorptive procedures represent highly effective options for treating obesity, the associated nutritional complications necessitate the need for long-term follow-up and supplementation and highlight the need for careful patient selection.

Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy/Single Anastomosis Duodenal Switch (SADI-S/SADS) IFSO Position Statement-Update 2023

The single anastomosis duodeno-ileostomy with sleeve gastrectomy/single anastomosis duodenal switch (SADI-S/SADS) has gained attention as an alternative to the traditional biliopancreatic diversion with duodenal switch (BPD-DS). In 2021, IFSO endorsed SADI-S/SADS as a safe and effective procedure, underscoring the necessity for long-term multidisciplinary care and randomized controlled trials (RCTs). A task force was established to conduct a systematic review of current evidence on SADI-S/SADS to guide clinical practice. A systematic review was conducted across three databases, focusing on studies examining SADI-S/SADS and its outcomes. A total of 93 studies were analyzed. SADI-S/SADS demonstrated efficacy in weight loss and medium-to-long-term control of type 2 diabetes mellitus (T2DM), along with positive outcomes regarding hypertension and hyperlipidemia. However, its impact on other comorbidities remains inconclusive. Frequent nutritional deficiencies were identified, particularly in fat-soluble vitamins, anemia, and hypoalbuminemia. Despite significant efforts, high-quality evidence on SADI-S/SADS remains scarce, prompting IFSO to advocate for increased registry participation, publication of long-term studies, and more RCTs. Lifelong supplementation and monitoring for nutritional deficiencies are recommended. The current position statement will be reviewed in 2 years.

Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article

As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.

Single anastomosis duodenal switch versus Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: a multi-centered comparative analysis

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has consistently demonstrated excellent weight loss and comorbidity resolution. However, outcomes vary based on patient's BMI. Single anastomosis duodeno-ileostomy with sleeve (SADI-S) is a novel procedure with promising short-term results. The long-term outcomes of SADI-S in patients with BMI ≥ 50 kg/m2 are not well described. We aim to compare the safety and efficacy of SADI-S with RYGB in this patient population.

METHODS

We performed a multicenter retrospective study of patients with a BMI ≥ 50 kg/m2 who underwent RYGB or SADI-S between 2008 and 2023. Patient demographics, peri- and post-operative characteristics were collected. Complication rates were reported at 6, 12, 24, and 60 months postoperatively. A multivariate linear regression was used to evaluate and compare weight loss outcomes between both procedures.

RESULTS

A total of 968 patients (343 RYGB and 625 SADI-S; 68.3% female, age 42.9 ± 12.1 years; BMI 57.3 ± 6.7 kg/m2) with a mean follow-up of 3.6 ± 3.6 years were included. Patients who underwent RYGB were older, more likely to be female, and have a higher rate of sleep apnea (p < 0.001), hypertension (p = 0.015), dyslipidemia (p < 0.001), and type 2 diabetes (p = 0.016) at baseline. The rate of bariatric surgery-specific complications was lower after SADI-S compared to RYGB. We reported no bariatric surgery related deaths after 1 year following both procedures. SADI-S demonstrated statistically higher and sustained weight loss at each time interval compared to RYGB (p < 0.001) even after controlling for multiple confounders. Lastly, the rate of surgical non-responders was lower in the SADI-S cohort.

CONCLUSIONS

In our cohort, SADI-S was associated with higher and sustained weight-loss results compared to RYGB. Comorbidity resolution was also higher after SADI-S. Both procedures demonstrate a similar safety profile. Further studies are required to validate the long-term safety of SADI-S compared to other bariatric procedures.

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.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity.

RESULTS

4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications.

CONCLUSION

GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

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.

Clinical outcomes and complications of single anastomosis duodenal-ileal bypass with sleeve gastrectomy: A 2-year follow-up study in Bogotá, Colombia

BACKGROUND

The global prevalence of obesity has increased over the past 40 years, and bariatric surgery has proven to be the most effective therapy for long-term weight loss. Its principles are based on modifying the brain-gut axis by altering the gastrointestinal anatomy and affecting the function of gastrointestinal hormones, thereby modifying satiety signals. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) combines both techniques and has become an alternative to gastric bypass and biliopancreatic diversion procedures for treating severe obesity and associated metabolic diseases in selected patients.

AIM

To describe the outcomes and complications of SADI-S.

METHODS

We retrospectively analyzed the data of patients who underwent SADI-S laparoscopically at the Clínica Reina Sofía in Bogotá, Colombia. This study assessed the therapeutic effectiveness of SADI-S in terms of short-term preoperative clinical characteristics, postoperative complications, comorbidities, nutritional defi-ciencies, and intraoperative complications during a 2-year follow-up.

RESULTS

Sixty-one patients with a mean body mass index (BMI) of 50 ± 7.1 kg/m2 underwent laparoscopic SADI-S. The mean operative time and hospital stays were 143.8 ± 42 min and 2.3 ± 0.8 d, respectively. The mean follow-up period was 18 mo, and the mean BMI decreased to 28.5 ± 12.2 kg/m2. The excess BMI loss was 41.8% ± 13.5%, and the weight loss percentage was 81.1% ± 17.0%. Resolution of obesity-related comorbidities, including type 2 diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea, was achieved and defined as complete or partial remission. No intraoperative complications were observed. Short-term complications were observed in four (6.8%) patients. However, larger studies with longer follow-up periods are required to draw definitive conclusions.

CONCLUSION

SADI-S has a low intraoperative and postoperative complication rate and is effective for weight loss and improving obesity-related comorbidities, including hypertension, type 2 diabetes mellitus, dyslipidemia, and sleep apnea syndrome.

Four-Year Nutritional Outcomes in Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Patients: an Australian Experience

Nutritional deficiencies following malabsorptive surgeries are a major concern.

PURPOSE

To present clinical-based, mid-term nutritional outcomes in single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) patients using a nutritional supplement based on the American Society for Metabolic & Bariatric Surgery (ASMBS) guidelines.

SETTING

Single private institute, Australia.

MATERIALS AND METHODS

Data from 196 patients who underwent a primary SADI-S by a single surgeon from January 2017 through March 2022 were retrospectively analysed. All patients received either original or altered formulated nutritional supplementation throughout the study. In total, three formulae, slightly different from each other, were used at three different time points to formulate the supplement.

RESULTS

In total, 196 patients were included. The average age and preoperative body mass index were 44.9 ± 6.7 years and 43.6 ± 22.5 kg/m², respectively. Nutritional follow-up was available on 77.5%, 73.2%, 73.4%, and 59.7% of patients at 12, 24, 36, and 48 months, respectively. At baseline, 48.3%, 30%, 14.9%, 13.3%, 12.4%, 3.8%, 2.3%, and 0.5% of the patients had vitamin D, calcium, folic acid, total protein, iron, vitamin B12, copper, and vitamin A deficiencies, respectively. Postoperatively, mild to moderate vitamin deficiencies were noted in 14.2% of the patients in the first 18 months; however, at 4 years, the cohort had zero nutritional deficiencies. There were no long-term complications, revisions/conversions, or mortalities related to nutritional deficiencies.

CONCLUSION

Factors, like preoperative and postoperative early, aggressive correction of nutritional deficiencies, regular laboratory monitoring and follow-ups with the multidisciplinary team, and adherence to our formulated nutritional supplement, have contributed to favourable nutritional outcomes at 4 years.

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.

Efficacy and safety of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy for the treatment of Chinese T2D patients with obesity

BACKGROUND

Bariatric surgery is the most effective treatment for obese T2D. As one of the most effective bariatric surgeries, SADI-S was recently introduced in China, and there is limited evidence of its efficacy and safety in the treatment of obese T2D. The aim of this study is to investigate the safety and efficacy of SADI-S in the treatment of obese T2D in China.

METHODS

The clinical data of 32 obese T2D patients who underwent SADI-S was included in this study. Changes in weight-related indicators, diabetes-related indicators, and patient nutritional outcomes were analyzed.

RESULTS

SADI-S was conducted successfully in all of the 32 cases without conversion to laparotomy or death. The incidence of surgical complications was 15.6% (5/32). The major complication rate was 6.3% (2/32). At 1 year after surgery, the BMI (kg/m²) significantly decreased from 40.8 ± 7.4 to 23.9 ± 2.9 (P < 0.05) and the mean HbA1c significantly decreased from 8.5% (6.4-11.5) to 5.0% (3.8-5.6) (P < 0.05). At 2 years after surgery, the BMI (kg/m²) significantly decreased to 24.9 ± 2.4 (P < 0.05) and the mean HbA1c significantly decreased to (4.8 ± 0.4)% (P < 0.05). The %TWL was (40.4 ± 6.5)% and (42.9 ± 4.9)% at 1 year and 2 years, respectively. The complete remission rates for T2D were both 100% at 1 year and 2 years. Triglyceride levels were significantly improved compared with preoperative, from (3.2 ± 3.0) mmol/L to (1.0 ± 0.3) mmol/L (P < 0.05), but there was no significant difference in other nutritional outcomes.

CONCLUSION

The SADI-S has excellent curative effect in the treatment of Chinese obese T2D, but the operation is challenging and the complication rate is high. Its long-term efficacy and safety require further study.

Based on Propensity Matching Scores: Comparison of the Efficacy of Two Kinds of Bariatric Surgery for Obese Type 2 Diabetes

PURPOSE

To compare the efficacy of OADS and SG in treating obese T2D in China.

MATERIALS AND METHODS

We included 99 obese Chinese patients with T2D undergoing OADS or SG with a 1-year postoperative follow-up from January 2014 to October 2021. Using the propensity score matching (PSM) method, patients from both groups were matched 1:1. Outcomes for losing weight, controlling diabetes, and nutrition were then determined.

RESULTS

There were 32 patients in each group after using the PSM method, and there was no statistically significant difference between the two groups in terms of all the baseline indicators (P > 0.05). When comparing weight loss outcomes, the OADS group outperformed the SG group in terms of change in BMI and %TWL, with statistically significant differences [15.0 (8.1-26.6) kg/m², 10.0 (4.10-23.5) kg/m² P = 0.001; 38.5% ± 6.7%, 29.5% ± 9.4%, P = 0.000]. When comparing the efficacy of diabetes, the OADS group outperformed the SG group in terms of HbA1C and complete remission of diabetes, with statistically significant differences [5.1 (3.8-5.6)%, 5.4 (4.3-7.9)%, P = 0.001; 100%, 75%, P = 0.005]. Besides, the incidence of postoperative zinc deficiency in the OADS group was significantly higher than in the SG group (P = 0.019) and there was no significant difference in other postoperative nutritional outcomes between the two groups.

CONCLUSION

Although OADS and SG are both effective in the treatment of obese T2D, OADS performs better. Besides, the long-term efficacy of both needs to be recorded at subsequent follow-up.

Outcomes of totally robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy: A large single-centre series

BACKGROUND

In recent years, the robot surgical system begins to be applied in single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S). However, only a few studies with very small sample size are present on robotic SADI-S.

OBJECTIVE

This retrospective study aimed to estimate the outcomes of totally robotic SADI-S.

METHODS

102 consecutive patients undergoing totally robotic SADI-S between March 2020 and December 2021 were included. Patient demographics, operative time, length of postoperative hospital stay, complications, conversion to laparotomy, reoperation, readmission, mortality, and postoperative weight loss were recorded to analyze the safety, effectiveness, and learning curve of totally robotic SADI-S. Based on the operative time, we evaluated the learning curve of robotic SADI-S by the cumulative sum (CUSUM) method.

RESULTS

The overall follow-up rate was 100%. The mean operative time was 186.13 ± 36.91 min. Short-term (≤30 days) complication was present in 6.9% (n = 7), of which major complications were identified in 2.9% (n = 3), including 2 gastric leakages and 1 postoperative acute respiratory failure. None of the patients experienced a long-term (＞30 days) complication. No conversion to laparotomy or deaths occurred during the study period. The mean percent of total weight loss (%TWL) at 3, 6, 12 and 24 months was 21.87 ± 4.44%, 32.49 ± 5.31%,40.86 ± 7.84%, and 44.64 ± 5.88%, respectively. The mean percent of excess weight loss (%EWL) at 3, 6, 12 and 24 months was 52.78 ± 16.99%,76.53 ± 17.99%,95.22 ± 18.59%, and 113.74 ± 23.30%, respectively. The cumulative sum (CUSUM) of operative time reached the first peak when the number of cases accumulated to the 16th case, then reached the second peak and continued to decline when the number of cases accumulated to the 27th case. Subsequently, all the patients were classified into the learning stage group (the first 27 patients) and the mastery stage group (the last 75 patients). Except for operative time, proportion of abdominal drainage tubes and lengths of postoperative hospital stay, there was no significant difference between the learning stage and mastery stage groups.

CONCLUSION

Totally robotic SADI-S seems to be feasible and effective in the treatment of morbid obesity, just like laparoscopic SADI-S. The learning curve of robotic SADI-S is 27 cases.

Patient Selection and 30-Day Outcomes of SADI-S Compared to RYGB: a Retrospective Cohort Study of 47,375 Patients

PURPOSE

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) offers a novel bariatric procedure with few comparative studies evaluating patient selection or perioperative outcomes. We aim to compare SADI-S to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing SADI-S to RYGB. Bivariate analysis was performed to determine intergroup differences. Multivariable logistic regression determined factors associated with serious complications and mortality.

RESULTS

We evaluated 47,375 patients, with 501 (1.1%) receiving SADI-S. Patients undergoing SADI-S had higher body mass index (51.4 ± 9.7 kg/m² SADI-S vs. 44.6 ± 7.9 kg/m² RYGB; p < 0.001), and more metabolic comorbidities including non-insulin dependent diabetes (21.7% SADI-S vs 19.0% RYGB; p = 0.011), insulin dependent diabetes (12.0% SADI-S vs. 8.6% RYGB; p = 0.011), and hypertension (54.9% SADI-S vs 47.6% RYGB; p < 0.001). Patients undergoing SADI-S experienced more anastomotic leaks (2.2% vs. 0.5%; p < 0.001), reoperations (5.0% vs 2.6%; p < 0.001), pneumonias (1.6% vs 0.5%; p < 0.001), had sepsis more frequently (1.4% vs 0.3%; p < 0.001), and required more unplanned reintubations (1.2% vs 0.3%; p = 0.004). SADI-S was independently associated with serious complications (OR 1.45, CI 1.09-1.95, p < 0.001) but was not a predictor of mortality (OR 3.29, p = 0.060).

CONCLUSIONS

In comparison to RYGB, patients undergoing SADI-S were found to have more metabolic comorbidities. Compared to RYGB, SADI-S has worse perioperative outcomes and is independently associated with serious complications. It remains unclear whether this represents a learning curve or true findings and prospective studies analyzing the risk-benefit ratio following SADI-S are needed.

Gastric Ischaemia After SADI with Right Gastric Artery Ligation

There are several bariatric procedures used for the effective management of obesity that employ restrictive or malabsorptive components to achieve effective weight loss and reduction in metabolic disease. The single anastomosis duodeno-ileal (SADI) bypass was first introduced as a simplification of the biliopancreatic diversion with a duodenal switch [1], often accompanied by sleeve gastrectomy (SADI-S) or as an alternative gastric sleeve revision procedure to Roux-en-Y gastric bypass [2]. SADI was developed to address the technical complexity associated with other bypass reconstructions by involving only one anastomosis while preserving pyloric function, minimising dumping symptoms. This procedure has been proven to be safe and effective for sustained weight loss and resolution of metabolic disease, particularly in patients with a high carbohydrate diet [3, 4]. Currently, the SADI/SADI-S procedure is still considered a relatively novel technique with no absolute consensus over the exact surgical technique, and serious postoperative complications can still occur. A key discussion point is the utility of right gastric artery ligation depending on surgeon preference. This paper aims to describe the presentation and management of the first reported case of gastric ischaemia following sleeve to SADI revision with right gastric artery ligation.

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.

General Practitioner's Knowledge about Bariatric Surgery Is Associated with Referral Practice to Bariatric Surgery Centers

(1) Background: Patients seeking treatment for obesity and related diseases often contact general practitioners (GPs) first. The aim of this study was to evaluate GPs’ knowledge about weight loss surgery (WLS) and potential stereotypes towards obese patients. (2) Methods: For this prospective cohort study, 204 GPs in the region of the bariatric surgery center at the University Hospital Aachen were included. The participants filled out a questionnaire comprising general treatment of obese patients, stigmatization towards obese patients (1–5 points) as well as knowledge regarding WLS (1–5 points). (3) Results: The mean age of the GPs was 54 years; 41% were female. Mean score for self-reported knowledge was 3.6 points out of 5. For stigma-related items, the mean score was 3.3 points out of 5. A total of 60% of the participants recognized bariatric surgery as being useful. Knowledge about bariatric surgery significantly correlated with the number of referrals to bariatric surgery centers (p < 0.001). No significant correlation was found between stigma and referral to surgery (p = 0.057). (4) Conclusions: The more GPs subjectively know about bariatric surgery, the more often they refer patients to bariatric surgery specialists—regardless of potentially present stereotypes. Therefore, GPs should be well informed about indications and opportunities of WLS.

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.

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.

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.

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.

Single-Anastomosis Duodenal Ileostomy with Sleeve Gastrectomy "Continued Innovation of the Duodenal Switch"

Single-anastomosis duodenal ileostomy with sleeve gastrectomy (SADI-S) is an important emerging procedure in bariatric surgery as an alternative to performing the Roux-en-Y gastric bypass (RYGB) or the Roux-en-Y duodenal switch. With this significant weight loss and low weight regain, SADI-S has low complication rates. SADI-S, because of its anatomic configuration, also does not increase ulcer risk in patients, with almost no ulcers observed. Because of the short common channel, malnutrition is a risk. Diabetes resolution is higher than with RYGB. Overall SADI-S is a safe and effective procedure for patients with higher body mass index and patients with diabetes.

Evaluation of Myocardial Function Following SADI-S

PURPOSE

The aim of this study was to compare myocardial mechanics using global longitudinal strain (GLS) before and after single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S).

MATERIALS AND METHODS

A total of 21 obese patients undergoing SADI-S were prospectively included. Transthoracic echocardiography was performed before and after the procedure, and left ventricle (LV) and right ventricle (RV) strain was assessed by two-dimensional speckle-tracking imaging (2DST).

RESULTS

Mean time between pre-procedural and post-procedural echocardiograms was 9.2 ± 3.3 months. Postoperatively, %total weight loss (%TWL) was 33.0 ± 1.7 and % excess weight loss (%EWL) was 75.5 ± 3.6. Body mass index (BMI) significantly decreased after surgery (45.6 ± 1.2 vs 29.6 ± 1.0; p < 0.001). Postoperatively, LV GLS experienced a significant improvement (-19.8% ± 0.5 vs -22.2% ± 0.4; p < 0.001). Regarding other relevant functional parameters, RV free-wall strain was equally recovered (-19.1% ± 0.7 vs -21.0% ± 0.8; p 0.047).

CONCLUSIONS

This study demonstrates important and favourable changes in cardiac deformation parameters after performing SADI-S. Malabsorptive bariatric techniques such as SADI-S induce significant weight loss, leading to an improvement in subclinical myocardial function in patients with obesity.

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.

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.

A Matched Cohort Comparison of Long-term Outcomes of Roux-en-Y Gastric Bypass (RYGB) Versus Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S)

BACKGROUND

The long-term effectiveness of Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is unknown.

PURPOSE

Compare the long-term outcomes.

SETTING

Single private institute, USA.

MATERIALS AND METHODS

Data from 1254 patients who underwent primary RYGB or SADI-S were used for a retrospective matched cohort. Data were obtained by matching every RYGB patient to a SADI-S patient of the same sex, body mass index (BMI), and weight. Only patients out 5 years and had at least one > 5-year follow-up visit were included.

RESULTS

The matched cohort included 61 RYGB and 61 SADI-S patients. There was no statistical, demographic difference between the two groups. At 5 years, a 100% follow-up was available in each group. The intraoperative outcomes were significantly better with SADI-S. The 30-day readmission, reoperation, emergency department (ED) visits, and complication rates were statistically similar between the two groups. The long-term complication rates, Clavien-Dindo grade IIIb complications, and number of patients with more than one complication were significantly lower with SADI-S. Weight loss was significantly greater in the SADI-S group at 5 years. The long-term weight-loss failure rate was significantly higher in the RYGB group. The SADI-S procedure was associated with fewer reintervention through 6 years (14.7% patients vs. 39.3% patients, p = 0.001). Conversion or reversal of the procedure was required only in the RYGB group. There also was no significant difference in nutritional outcomes between the two procedures.

CONCLUSIONS

This study showed that problems, including long-term complications, reinterventions, weight-loss failure, and conversion, were more often associated with RYGB than with SADI-S. The SADI-S may be considered one of the viable alternatives to RYGB.