Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy

Single-anastomosis duodenal-ileal bypass with sleeve gastrectomy for diabetes: predictors of remission and metabolic outcomes in a multicenter study

BACKGROUND

The single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) combines the restrictive aspects of a sleeve gastrectomy (SG) with the hypoabsorptive advantages of a gastric bypass. SADI-S has demonstrated excellent weight loss outcomes and technical feasibility.

OBJECTIVES

To evaluate the benefits of SADI-S in patients with obesity and type 2 diabetes mellitus.

SETTING

Academic and private practice hospitals, United States.

METHODS

Following the institutional review board (IRB) approval, a multicenter retrospective review was conducted to evaluate adult patients with obesity and type 2 diabetes who underwent SADI-S between January 1, 2013, and April 1, 2023. Type 2 diabetes remission was defined as a hemoglobin A1C (HbA1C) value of <6.5% in the absence of any antidiabetic medication use. Patient demographics and bariatric and metabolic-related parameters were collected.

RESULTS

A total of 419 consecutive patients were identified with a median age of 50.0 years (interquartile range [IQR] 17) and a mean body mass index (BMI) of 47.1 ± 8.9 kg/m2. The mean percentage of total weight loss (%TWL) was 31.9% with a type 2 diabetes remission rate of 60.1% and a mean follow-up period of 2.0 years. Two hundred twenty-six patients were included in the final analysis. Preoperative insulin use and higher BMI were negative predictors of type 2 diabetes remission, whereas greater %TWL was associated with a higher likelihood of type 2 diabetes remission at the last follow-up. On average, patients maintained reduced HbA1C values.

CONCLUSIONS

SADI-S is an effective and durable metabolic and bariatric surgery (MBS) for patients with obesity and type 2 diabetes. Patients with higher preoperative BMI and insulin use are less likely to experience type 2 diabetes remission after surgery.

Laparoscopic Single Anastomosis Duodeno-Ileal Bypass Versus One Anastomosis Gastric Bypass as Revisional Procedures after Sleeve Gastrectomy: Meta-analysis and Systematic Review

BACKGROUND

It has been observed that 5-8% of primary bariatric procedures result in inadequate treatment response, necessitating the need for revisional surgery. In this systematic review and meta-analysis, we aim to compare the effectiveness of single anastomosis duodeno-ileal bypass (SADI) and one anastomosis gastric bypass (OAGB) in addressing weight recurrence following sleeve gastrectomy.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases. Studies were considered eligible if they compared SADI with OAGB as revisional surgeries following sleeve gastrectomy.

RESULTS

Our search strategy yielded four articles with a total of 309 patients. Regarding weight loss at 1 year of follow-up, SADI was favorable based on excess weight loss percentage (EWL%) and total weight loss percentage (TWL%). At 2 years of follow-up, EWL% did not show a statistically significant difference between the two operations although TWL% was higher in SADI group. Regarding postoperative bile reflux, the OAGB group had a significantly higher incidence of biliary reflux (OR 0.15; 95% CI 0.04 to 0.53; P = 0.003). Patients enrolled in SADI did not develop anastomotic ulcers according to the four studies included in the analysis. In contrast, seven patients in the OAGB group did develop anastomotic ulcers, but the difference was not statistically significant (OR 0.23; 95% CI 0.05 to 1.10; P = 0.07).

CONCLUSION

ADI is a feasible procedure with a favorable outcome compared to OAGB as a revisional surgery following sleeve gastrectomy regarding weight loss at 1 year with a lower incidence of postoperative biliary reflux.

Long-term results of Roux-en-Y gastric bypass (RYGB) versus single anastomosis duodeno-ileal bypass (SADI) as revisional procedures after failed sleeve gastrectomy: a systematic literature review and pooled analysis

PURPOSE

Revisional bariatric surgery (RBS) has flourished during the last decades in many countries, due to suboptimal weight loss or long-term complications of primary bariatric surgery. Restrictive procedures, and in particular sleeve gastrectomy (SG), although widely performed as primary bariatric surgery, seems particularly prone to need surgical revision for the above-mentioned reasons during long-term follow-up. The aim of this systematic review was to compare the long-term (5-year) safety and efficacy between Roux-en-Y gastric bypass (RYGB) and single anastomosis duodeno-ileal bypass (SADI) after 'failed' SG.

METHODS

A systematic review was performed from 2007 to September 2024. Articles were included if SADI or RYGB were performed as RBS after 'failed SG' with follow-up at least 5 years. Pooled analysis was performed to summarize the data.

RESULTS

Among the seven studies eligible and included in this review, the SADI procedure showed comparable results to RYGB in terms of weight loss, nutritional deficiencies, and resolution of comorbidities during the long-term follow-up. However, RYGB proved superior in terms of remission of reflux disease and other functional problems after SG.

CONCLUSIONS

The present review found that SADI seems to be a promising and suitable method for suboptimal weight loss after SG, with comparable or even better results to RYGB after 5-year follow-up.

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.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center

BACKGROUND

Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described.

METHODS

A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes.

RESULTS

Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization.

CONCLUSIONS

Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

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.

Endoscopic Revisional Gastroplasty After Bariatric Surgery with a Single-Channel Endoscope

BACKGROUND

Less invasive endoscopic bariatric procedures are under development for the management of recurrence of obesity. The purpose of the current manuscript was to evaluate the safety of the endoscopic revisional gastroplasty (ERG) for patients with recurrence of weight gain following different bariatric procedures.

MATERIALS AND METHODS

This is a retrospective single-center study over 22 patients using the ERG between January 2020 to July 2022 at Bouchard Private Hospital (Marseille, France). The demographic data, past surgical history, obesity complications, time interval between the surgical and endoscopic procedures, and intra and postoperative parameters and outcomes were analyzed.

RESULTS

A total of 22 patients underwent ERG: 19 female (86.4%) with a mean age of 34.2 years and a mean BMI of 32.9 kg/m2 (± 3.4). Average time between the revisional bariatric surgery and ERG was 14.4 months (range 5-36). There were 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%), and 3 cases with previous gastric band. All procedures were completed by endoscopy with no complication and a mean length of hospital stay of 1.1 days (± 0.9). The weight loss results at 1-year follow-up were available for 17 of the 22 patients: two patients were lost to follow-up (4%) and 3 patients had less than a 1-year follow-up from the ERG. The mean BMI, 1 year after ERG, was 28.7 kg/m2 (± 7.4); the mean BMI loss and %EWL were, respectively, 4.2 kg/m2 (± 4.7) and 53.1% (± 17).

CONCLUSION

Endoscopic revisional gastroplasty represents a safe minimal invasive approach that can be considered an effective and well-tolerated procedure for patients with previous bariatric surgery.

Single Anastomosis Duodeno-Ileal Bypass (SADI) as a Second Step After Failed Sleeve Gastrectomy: Systematic Review and Meta-analysis

Purpose

Our aim in this study is to assess single anastomosis duodeno-ileal bypass (SADI) as a salvage procedure following sleeve gastrectomy (SG), examining its technical feasibility, outcomes, and potential complications.

Materials and Methods

A systematic review and meta-analysis were conducted, drawing data from PubMed, Medline, and the Cochrane library. The analysis encompassed 14 studies, involving 1,066 patients. We evaluated operative time, comorbidity resolution (hypertension, dyslipidemia, diabetes), post-operative diarrhea incidence, excess weight loss (EWL) at six, twelve, and twenty-four months, and post-operative leak rates.

Results

SADI as a salvage procedure following SG yielded positive outcomes. Mean operative time was 125.98 minutes (95% CI 102.50-149.46, I2=99%). Importantly, SADI led to comorbidity resolution in a notable proportion of cases: hypertension in 48% (95% CI 38-57%, I2=44%), dyslipidemia in 55% (95% CI 40-69%, I2=30%), and diabetes in 63% (95% CI 53-72%, I2=30%) of patients. Post-operative diarrhea incidence was relatively low at 2% (95% CI 1-9%, I2=75%). In terms of weight loss, SADI patients exhibited substantial EWL: 47.73% (95% CI 37.86-57.61, I2=95%) at six months, 59.39% (95% CI 51.18-67.61, I2=95%) at twelve months, and 23.84% (95% CI 5.76-41.92, I2=100%). At twenty-four months. Furthermore, post-operative leak rate was relatively low, reported in only 1% (95% CI 0-5%, I2=80%) of cases.

Conclusion

SADI as a salvage procedure post-SG demonstrates technical feasibility and marked effectiveness. It offers substantial comorbidity resolution, significant weight loss, and low post-operative complication rates, notably post-operative leaks. Further research should investigate the long-term impact of SADI on patient nutritional status to facilitate its broader adoption.

Re-sleeve gastrectomy is a safe and sensible intervention in selected patients: retrospective cohort study

INTRODUCTION

Sleeve gastrectomy is a good treatment intervention to control the metabolic syndrome in patients with obesity worldwide. However, weight regain is of great concern and would usually necessitate a reintervention. In recent years, re-sleeve gastrectomy (ReSG) has been proposed to treat weight regain in the context of a large residual stomach. Our objective was to analyze the long-term results and safety profile of this intervention in a large case series.

METHODS

From September 2010 to March 2021, a retrospective cohort study in a tertiary nonuniversity hospital was performed. Seventy-nine patients received a ReSG by laparoscopy. Preoperative radiologic imaging showed a dilation of the gastric pouch exceeding 250 cc in all cases.

RESULTS

A total of 79 patients (87% females) with a mean age of 44.8 years old and a mean BMI of 40.0 kg/m 2 were enrolled in the study. The mean follow-up was 44.8 months. The ReSG indication was insufficient weight loss in 37 patients (46.8%) and weight regain in 39 patients (53.2%). The authors noticed a 10.1% complications rate: gastric stenosis (5.1%), bleeding (2.5%), and incisional site hernia in 2.5%, with no death. There was no gastric fistula detected. The mean BMI decreased to 33.1 kg/m 2 after ReSG (a decrease of 6.9 kg/m 2 ).

CONCLUSION

After insufficient weight loss or weight regain following sleeve gastrectomy and in the presence of localized or global gastric tube dilation, ReSG seems to be a good treatment choice and a safe procedure.

Single Anastomosis Duodenal Switch versus Classic Duodenal Switch: Long-term Outcomes from a Prospective Comparative Cohort Study

PURPOSE

The literature on long-term outcomes of duodenal switch (DS) compared to single anastomosis duodenal switch (SADI-S) procedures is lacking. We evaluated the long-term outcomes of SADI-S compared to those after the classic DS procedure.

METHODS

This is a follow-up report from a single-institution prospective cohort study comparing long-term outcomes of SADI-S versus DS both as one- and two-stage procedures (ClinicalTrials.gov: NCT02792166). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

Forty-two patients underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). Of 20 patients who underwent DS, twelve had it as a second-stage procedure (60%). Both groups were similar at baseline. Median follow-up times for one-stage SADI-S and DS were 57 (24) and 57 (9) months, respectively (p = 0.93). Similar BMI reductions were observed after one-stage SADI-S (16.5 kg/m2 [8.5]) and DS (18.9 kg/m2 [7.2]; p = 0.42). At median follow-up of 51 (21) and 60 (15) months after second-stage SADI-S and DS, respectively (p = 0.60), surgical procedures yielded reductions in BMI of 20.5 kg/m2 (14.0) and 24.0 kg/m2 (13.9), respectively (p = 0.52). Follow-up rates were similar for one-stage (≥ 88%; p = 0.29) and second-stage procedures (≥ 83%; p = 0.16). Similar diabetes and hypertension remissions were found (p = 0.77; P = 0.54, respectively). Despite fat-soluble vitamin deficiencies at baseline, after supplementation, they were either eliminated or less prevalent long-term after SADI-S. Daily bowel movements were also less frequent.

CONCLUSIONS

Long-term weight and comorbidity outcomes after SADI-S are similar to those of DS both as one- and two-stage surgeries. SADI-S procedure may allow for similar beneficial outcomes with less burden from gastrointestinal symptoms and fat-soluble vitamin deficiencies.

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.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience

BACKGROUND

Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits.

METHODS

Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW).

RESULTS

768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation.

CONCLUSION

Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass to Enhance Weight Loss: Single Enterprise Mid-Term Outcomes and Literature Review

Background

Suboptimal weight loss (SWL) occurs up to 30% after sleeve gastrectomy (SG). Conversion to Roux-en-Y gastric bypass (cRYGB) has shown heterogeneous results in terms of additional weight loss and resolution of weight-related comorbidities. We aim to evaluate mid-term outcomes of cRYGB specifically for SWL after SG.

Methods

All patients who underwent cRYGB for SWL from April 2010 to June 2019 from prospective registries at three affiliated tertiary care centers were retrospectively reviewed. Patients who underwent revision or conversion for complications were excluded. Mixed-effects and polynomial regression models were used to evaluate weight loss results after conversion.

Results

Thirty-two patients underwent cRYGB from SG. About 68.7% were women with mean age of 46.6 years. Mean body mass index (BMI) before SG was 55.3 kg/m². Before conversion, mean BMI was 44.5 kg/m² with 17.3% total weight loss (TWL). All procedures were completed laparoscopically in a median surgical time of 183 min. Three major complications occurred (9.3%), one gastrojejunal (GJ) leak and two reoperations. Four cases (12.5%) of GJ stenosis were diagnosed. No mortality was registered. Mean follow-up time was 24 months and patients had 36 kg/m² mean BMI, 17.4% TWL, 27.2% had BMI >35 kg/m².

Conclusions

cRYGB after SG for SWL showed good mid-term results, better than those reported in literature.

Single-Anastomosis Sleeve Jejunal (SAS-J) Bypass as Revisional Surgery After Primary Restrictive Bariatric Procedures

Purpose

Single-anastomosis sleeve jejunal (SAS-J) bypass is the modification of a single-anastomosis sleeve ileal (SASI) bypass with a short biliary limb. SAS-J bypass is reported to be a good primary bariatric procedure. This study aimed to evaluate the results of SAS-J bypass as a revisional surgery after failed primary restrictive bariatric procedures.

Material and Methods

This was a prospective cohort study including 43 patients who underwent SAS-J bypass as a revisional surgery for weight regain after laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric band (LAGB), or laparoscopic gastric plication.

Results

Of the total patients, 35 (81.4%) were female, and 8 (18.6%) were male. The mean BMI was 46.3 kg/m². The mean age was 41 years. Thirty-two patients (74.4%) had a failed sleeve, 9 (20.9%) had a failed LAGB, and 2 (4.7%) had a failed gastric plication. The mean operative time was 104 min. Intra-abdominal bleeding occurred in 1 case (2.3%), and intraluminal bleeding occurred in 3 cases (7%). No case (0%) developed a leak. The percentage of excess weight loss (%EWL) reached 76.5% after 1 year. Type 2 diabetes mellitus remission occurred in all diabetic patients, hypertension remitted in 80%, hyperlipidemia remitted in 83.3%, and obstructive sleep apnea syndrome improved in all cases. Gastroesophageal reflux disease (GERD) symptoms were improved in 86.7% of patients. Significant biliary gastritis occurred in 4 patients (9.3%). Dumping syndrome was reported in 4 patients (9.3%).

Conclusions

SAS-J bypass was effective as a salvage surgery after failed restrictive bariatric procedures, but long-term follow-up is needed.

Graphical abstract

The Impact of the Length of the Common Intestinal Loop on Metabolic and Nutritional Outcomes of Patients with Severe Obesity Who Undergo of Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy: 5-Year Follow-Up

Introduction: Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a recent bariatric surgery technique, highly effective in terms of weight loss. Nevertheless, data regarding the impact of SADI-S at mid-long term (after >5 years of follow-up) are scarce. Objectives: To evaluate the effect of lengths of common intestinal loop on the evolution of patients with morbid obesity (MO), who undergo SADI-S. Materials and Methods: Descriptive study (case series), including patients with MO who underwent SADI-S procedure between January 2012 and December 2015 with at least 5 years of follow-up. Patients were classified as "Old-SADI-S" (OS) when length of the common alimentary loop was <2.5 m and "New-SADI-S" (NS) when length was >2.5 m. Clinical parameters and nutritional parameters were included. Results: Twenty-nine cases were included (17 OS; 12 NS), 86.2% women and mean age 46.7 ± 1 years. After 12 months, OS had significantly lower body mass index (29.7 ± 4.8 kg/m² versus 32.0 ± 5.1 kg/m², P = .01), without significant differences in the resolution of comorbidities. Nevertheless, OS group had severe malabsorptive complications requiring surgical conversion of OS to NS in 7 patients after 8 months. At 5 years of follow-up, no significant difference was seen between the two groups and resolution of comorbidities was maintained during this period of time. Conclusions: SADI-S is effective in terms of weight loss and resolution of comorbidities at 5 years of follow-up, regardless of the length of the common intestinal loop. However, a common intestinal loop <2.5 m was associated with severe malabsorptive complications that determined the surgical re-conversion in all cases.

Long-Term Results of Single-Anastomosis Duodeno-ileal Bypass with Sleeve Gastrectomy (SADI-S)

BACKGROUND

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a simplification of the duodenal switch (DS) in which the alimentary limb is eliminated, and the common channel is lengthened from 200 to 300 cm. Short-term results have demonstrated that SADI-S is safe and reproducible and that weight loss and comorbidities resolution are comparable to biliopancreatic diversion or DS.

OBJECTIVE

To analyze the long-term outcomes of SADI-S.

METHODS

From May 2007 to December 2015, 164 patients were consecutively submitted to a one-step SADI-S. The mean age was 47 years, and the mean body mass index (BMI) was 45.8 kg/m². A total of 101 patients had type 2 diabetes, 91 arterial hypertension, 81 obstructive apnea, and 118 dyslipidemia. Limb length was 200 cm in 50 cases, 250 cm in 99, and 300 cm in 15.

RESULTS

There was no mortality. One patient had a gastric leak, and 2 patients had an anastomotic leak. A total of 25% of the patients were lost to follow-up at 10 years. Excess weight loss and total weight loss were 87% and 38% at 5 years and 80% and 34% at 10 years. A total of 12 patients were submitted to revisional surgery for hypoproteinemia. Preoperatively 41 diabetics were under insulin treatment; at 5 years, 7 remained with insulin and 12 at 10 years. Mean glycemia was 104 mg/dL at 5 years and 118 mg/dL at 10 years. Mean HbA1c was 5.51% at 5 years and 5.86 at 10 years.

CONCLUSION

In the long term, SADI-S offers satisfactory weight loss and comorbidities resolution.

Combined Re-sleeve and Single Anastomosis Sleeve Ileal (SASI) Bypass as a Second Stage After Sleeve Gastrectomy (Video Report)

BACKGROUND

In comparison with purely restrictive procedures, combined restrictive and malabsorptive procedures seem to produce better weight loss and comorbidity control in patients with morbid obesity. Two-stage bariatric surgery is popular and is a safe and efficient strategy for patients with super obesity (BMI > 50 kg/m²) and super-super obesity (BMI > 60 kg/m²).

METHODS

The patient in this video was a 36-year-old man with an initial BMI of 53.2 kg/m². Two-stage bariatric surgery was planned. The patient underwent the first stage, laparoscopic sleeve gastrectomy, in 2018. Eighteen months after surgery, his lowest BMI was 38.8 kg/m², and his excess weight loss was 50.9%. In 2021, he regained weight and reached a BMI of 42.4 kg/m². Then, a second-stage bariatric surgery was performed.

RESULTS

As shown in the video, combined re-sleeve and single anastomosis sleeve ileal (SASI) bypass constituted the second stage of bariatric surgery. During the operation, adhesiolysis was first performed, and the stomach was mobilized through a lateral-to-medial approach. Gastric transection was performed with a 36-Fr bougie. Then, the ileocecal junction was identified, and a location 250 cm from the cecum was selected as the anastomosis site. Gastro-ileal anastomosis (3 cm in diameter) was established with a stapler, and the two-layer suture method was used to close the defect. The postoperative period was uneventful, and the patient was discharged 5 days after surgery.

CONCLUSIONS

Combined re-sleeve and SASI bypass has a few surgical morbidities and is promising as an alternative to second-stage duodenal switch in patients with super obesity.

Single Anastomosis Duodeno-ileal Bypass As a Revisional Procedure Following Sleeve Gastrectomy: Review of the Literature

Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.

Direct and two-step single anastomosis duodenal switch (SADI-S): Unicentric comparative analysis of 232 cases

INTRODUCTION

The "Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy" (SADI-S) is a bariatric surgery conceived to simplify the duodenal switch in order to reduce its postoperative complications. The objective of this study is to assess the safety and efficacy of SADI-S, comparing its results in both direct and two-step procedure.

METHODS

Unicentric cohort study that includes patients submitted to SADI-S, both direct or in two-step, between 2014 and 2019.

RESULTS

Two hundred thirty-two patients were included, 192 were submitted to direct SADI-S and 40 had previously undergone a sleeve gastrectomy. The severe complications rate (Clavien-Dindo ≥ IIIA) was 7.8%, being hemoperitoneum and duodenal stump leak the most frequent ones. One patient was exitus between the first 90 days after surgery (0.4%). Patients submitted to direct SADI-S had an initial body mass index (BMI) of 49.6 kg/m² in comparison of 56.2 kg/m² in the two-step SADI-S (P < .001). The mean excess weight loss (EWL) at two years was higher in direct SADI-S (77.3 vs. 59.3%, P < .05). Rate of comorbidities resolution was 88.5% for diabetes, 73.0% for hypertension, 77.0% for dyslipidemia and 85.7% for sleep apnea, with no differences between both techniques.

CONCLUSION

In medium term, SADI-S is a safe and effective technique that offers a satisfactory weight loss and remission of comorbidities. Patients submitted to two-step SADI-S had a higher initial BMI and presented a lower EWL than direct SADI-S.

Comparison of single- versus double-anastomosis duodenal switch: a single-center experience with 2-year follow-up

BACKGROUND

Single-anastomosis duodenal switch (SADS) has emerged in recent years as an alternative to the standard double-anastomosis duodenal switch (DADS). The objective of this study was to compare short- and medium-term outcomes between SADS and DADS.

METHODS

Data collected in the Ontario Bariatric Registry between 2010 and 2019 were used for this retrospective study to determine outcomes of patients undergoing primary laparoscopic SADS versus DADS at a Canadian tertiary hospital and bariatric center of excellence. The primary outcome was weight loss at 1 and 2 years after surgery. Short-term secondary outcomes included operative times, intra- and early postoperative complications, hospital length of stay (LOS), and 30-day readmissions. Medium-term secondary outcomes included late postoperative complications as well as nutritional deficiencies and persistent diarrhea at 1 and 2 years after surgery. Subgroup analyses were performed to compare patients undergoing one- and two-stage procedures.

RESULTS

Data of 107 patients who underwent SADS (n = 25) or DADS (n = 82) were included in the study. Follow-up data were available for 59/107 (55.1%) patients at 1 year and 47/107 (43.9%) at 2 years after surgery. Patients in the SADS and DADS groups had similar %TBWL at 1 year (23.6 versus 26.2, P = 0.617) and 2 years (24.8 versus 30.2, P = 0.116) after surgery. Short- and medium-term outcomes were similar between groups. There was no difference between patients undergoing one- versus two-stage procedures.

CONCLUSION

This study showed that patients undergoing SADS and DADS had similar weight loss at 1 and 2 years. Early and late postoperative morbidity, operative times, early readmissions, and LOS were also similar between groups. Further studies with longer follow-up are required to confirm these results.

A Rodent Model of Jejunal-Ileal Loop Bipartition (JILB): a Novel Malabsorptive Operation

BACKGROUND

We designed a novel malabsorptive procedure named as jejunal-ileal loop bipartition (JILB), in which a jejunal-ileal loop is created to reduce the effective length of food chyme passage in the small bowel, but without exclusion of any segment of the intestine. This study is to investigate the feasibility and efficacy of JILB on weight loss and glycemic control in obese diabetic mouse model.

METHODS

High-fat diet-induced C57BL/6 mice with typical obese and diabetic phenotypes were randomly divided into two groups according to the surgical procedure performed, including JILB (n = 8) and sham group (n = 8). Age-matched naïve C57BL/6 mice fed with rodent chow diet were adopted as normal controls. Body weight, food intake, fasting plasma glucose (FPG), fasting plasma insulin (FPI), and oral glucose tolerance test (OGTT) were measured in vivo before and 2, 4, and 8 weeks after surgery. Plasma glucagon-like peptide 1 (GLP-1) was assayed before and 15 min after oral glucose challenge at the 8th week postoperatively.

RESULTS

Comparing to the sham animals, JILB group consumed similar amount of food, but had lower body weight after surgery (P < 0.01). It led to significant lower FPG (p < 0.05) and improved glucose tolerance with lower FPI (p < 0.001). And GLP-1 secretion at 15 min after oral glucose challenge was higher than shams (P < 0.05). No intestinal obstruction was identified.

CONCLUSIONS

JILB is potentially a metabolic and bariatric procedure that leads to effective weight loss and diabetes remission in obese diabetic subjects.

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.

Direct and two-step single anastomosis duoenal switch (SADI-S): Unicentric comparative analysis of 232 cases

INTRODUCTION

The «Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy» (SADI-S) is a bariatric surgery conceived to simplify the duodenal switch in order to reduce its postoperative complications. The objective of this study is to assess the safety and efficacy of SADI-S, comparing its results in both direct and two-step procedure.

METHODS

Unicentric cohort study that includes patients submitted to SADI-S, both direct or in two-step, between 2014 and 2019.

RESULTS

Two hundred thirty-two patients were included, 192 were submitted to direct SADI-S and 40 had previously undergone a sleeve gastrectomy. The severe complications rate (Clavien-Dindo ≥ IIIA) was 7.8%, being hemoperitoneum and duodenal stump leak the most frequent ones. One patient was exitus between the first 90 days after surgery (0.4%). Patients submitted to direct SADI-S had an initial body mass index (BMI) of 49.6 kg/m² in comparison of 56.2 kg/m² in the two-step SADI-S (p < 0.001). The mean excess weight loss (EWL) at two years was higher in direct SADI-S (77.3 vs. 59.3%, p < 0.05). Rate of comorbidities resolution was 88.5% for diabetes, 73.0% for hypertension, 77.0% for dyslipidemia and 85.7% for sleep apnea, with no differences between both techniques.

CONCLUSION

In medium term, SADI-S is a safe and effective technique that offers a satisfactory weight loss and remission of comorbidities. Patients submitted to two-step SADI-S had a higher initial BMI and presented a lower EWL than direct SADI-S.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S): short-term outcomes from a prospective cohort study

BACKGROUND

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the classic duodenal switch (DS). These modifications are intended to address concerns about DS, including malnutrition, longer operative times, and technical challenges, while preserving the benefits.

OBJECTIVES

To evaluate safety and outcomes of SADI-S as it compares to classic DS procedure.

SETTING

Bariatric Surgery Center of Excellence, University Hospital, Montreal, Canada.

METHODS

In a single-institution prospective cohort study, we compared safety and outcomes of the SADI-S versus DS procedures (ClinicalTrials.gov: NCT02792166; registered: 06/2016). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

There were 42 patients who underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). There were 20 patients who underwent DS, of whom 12 had it as second-stage procedures (60%). Both groups were similar at baseline. The median age was 45 (14) years, 39 (63%) were female, the median body mass index (BMI) was 48.2 (7.7) kg/m², and 29 (47%) patients had diabetes. The operative time was shorter for 1-stage SADI-S versus DS surgery (211 [70] versus 250 [60] min, respectively; P = .05) but was similar for second-stage procedures (P = .06). The 90-day complication rates were 11.9% (N = 5/42) after SADI-S and 5.0% (N = 1/20) after DS surgery (P = .64). There were no mortalities. Median follow-ups for 1-stage SADI-S and DS were 17 (11) and 12 (24) months, respectively (P = .65). Similar BMI changes were observed after 1-stage SADI-S (17.9 kg/m² [8.7]) and DS (17.5 kg/m² [16]; P = .65). At median follow-ups of 10 (20) and 14 (16) months after second-stage SADI-S and DS, respectively (P = .53), surgical procedures yielded added 5.0 kg/m² (5.8) and 6.5 kg/m² (7.1) changes in BMI, respectively (P = .26). Complete remission rates for diabetes were 91% after SADI-S (n = 21/23) and 50% after DS (n = 3/6). Compared with the SADI-S procedure, DS surgery was associated with higher frequencies of deficiencies in some fat-soluble vitamins, especially vitamin D.

CONCLUSIONS

The SADI-S procedure is safe, and its short-term outcomes, including weight loss and the resolution of co-morbidities, are similar to those of DS. SADI-S surgery also has promising potential as a second-stage procedure after sleeve gastrectomy.

Conversion from Duodenal Switch to Single Anastomosis Duodenal Switch to Deal with Postoperative Malnutrition

BACKGROUND

Duodenal switch (DS) is considered one of the most effective bariatric techniques for long-term weight and comorbidity control. After these operations, some patients may get severe complications related to malnutrition and a few of them may need surgical revision. Lengthening the common channel (CC) is usually the solution: changing the Roux anastomosis or with a side-to-side anastomosis (kissing X). We propose that when simplified construction of the DS is used, conversion to single anastomosis DS (SADI-S/OADS) is an easy and safe choice.

OBJECTIVES

To evaluate the safety and effectiveness of conversion from DS to SADI-S in cases of malnutrition.

METHODS

We report three patients with severe malnutrition after a DS at 9, 74, and 84 months. One of them had also liver failure related to alcohol abuse and malnutrition. Laparoscopic reoperations included a new ileo-ileal anastomosis and takedown of the Roux-en-Y anastomosis with the aim of lengthening the CC.

RESULTS

All three patients were successfully converted by laparoscopy. After a median follow-up of 54.6 months [32-76 months], all of them had moderate weight regain and returned to normal biochemical nutritional parameters. Two patients with type 2 diabetes (T2DM) before DS had complete remission before conversion; one of them had recurrence of T2DM after conversion. The patient with liver failure improved significantly after conversion.

CONCLUSIONS

Conversion from DS to SADI-S/OADS is a simple operation with excellent results in resolving malnutrition in those patients. However, weight regain and recurrence of comorbidities may arise.

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.

Bariatric Surgery and the Mechanisms of Gastroesophageal Reflux Disease

Introduction: The association between obesity and gastroesophageal reflux disease (GERD) is very well known and the pathophysiology of GERD is not completely understood but is likely to have a multifactorial nature especially after bariatric procedures. Methods: The current editorial summarizes the principal mechanisms involved in the reflux disease following different bariatric procedures. Results: Laparoscopic adjustable gastric banding could reduce the gastroesophageal reflux in the short term in some cases, but overeating will inevitably lead to enlargement of the pouch with loss of its antireflux properties. Although the laparoscopic Roux-en-Y gastric bypass was considered the gold standard procedure for obese patients with reflux disease, many patients had at least one complication within their follow-up period. One anastomosis gastric bypass remains a controversial procedure for GERD, especially when it is proposed as revisional surgery after laparoscopic sleeve gastrectomy. As revisional surgery, either single anastomosis duodeno-ileostomy (SADI) or duodenal switch (DS) have little or no impact on GERD and in our experience the indication for SADI/DS is a valid option in case of absence of any symptoms of reflux. The effect of sleeve for GERD is contradictory. Conclusion: For those with moderate reflux, since specific procedure guidelines are missing, surgical treatment for morbid obese patients must be selected according to the clinical characteristics of the patient, his eating habits and patient willingness. It should be based on a preoperative workup with shared decision making, with the double purpose of treating both GERD and obesity.

Single-anastomosis duodenoileal bypass as a revisional or second-step operation after sleeve gastrectomy

BACKGROUND

One-loop duodenal switch leads to weight loss and improvement or resolution of co-morbidities similar to standard duodenal switch, and it is technically less demanding.

OBJECTIVES

To analyze the weight loss and metabolic improvement after conversion of sleeve gastrectomy to single-anastomosis duodenoileal bypass.

SETTING

University Hospital, Madrid, Spain.

METHODS

This was a retrospective cohort study. Patients submitted to sleeve gastrectomy with insufficient weight loss or programmed for a 2-step surgical approach were included. Single-anastomosis duodenoileostomy was completed if there was no stricture in the stomach and no severe symptoms of gastroesophageal reflux.

RESULTS

Fifty-one patients with a mean initial body mass index of 52 kg/m2 were included. Maximum excess weight loss after the sleeve procedure was 63%. Mean time to the second operation was 36 months. The common channel was 250 cm in 41 patients and 300 cm in 10 patients. The follow-up rate was 77% at 5 years. Excess weight loss and total weight loss were 79% and 39%, respectively, at 1 year from the second surgery and 79% and 41%, respectively, at 5 years. Furthermore, 47% of the patients with diabetes achieved complete remission after sleeve gastrectomy, and 94% achieved remission after conversion to single-anastomosis duodenoileal bypass. Final weight loss was significantly higher in those patients who achieved better weight loss after the sleeve gastrectomy than those who did not.

CONCLUSIONS

Single-anastomosis duodenoileal bypass is a beneficial procedure after sleeve gastrectomy for those who fail to lose weight or those with co-morbidities or as a planned second step.

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.

Roux-en-Y Gastric Bypass as an Effective Bariatric Revisional Surgery after Restrictive Procedures

INTRODUCTION

Revisional surgery must be considered when insufficient weight loss is attained or weight is subsequently regained. This study aimed to investigate the value of Roux-en-Y gastric bypass (RYGB) as a revisional procedure after restrictive surgery.

MATERIALS AND METHODS

An observational, retrospective study including patients initially operated on for morbid obesity with restrictive techniques (vertical-banded gastroplasty [VBG], adjustable gastric band [AGB], and sleeve gastrectomy) and reoperated with RYGB in our centre between December 1994 and January 2019. Demographic and anthropometric data, associated comorbidities (diabetes mellitus type II, arterial hypertension, dyslipidaemia, and chronic obstructive pulmonary disease) and surgery-related data (approach, complications, and hospital stay) were evaluated at 5 different time points: initial (prior to first intervention), after the first surgical intervention, before the second intervention (gastric bypass), after the gastric bypass, and at present.

RESULTS

A total of 63 patients were included. VBG was the most frequent initial procedure (n = 33). The mean age was 39 ± 9.52 years, and the average initial weight was 143.53 ± 28.6 kg. Weight loss was achieved in all groups, with a median excess weight loss of 58% after the first surgery and 40.3% after gastric bypass. In terms of weight loss, the best results after the second surgery were obtained when the first surgery was AGB, with statistically significant differences.

CONCLUSIONS

RYGB is effective as a conversion procedure after a previous restrictive surgery, obtaining a significant reduction in weight and BMI. It has an acceptable morbidity rate and is more effective after an AGB.

N-SLEEVE GASTRECTOMY: AN OPTION FOR OBESITY AND GERD

Background:

Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that’s why some patients have reflux after sleeve.

Aim:

To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve.

Method:

In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care.

Results:

This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after.

Conclusion:

N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

An Analysis of Mid-Term Complications, Weight Loss, and Type 2 Diabetes Resolution of Stomach Intestinal Pylorus-Sparing Surgery (SIPS) Versus Roux-En-Y Gastric Bypass (RYGB) with Three-Year Follow-Up

BACKGROUND

For many years, the Roux-en-Y Gastric Bypass (RYGB) was considered a good balance of complications and weight loss. According to several short-term studies, single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (SIPS) offers similar weight loss to RYGB with fewer complications and better diabetes resolution. No one has substantiated mid-term complication and nutritional differences between these two procedures. This paper seeks to compare complication and nutritional outcomes between RYGB and SIPS.

METHODS

A retrospective analysis of 798 patients who either had SIPS or RYGB from 2010 to 2016. Complications were gathered for each patient. Nutritional outcomes were measured for each group at 1, 2, and 3 years. Regression analysis was applied to interpolate each patient's weight at 3, 6, 9, 12, 18, 24, and 36 months. These were then compared with t tests, Fisher's exact tests, and chi-squared tests.

RESULTS

RYGB and SIPS have statistically similar weight loss at 3, 6, 9, 12, and 36 months. They statistically differ at 18 and 24 months. At 36 months, there is a trend for weight loss difference. There were only statistical differences in nutritional outcomes between the two procedures with calcium at 1 and 3 years and vitamin D at 1 year. There were statistically significantly more long-term class IIIb-V complications, class I-IIIa complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the RYGB than the SIPS.

CONCLUSION

With comparable weight loss and nutritional outcomes, SIPS has fewer short- and long-term complications than RYGB and better type 2 diabetes resolution rates.

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

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

Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients

BACKGROUND

Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising.

OBJECTIVES

The aim of this study was to look at our intermediate outcomes after LDJB-SG.

SETTING

An academic medical center.

METHODS

A prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications.

RESULTS

A total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m², respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m² at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period.

CONCLUSION

At 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.

Failed Sleeve Gastrectomy: Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass? A Multicenter Cohort Study

BACKGROUND

Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. Unfortunately, a significant portion of patients show insufficient weight loss or weight regain after a few years.

OBJECTIVE

To investigate the effectiveness of the single anastomosis duodenoileal (SADI) bypass versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in morbid obese patients who had undergone SG previously, with up to 2 years of follow-up.

METHODS

From 2007 to 2017, 140 patients received revisional laparoscopic surgery after SG in four specialized Dutch bariatric hospitals. Data was analyzed retrospectively and included comparisons for indication of surgery, vitamin/mineral deficiencies, and complications; divided into short-, medium-term. To compare weight loss, linear regression and linear mixed models were used.

RESULTS

Conversion of a SG to SADI was performed in 66 patients and to RYGB in 74 patients. For patients in which additional weight loss was the main indication for surgery, SADI achieved 8.7%, 12.4%, and 19.4% more total body weight loss at 6, 12, and 24 months compared to RYGB (all p < .001). When a RYGB was indicated in case of gastroesophageal reflux or dysphagia, it greatly reduced complaints almost directly after surgery. Furthermore, a similar amount of complications and nutritional deficiencies was observed for both groups. There was no intra- or post-operative mortality.

CONCLUSION

Conversion into a SADI resulted in significantly more weight loss while complications rates and nutritional deficiencies were similar and may therefore be considered the recommended operation for patients in which only additional weight loss is required.

Resectional One Anastomosis Gastric Bypass/Mini Gastric Bypass as a Novel Option for Revision of Restrictive Procedures: Preliminary Results

BACKGROUND

Revisional surgery is becoming a common and challenging practice in bariatric centers. The aim of this study was to evaluate resectional one anastomosis gastric bypass/mini gastric bypass (R-OAGB/MGB) as a revisional procedure.

METHODS

From January 2016 to February 2017, data on 21 consecutive patients undergoing R-OAGB/MGB for weight loss failure after primary restrictive procedures were prospectively collected and analysed.

RESULTS

Mean age was 39 ± 12 years (18-65), and 11 (52.3%) were women. The mean operative time was 96.4 ± 20.9 min (range, 122-80), and the mean postoperative stay was 47.8 ± 7.4 hours (range, 36-73). There were no deaths and no procedure-related complications. The mean body mass index (BMI) decreased from 42.9 ± 6.5 at the time of R-OAGB/MGB to 28.5 ± 4 at the 12-month follow-up. At that time point, the mean percentage of BMI loss (%EBL) and the mean percentage of total body weight loss (%TWL) reached 81.6 ± 0.17% and 35 ± 0.01%, respectively.

CONCLUSION

R-OAGB/MGB was technically straightforward, effective, and safe in this at-surgical risk population. R-OAGB/MGB should be added to the armamentarium of revisional bariatric procedures considering its technical aspects and the potential advantage on weight loss.

MANAGEMENT OF ENDOCRINE DISEASE: Which metabolic procedure? Comparing outcomes in sleeve gastrectomy and Roux-en Y gastric bypass

Obesity and its associated comorbidities have become one of the largest challenges for health care in the near future. Conservative therapy for obesity and related comorbidities has a very high failure rate and poor long-term results. Similarly, the conservative and medical management of the majority of metabolic diseases such as type 2 diabetes mellitus are only able to slow down disease progression but have no causal effect on the disease process. Obesity surgery has evolved as a highly effective therapy for severe obesity achieving long-lasting weight loss. Furthermore, several studies have demonstrated the beneficial effects of obesity surgery on reduction of overall mortality, reduction of cardiovascular events and superior control of obesity-related diseases such as type 2 diabetes mellitus, dyslipidemia and also the non-alcoholic steatohepatitis compared to medical therapy. Based on these findings, the term 'metabolic surgery' with the focus on treating metabolic diseases independent of body weight has been coined. Of great interest are recent studies that show that even existing complications of metabolic diseases such as diabetic nephropathy or the non-alcoholic steatohepatitis can be reversed by metabolic surgery. Although metabolic surgery has proven to be a safe and effective treatment for obesity, resolution of comorbidities and enhancing quality of life, it is still uncertain and unclear, which surgical procedure is the most effective to achieve these metabolic effects. The aim of this review is to compare the effects of the two currently most widely used metabolic operations, the Roux-en-Y gastric bypass and the sleeve gastrectomy in the treatment of obesity and its related comorbidities.