Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S): experience from a high-bariatric volume center

Outcomes of Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy (SADI-S): A Single Bariatric Center Experience

Introduction Bariatric surgery is increasingly employed to address the global burden of morbid obesity, with Roux-en-Y gastric bypass (RYGB) representing the predominant procedure. However, some patients, particularly those with extreme obesity (BMI >50 kg/m²), may experience unsatisfactory weight-related outcomes following RYGB. While biliopancreatic diversion with duodenal switch (BPD-DS) offers superior weight reduction for this population, its complexity and associated risks limit its widespread use. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was developed as a simpler substitue to BPD-DS, aiming to gain equivalent weight loss with improved safety profile. This analysis examined the efficacy of SADI-S in facilitating weight loss and ameliorating concomitant conditions (type 2 diabetes mellitus, hypertension, and obstructive sleep apnea) at various time points up to nine years post-procedure. Additionally, the study assessed the incidence of nutritional deficiencies following SADI-S. Material and methods This retrospective analysis utilized data obtained from patients undergoing SADI-S at a high-volume specialized bariatric centre between January 2016 and December 2022. Inclusion criteria encompassed individuals with high BMI and uncontrolled obesity-related comorbidities who had experienced insufficient weight-related outcomes following a previous bariatric surgery and demonstrated good compliance within a Tier 3 weight management program. Patients were excluded if they were non-compliant, unfit for surgery, or under 18 years old. Participants were followed up quarterly in the first year, every four months in the second year, and yearly thereafter. Nutritional assessments were performed in accordance with British Obesity and Metabolic Surgery Society (BOMSS) guidelines. Relevant data were extracted from patient clinical records and institutional electronic databases and analyzed using Microsoft Excel. Results There were 4000+ bariatric procedures conducted during this time. Seventeen patients were deemed as suitable candidates for SADI-S after multidisciplinary team discussion. The surgeries were performed by various surgeons. Most participants were women, with an age range of 23 to 64 years. The median BMI was 63.4 kg/m² (range: 35 kg/m² to 96.2 kg/m²). Mean percentage excess weight loss (%EWL) was 32% (range: 15% to 53%) at six months, 69.6% (range: 34% to 90%) at one year, and 86.2% (range: 43% to 109%) at two years post-procedure. Extended follow-up data (six to nine years) were available for 16 patients, with one patient lost to subsequent assessments. At this stage, the mean %EWL was 76% (range: 62% to 96%). No patients developed protein-energy malnutrition. However, micronutrient deficiencies were observed, with four patients (23.53%) exhibiting zinc deficiency and three (17.65%) presenting with calcium deficiency. All deficiencies were successfully managed with oral supplementation. Conclusion SADI-S effectively achieves substantial and sustained weight loss with high comorbidity resolution in individuals with high BMI. While micronutrient deficiencies require proactive management, SADI-S appears safe and yields favourable outcomes comparable to, or exceeding, those reported in larger studies. Long-term weight maintenance is promising. This study contributes valuable real-world evidence supporting the efficacy and safety of SADI-S, though larger studies are needed for further validation.

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.

Comparison between DaVinci® and Hugo™-RAS Roux-en-Y Gastric Bypass in bariatric surgery

The application of a robotic platform in the bariatric surgical field is intended to enhance the already established advantages of minimally invasive surgery in terms of both technical and clinical outcomes. These advantages are especially relevant for technically challenging multiquadrant operations such as Roux-en-Y Gastric Bypass (RYGB). Consequently, robotic-assisted surgery has emerged as a possible application for bariatric surgeries. The study attempts to assess feasibility and safety of the Hugo™-Robotic-Assisted Surgery System (Hugo™-RAS) platform compared to the DaVinci® Surgical System (DaVinci®-SS) with a focus on complication rates and operative times. We retrospectively reviewed bariatric procedures performed from January 2013 until December 2023. We included all robotic RYGBs performed using Hugo™-RAS and DaVinci®-SS platforms. The study utilized Propensity Score Matching (PSM) analysis to address bias in selection, matching patients based on age, gender, body mass index, comorbidities and past abdominal operations. One hundred thirty-five patients were identified: 90 DaVinci®-SS and 45 Hugo™-RAS procedures. After PSM, each group consisted of 45 patients. There was no discernible disparity observed in relation to early (≤ 30 days) postoperative complications rate (p = 1), mean operative time (for docking time, console time and total operative time: p = 0.176, p = 0.678, p = 0.229, respectively) and postoperative hospital stay (p = 0.052) between DaVinci®-RSS and Hugo™-RAS procedures. Our results suggest that application of both Hugo™-RAS and DaVinci®-SS robotic platforms to RYGB is related to comparable safety profiles. Although DaVinci®-SS remains the most widely adopted platform in clinical practice, this study underscores the potential role of the Hugo™-RAS to provide effective solutions in robotic bariatric procedures.

Primary Versus Revisional Bariatric and Metabolic Surgery in Patients with a Body Mass Index ≥ 50 kg/m2-90-Day Outcomes and Risk of Perioperative Mortality

BACKGROUND

Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50 kg/m2.

MATERIALS AND METHODS

A retrospective analysis of patients with a BMI ≥ 50 kg/m2 undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery.

RESULTS

A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13 years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively).

CONCLUSION

Revisional BMS in patients with a BMI ≥ 50 kg/m2 is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery.

Sleeve gastrectomy with duodenoileal bipartition using linear magnets: feasibility and safety at 1-year follow-up

BACKGROUND

Single-anastomosis metabolic/bariatric surgery procedures may lessen the incidence of anastomotic complications. This study aimed to evaluate the feasibility and safety of performing side-to-side duodenoileal (DI) bipartition using magnetic compression anastomosis (MCA). In addition, preliminary efficacy, quality of life (QoL), and distribution of food through the DI bipartition were evaluated.

METHODS

Patients with a body mass index (BMI) of ≥35.0 to 50.0 kg/m2 underwent side-to-side DI bipartition with the magnet anastomosis system (MS) with sleeve gastrectomy (SG). By endoscopic positioning, a distal magnet (250 cm proximal to the ileocecal valve) and a proximal magnet (first part of the duodenum) were aligned with laparoscopic assistance to inaugurate MCA. An isotopic study assessed transit through the bipartition.

RESULTS

Between March 14, 2022 to June 1, 2022, 10 patients (BMI of 44.2 ± 1.3 kg/m2) underwent side-to-side MS DI. In 9 of 10 patients, an SG was performed concurrently. The median operative time was 161.0 minutes (IQR, 108.0-236.0), and the median hospital stay was 3 days (IQR, 2-40). Paired magnets were expelled at a median of 43 days (IQR, 21-87). There was no device-related serious advanced event within 1 year. All anastomoses were patent with satisfactory diameters after magnet expulsion and at 1 year. Respective BMI, BMI reduction, and total weight loss were 28.9 ± 1.8 kg/m2, 15.2 ± 1.8 kg/m2, and 34.2% ± 4.1%, respectively. Of note, 70.0% of patients reported that they were very satisfied. The isotopic study found a median of 19.0% of the meal transited through the ileal loop.

CONCLUSION

Side-to-side MCA DI bipartition with SG in adults with class II to III obesity was feasible, safe, and efficient with good QoL at 1-year follow-up. Moreover, 19% of ingested food passed directly into the ileum.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single Anastomosis 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.

Robot-assisted vs laparoscopic bariatric procedures in super-obese patients: clinical and economic outcomes

The increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m2) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m2) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m2, primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients.

Robotic-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients

Robotic assisted surgery is a rapidly developing field in bariatric surgery. Its wide diffusion has led to the development and standardisation of robotic assisted approaches for various bariatric operations. However, further application has been limited thus far due to issues of cost-effectiveness and accessibility. The introduction of new robotic platforms may help overcome those obstacles. In this study, we present the first fifteen cases of Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA). From January to March 2023, consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were randomly selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied. Seven female and eight male patients with a median BMI of 42 (range: 36-50) and obesity-related comorbidities in eight cases underwent RYGB. The median docking time was 7 min (range: 6-8.5) and the median console time was 100 min (range: 70-150). Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. Operative times were indicative of a steep learning curve. No early post-operative complications were observed. Based on our initial experience, RYGB with the Hugo™ RAS system is promising and may be integrated in established robotic programmes without requiring a long adaptation period.

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.

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know

ABSTRACT

The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Revisional Procedures after Sleeve Gastrectomy for Weight Recurrence or Inadequate Weight Loss: An Analysis of the MBSAQIP Database

INTRODUCTION

The safety of conversional bariatric procedures after sleeve gastrectomy (SG) for weight recurrence (WR) or inadequate weight loss (IWL) is debated due to limited evidence. Conversion options include Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI), and biliopancreatic diversion with duodenal switch (BPD-DS). We aimed to compare serious complications and mortality rates between these procedures within 30 days.

METHODS

Using the 2020 and 2021 MBSAQIP databases, we identified patients who underwent a conversion from SG to RYGB, SADI, or BPD-DS. We performed a multivariable logistic regression to assess predictors of 30-day complications and mortality.

RESULTS

Among 7388 patients (77.6% RYGB, 8.7% SADI, 13.7% BPD-DS), those undergoing SADI and BPD-DS had higher preoperative body mass index. Conversion reasons included WR (63.0%) and IWL (37.0%). SADI and BPD-DS patients had longer operative times (p < 0.001) and higher leak rates (p = 0.001). Serious complications, reoperations, readmissions, and 30-day mortality were similar across groups. Conversion procedure type was not an independent predictor of complications.

CONCLUSION

RYGB was the most performed conversional procedure after SG. The study indicated a similar safety profile for revisional RYGB, SADI, and BPD-DS, with comparable 30-day complications and mortality rates. However, SADI and BPD-DS patients had longer operative time and higher leak rates.

Barbed vs. Conventional Sutures in Bariatric Surgery: Early and Late Outcomes

The implementation of barbed sutures appears to enhance the process of suturing and knot tying, particularly in the field of bariatric surgery, where they can offer significant advantages. The objective of this study is to evaluate the safety and effectiveness of utilising barbed sutures for gastric pouch-jejunal anastomosis (GPJA) and jejuno-jejunal anastomosis (JJA) anastomosis in Roux-en-Y Gastric Bypass (RYGB). Data from patients who underwent primary RYGB between January 2012 and October 2018 were retrospectively collected using Propensity Score Matching (PSM) to randomise groups (barbed sutures—BS-G and conventional sutures—CS-G). The primary outcome was postoperative early complications. The secondary outcomes were late complications (internal hernias and small bowel obstructions), operative time and postoperative hospital stay. A total of 969 patients were included. After PSM, 322 (161 in BS-G vs. 161 in CS-G) patients were compared (chi-square 0.287, p = 0.862). Postoperative early and late complications were comparable between the two groups. BS-G had a significantly shorter median operative time (65 vs. 95 min p < 0.001). Median postoperative hospital stay was significantly shorter for BS-G (2 vs. 5 days, p < 0.001). Barbed sutures effectively reduce the operation duration and are as safe as conventional sutures for closing anastomotic defects during RYGB.

Obesity management for cardiovascular disease prevention

Background

Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies.

Methods

A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects.

Results

This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1].

Conclusion

Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

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.

Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO™ RAS

Introduction

Robotic assisted surgery is a rapidly developing field of minimally invasive bariatric surgery in the last 20 years. Its wide diffusion has led to the development and standardization of robotic assisted approaches for bariatric operations. In this study, we present the first four Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA).

Methods

In January and February 2023, 4 consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied.

Results

Four patients, two females and two males, underwent RYGB with a median BMI of 40 Kg/m² (range: 36-46) and diabetes mellitus in two cases. The median docking time was 8 min (range: 7-8.5) and the median console time was 127.5 min (range: 95-150). A description of the operating theatre, robotic arms and docking setup is provided. Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. No additional ports were needed to be placed. System's function and docking were uneventful. No early post-operative complications were observed.

Conclusions

Based on our initial experience, RYGB with the Hugo™ RAS system is feasible. This study provides the configurations necessary to perform RYGB with the Hugo™ RAS system as well as general information and insights from our preliminary experience.

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.

Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures. They are often indicated in superobese patients (BMI ≥ 50 kg/m²), as robotic platform could improve ergonomics against a thick abdominal wall, preventing bending of instruments and simplifying hand-sewn anastomoses. We aimed to report our experience with robotic SADI-S (R-group) and to compare outcomes with the laparoscopic (L-group) approach. Among 2143 patients who underwent bariatric procedures at our institution between July 2016 and June 2021, 116 (5.4%) consenting patients were scheduled for SADI-S as primary or revisional procedure: 94 L-group, 22 R-group. R-group and L-group patients were matched using PSM analysis to overcome patients selection bias. Postoperative complications, operative time (OT), post-operative stay (POS) and follow-up data were compared. After PSM, 44 patients (22 patients for each group) were compared (Chi-square 0.317, p = 0.985). Median age, gender, median BMI, preoperative rates of comorbidities, previous abdominal bariatric and non-bariatric surgeries and type of surgical procedures (SADI-S/SADI) were comparable. Median OT was shorter in the L-group (130 Vs 191 min, p < 0.001). 30-days' re-operative complications and late complications rates were comparable. At 25-months' mean follow-up, the median Percentage Excess Weight Loss (72%) was comparable between the groups (p = 0.989). L-group and R-group were comparable in terms of re-operative complication rate and short-term outcomes. The robotic platform may increase the rate of single step procedure in challenging cases. Larger studies with longer follow-up and cost-analysis are necessary to draw definitive conclusions.

Controversial Role of Robot in Primary and Revisional Bariatric Surgery Procedures: Review of the Literature and Personal Experience

Laparoscopy is the surgical standard of care for bariatric procedures; however, during the last two decades, the robotic approach has gained increasing interest. It is currently considered a safe and effective alternative to laparoscopy. This literature review investigates the role of the robotic approach for primary and revisional bariatric procedures, with the particular aim of comparing this technique with the standard-of-care laparoscopic approach. The feasibility of robotic dissection and suturing could have potential advantages: robotics may prevent the risk of leak and bleeding and other surgical complications, determining potential benefits in terms of operative time, length of hospital stay, and learning curve. Considering primary procedures, the literature reveals no advantages in robotic versus the laparoscopic approach for adjustable gastric banding and sleeve gastrectomy. Robotic Roux-en-Y gastric bypass is associated with a longer operative time and a shorter hospital length of stay than laparoscopy. The robotic approach in revisional surgery has been proven to be safe and effective. Despite the longer operative time, the robotic platform could achieve a lower bleeding rate compared with laparoscopy. The surgeon’s selection criteria related to referrals to the robotic approach of difficult-perceived cases could represent a bias. In conclusion, robotic surgery can be considered a safe and effective approach in both primary and revisional bariatric surgery, despite the lack of evidence to support its routine use in primary bariatric surgery. However, in revisional bariatric surgery and in surgical complex procedures, the robotic approach could have potential benefits in terms of surgical complications and learning curves.