1-Year Follow-up of Single Anastomosis Sleeve Ileal (SASI) Bypass in Morbid Obese Patients: Efficacy and Concerns

Outcomes of Single Anastomosis Sleeve Ileal (SASI) Bypass as an Alternative Procedure in Treating Obesity: An Updated Systematic Review and Meta-Analysis

PURPOSE

The Single Anastomosis Sleeve Ileal (SASI) bypass is a novel bariatric procedure that simplifies Santoro's procedure, balancing functional restriction and neuroendocrine modulation while preserving anatomy. We aim to conduct a single-arm meta-analysis of the SASI bypass to explore its moderate-term efficacy, as this might expand the available choices for surgeons to choose the best bariatric surgery that suits the patient's condition.

MATERIALS AND METHODS

We conducted a comprehensive search on PubMed, Scopus, EMBASE, and Cochrane to identify studies for the SASI bypass surgery focusing on outcomes such as %EWL, %TWL, remission rate of comorbidities, and complications. The statistical analysis was carried out using RStudio version 4.3.2. Heterogeneity was assessed using the Cochrane Q test and I2 statistics.

RESULTS

Our findings illuminate SASI's potency by undertaking a single-arm meta-analysis involving 1873 patients across 26 studies. At 12 months, we report a noteworthy % Excess Weight Loss (%EWL) (Mean 84.13; 95% CI 78.41-89.85; I2 = 95%), and % Total Weight Loss (%TWL) (Mean 35.17; 95% CI 32.30-38.04; I2 = 97%), highlighting SASI's efficacy on weight loss. Cumulative meta-analyses supported these findings. More weight loss was observed with a 250 cm common limb and a greater than 3 cm anastomosis. An 88.28% remission rate in type 2 diabetes mellitus (95% CI 79.74-95.03; I2 = 84%) at 12 months was observed. Beyond weight outcomes, SASI impacts comorbidities with a good safety profile.

CONCLUSION

Our study positions the SASI bypass as a good alternative option. However, long-term efficacy is yet to be explored in the future.

Efficiency and safety of single anastomosis sleeve ileal (SASI) bypass in the treatment of obesity and associated comorbidities: a systematic review and meta-analysis

INTRODUCTION

The Single Anastomosis Sleeve Ileal (SASI) bypass is a new bariatric surgery corresponding to an adaptation of the Santoro approach, consisting of a sleeve gastrectomy (SG) followed by loop gastroileostomy. Therefore, we aimed to systematically assess all the current literature on SASI bypass in terms of safety, weight loss, improvement in associated comorbidities, and complications.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) recommendations, we conducted a systematic review and meta-analysis by searching three databases (PubMed, Scopus, and Web of Science). We performed a meta-analysis of risk ratios and mean differences to compare surgical approaches for excessive weight loss, improvement/remission in type 2 diabetes mellitus (T2DM), hypertension (HT), dyslipidemia (DL), obstructive sleep apnea (OSA), and complications. Heterogeneity was assessed using the I2 statistic.

RESULTS

Eighteen studies were included in the qualitative analysis and four in the quantitative analysis, comparing SASI bypass with SG and One-Anastomosis Gastric Bypass (OAGB). A comparison between Roux-en-Y Gastric Bypass (RYGB) and SASI bypass could not be performed. Compared to SG, the SASI bypass was associated with improved weight loss (MD = 11.32; 95% confidence interval (95%CI) [7.89;14.76]; p < 0.0001), and improvement or remission in T2DM (RR = 1.35; 95%CI [1.07;1.69]; p = 0.011), DL (RR = 1.41; 95%CI [1.00;1.99]; p = 0.048) and OSA (RR = 1.50; 95%CI [1.01;2.22]; p = 0.042). No statistically significant differences in any of the assessed outcomes were observed when compared with OAGB. When compared to both SG and OAGB, the complication rate of SASI was similar.

CONCLUSION

Although studies with longer follow-up periods are needed, this systematic review and meta-analysis showed that SASI bypass has a significant effect on weight loss and metabolic variables. Variations in outcomes between studies reinforce the need for standardization.

The Alarming Rate of Malnutrition after Single Anastomosis Sleeve Ileal Bypass. A single Centre Experience

BACKGROUND

Single anastomosis sleeve ileal (SASI) bypass is a modification of sleeve gastrectomy with transit bipartition (SG + TB). This study aims to assess the safety and efficacy of SASI as a primary metabolic and bariatric surgery (MBS).

METHODS

This is a retrospective case series of 30 patients who underwent SASI bypass from January to December 2021. All patients completed at least 12 months of follow-up.

RESULTS

Among the 30 patients, 93.3% were women, the mean age was 37.4 years, and the mean body mass index (BMI) was 45.6 kg/m2. The percentage of total body weight loss (TWL%) was 42.7%, the percent excess body weight loss (EWL%) was 92.7%, and the mean BMI at 12 months went from 45.6(35.2-58.4) to 25.8 kg/m2 (19.2-33.4). The obesity-associated complications remission rate was 87.5% for type 2 diabetes (T2D), 71.4% for hypertension (HTN) and 100% for obstructive sleep apnea (OSA). Thirteen patients (43.3%) had diarrhea, 7 (23.3%) had hypoalbuminemia, defined as serum albumin < 3 g/dl, and 6 (20%) underwent reversal of their index SASI. As for other nutritional issues, iron deficiency anemia was present in 21 patients (70%), while 19 patients (63.3%) had vitamin D, and 2(6.6%) had vitamin B12 deficiency.

CONCLUSION

Despite good short-term weight loss and improvement of obesity-associated complications, SASI is accompanied by high alarming malnutrition, even in short-term follow-up. Novel MBS should be judged for their long-term effects and compared to well-tested standard operations before they are used in routine clinical practice.

[Anastomotic techniques in minimally invasive bariatric surgery]

BACKGROUND

Recommendations for the use of specific anastomotic techniques are not available in laparoscopic bariatric surgery. Recommendation criteria should consider the rate of insufficiency, bleeding, tendency to stricture or ulceration as well as the impact on weight loss or dumping.

OBJECTIVE

This article gives a review of the available evidence on the anastomotic techniques of typical surgical procedures in laparoscopic bariatric surgery.

MATERIAL AND METHODS

The current literature was reviewed and is discussed regarding anastomotic techniques for Roux-en‑Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), single anastomosis sleeve ileal (SASI) bypass and biliopancreatic diversion with duodenal switch (BPD-DS).

RESULTS

Few comparative studies exist, except for the RYGB. In RYGB gastrojejunostomy, a complete manual suture was shown to be equivalent to a mechanical anastomosis. In addition, the linear staple suture showed slight advantages over the circular stapler in terms of wound infections and bleeding. The anastomosis technique of the OAGB and SASI can be performed entirely with a linear stapler or with suture closure of the anterior wall defect. There seems to be an advantage of manual anastomosis in BPD-DS.

CONCLUSION

Due to the lack of evidence, no recommendations can be made. Only in RYGB was there an advantage of the linear stapler technique with hand closure of the stapler defect compared to the linear stapler. In principle, prospective, randomized studies should be strived for.

Comparison of Laparoscopic Sleeve Gastrectomy and Single Anastomosis Sleeve Ileal Bypass in Type 2 Diabetes Mellitus Remission Using International Criteria

Introduction: Single anastomosis sleeve ileal (SASI) bypass procedure is recommended in the treatment of patients with obesity, who have comorbidities such as type 2 diabetes mellitus (T2DM). Meanwhile, laparoscopic sleeve gastrectomy (LSG) has become the most preferred contemporary bariatric procedure. Research comparing these two techniques are scarce in the literature. In this study, we aimed to compare LSG and SASI procedures in terms of weight loss and diabetes remission. Materials and Methods: Thirty patients, who underwent LSG and 31 patients, who underwent SASI, with a body mass index (BMI) of 35 and above, and under unsuccessful medical treatment, in terms of T2DM, were included in the study. Patients' demographic data were recorded. Oral antidiabetic drugs and insulin use, HbA1c and fasting blood glucose values, and BMI values were recorded preoperatively, at thd sixth month and at first year. According to these data, patients were compared in terms of primarily diabetes remission and secondarily weight loss. Results: At the sixth month and first year, the mean excess weight loss (EWL) values of the SASI group were 55.2% ± 12.45% and 71.67% ± 15.75%, respectively, while EWL values of the LSG group were 57.41% ± 16.22% and 69.73% ± 16.65%, respectively (P > .05). T2DM evaluations revealed that in the SASI group, 25 (80.65%) patients at the sixth month and 26 (83.87%) patients at the first year had either clinical improvement or remission, whereas 23 (76.67%) patients at the sixth month and 26 (86,67%) patients at the first year in the LSG group had the same outcomes (P > .05). Conclusion: The short-term comparison of LSG and SASI procedures revealed similar results in terms of weight loss and T2DM remission. Hence, LSG can be considered as the first-step treatment of morbid obesity accompanied by T2DM, since it is a simpler surgical procedure.

Safety and Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass Surgery on Obese Patients with Type II Diabetes Mellitus during a One-Year Follow-up Period: A Single Center Cohort Study

BACKGROUND

We aimed to evaluate the safety and efficacy of single anastomosis sleeve ileal (SASI) bypass surgery on obese patients with type II diabetes mellitus during a one-year follow-up period.

METHODS

We included patients with a body mass index (BMI) more than 35 kg/m2 and at least one-year history of type II diabetes mellitus. We excluded patients aged under 25 or above 66 years, those who were not candidates for surgery, needed another bariatric surgery, and those not willing to participate in the study. All the patients were visited in the outpatient office on the 10th and 45th days as well as the 3rd month of the post-operative period until the end of the first year.

RESULTS

in this study, we investigated 14 male (23.0%) and 47 female (77.0%) morbidly obese patients with type II diabetes mellitus who underwent SASI bypass. The mean excess weight loss (%EWL) was 60.99±15.69 and the mean total weight loss (%TWL) was 30.39±6.52 at the end of the one-year follow up. Finally, 44 patients (72.1%) had a complete and 15 patients (24.6%) had partial remission of type II diabetes mellitus. Of note, severe complications were recorded in two patients (3.2%). Paired t test analysis demonstrated a significant decrease for fasting plasma sugar (FBS) after one-year follow-up in comparison with FBS before surgery (P<0.0001). Furthermore, this difference was observed in HbA1c (P<0.0001).

CONCLUSION

SASI bypass is an effective method for weight loss and controlling type II diabetes mellitus.

Association of Hypercholesterolemia With Gastric Intestinal Metaplasia, Findings After Sleeve Gastrectomy Pathology Review

BACKGROUND

We evaluated the relationship between comorbidities associated with obesity, body mass index (BMI), and development of intestinal metaplasia (IM) after vertical sleeve gastrectomy (VSG).

MATERIALS AND METHODS

All VSG specimens performed at an academic center between 2011 and 2018 were reviewed. All specimens underwent histopathologic assessment, while those with findings suspicious for IM underwent additional immunohistochemical work up. Baseline patient characteristics and demographic data were obtained from Iran National Obesity Surgery Database by retrospective review.

RESULTS

A total of 862 adult individuals underwent VSG during the study period and specimens were histopathologically examined. All patients had preoperative upper endoscopy. The most common histopathologic diagnosis was miscellaneous findings (57.8%) followed by no pathologic finding (36.7%). The minority of patients (5.5%) had IM. Although 40.5% of patients had positive Helicobacter pylori infection preoperatively, just 13.8% had still positive infection postoperatively. A significant association was found between IM and hypercholesterolemia (odds ratio: 1.95; 95% confidence interval: 1.1, 3.5).

CONCLUSION

This study found a correlation between histopathologic changes in patients with IM and hypercholesterolemia. Prospective research studies are recommended to further examine this correlation.

Optimal Length of Biliopancreatic Limb in Single Anastomosis Sleeve Gastrointestinal Bypass for Treatment of Severe Obesity: Efficacy and Concerns

PURPOSE

The present study aimed to compare two newly introduced procedures, single anastomosis sleeve jejunal (SASJ) with ileal (SASI) bypass in terms of weight loss, remission of obesity-associated medical problems, complications, and nutritional status.

MATERIALS AND METHODS

This retrospective study was carried out with 162 patients who underwent single anastomosis sleeve gastrointestinal bypass from October 2017 to September 2021, either single anastomosis sleeve jejunal bypass (SASJ) or single anastomosis sleeve ileal bypass (SASI). The main outcome measures were weight loss and improvement in obesity-associated medical problems, nutritional status, and complications at 12 months post-surgery.

RESULTS

At 12 months, both groups showed significant weight loss and remission in obesity-associated medical problems. There were significant differences in body mass index (BMI), total weight loss (TWL), and excess weight loss (EWL) between SASI and SASJ bypass (P < 0.05). Improvements in associated medical problems after the two procedures were similar except for hypertension. The reversal surgery rate of the SASI group was significantly higher than that of the SASJ group (5.5% vs. 0.0%, p = 0.03).

CONCLUSIONS

SASJ and SASI bypass achieved satisfactory weight loss and improvement in obesity-associated medical problems that were comparable between the two groups. SASI bypass was followed by a significant difference in the rate of reversal surgery at 1 year due to a short common channel, which was not observed after SASJ bypass.

Single anastomosis sleeve jejunal (SAS-J) bypass as a treatment for morbid obesity, technique and review of 1986 cases and 6 Years follow-up. Retrospective cohort

BACKGROUND

Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb.

MATERIAL AND METHODS

This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results.

RESULTS

In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency.

CONCLUSIONS

Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up.

Laparoscopic Single Anastomosis Sleeve Ileal Bypass with Follow-up of Weight Loss and Metabolic Impact

Background: Bariatric surgery has been an effective safe management for severe obesity. The newly developed single-anastomosis sleeve ileal (SASI) bypass has shown efficacy as a functional as well as mechanical restrictive bariatric procedure, with a neuroendocrine modulation effect. SASI bypass is still an investigational procedure, hence, more evidence is needed till it is declared as a standard bariatric procedure by the IFSO. Aim of the study: The current work aimed to describe our experience regarding the technical steps, the efficacy and the short-term outcome of SASI bypass procedure in patients with severe obesity. Patients and methods: Forty seven patients with severe obesity underwent SASI bypass procedure. They were followed till 1 year postoperatively. The weight loss, comorbidities and laboratory changes were assessed. Results: Patients evaluation at the 1-year postoperative follow up revealed a mean %TWL of 37.55 ± 6.17 and a mean %EBWL of 76.21 ± 9.8. The remission rates of T2DM, hyperlipidemia and hypertension were 85.7%, 94.7% and 89.66%, respectively, with statistically high significant differences between the preoperative and 1-year postoperative comorbidities rate. Stepwise regression analysis demonstrated that only the preoperative HbA1C remained in the model predicting the %TWL, and the preoperative BMI was the remaining factor in the model predicting the %EBWL in the study patients. Conclusion: The present study adds a new evidence to the promising outcome of the newly introduced SASI bypass procedure. After one year, the study patients showed excellent weight loss and comorbidities remission together with acceptable major complication rates.

Bariatric endoscopic-surgical therapies for NAFLD. Should they be considered viable options among current treatments?

Nowadays, non-alcoholic fatty liver disease is one of the first causes of liver transplant worldwide; many efforts have been done to find the perfect drug for this multifactorial disease. Presently we just have a few drugs that could be used in specific and limited clinical scenarios. Current evidence suggests that bariatric endoscopic and surgical therapies could be strategies with optimal outcomes, with high impact in quality of life, decrease of cardiovascular risk, and improvement in metabolic profile, despite being considered expensive procedures. This review proposes to consider these therapies early together with liver fibrosis evaluation, with long term cost-effectiveness benefits in the absence of response to lifestyle modifications and pharmacological treatments.

Short-term Results of Transit Bipartition to Promote Weight Loss After Laparoscopic Sleeve Gastrectomy

Objective

To evaluate (1) the efficacy of transit bipartition (TB) as revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG); (2) the impact of the length of the common channel (CC) on weight loss.

Background

LSG in combination with TB has been shown to be highly efficacious for treating morbid obesity. The role of TB as RBS to address the problem of primary failure or weight recidivism after LSG is less well defined.

Methods

Observational study of outcomes in 100 morbidly obese patients who received a TB following LSG. Follow-up examinations (FE) were performed at 1, 3, 6, and 12 months. Variables analyzed included BMI, percent excess weight loss (%EWL), total body weight loss (%TBWL), effect on obesity-related conditions and complications.

Results

The mean BMI before LSG was 49.9 ± 8.5 kg/m2. A nadir of 32.7 ± 6.1 kg/m2 was reached 22.1 ± 16.9 months after LSG (%EWL 70.0 ± 14.5). The time interval between LSG and TB was 52.2 ± 26.6 months at which the BMI had increased to 37.6 ± 7.1 kg/m2 and %EWL decreased to 49.4 ± 19.7. Following TB, the BMI decreased continuously to 31.4 ± 5.7 kg/m2 after 12 months with a parallel increase in %EWL to 74.7 ± 20.3 and %TWL reaching 36.3 ± 10.5. Weight loss was significantly higher for CC length of 250 versus 300 cm after 12 months (BMI 29.4 ± 5.3/33 ± 5.3 kg/m2, P = 0.002; %EWL 79.8 ± 26.6/70.4 ± 17; P = 0.009). Improvement of comorbidities was observed in a high proportion of patients. Major early complications occurred in 3% of the patients.

Conclusion

TB is an effective second-step procedure to address insufficient weight loss or weight recidivism after LSG. CC length of 250 versus 300 cm had a significant impact. While most improvements of obesity-related comorbidities are likely linked to weight loss, amelioration of GERD is largely mediated by accelerated gastric emptying. Major complications were observed in 3% of patients and managed without fatalities.

Systematic review of the outcome of single-anastomosis sleeve ileal (SASI) bypass in treatment of morbid obesity with proportion meta-analysis of improvement in diabetes mellitus

BACKGROUND

Single-anastomosis sleeve ileal (SASI) bypass has emerged as a promising bariatric and metabolic procedure. We aimed to review the current literature on the outcome of SASI procedure in terms of weight loss, improvement in comorbidities, and complications.

METHODS

We conducted a systematic literature search, querying electronic databases and Google Scholar, for studies that reported the outcome of the SASI bypass. The main outcome measures of the review were change in body mass index (BMI), % of excess weight loss (%EWL), improvement in comorbidities, and complications after SASI bypass.

RESULTS

This systematic review comprised ten studies including 941 patients with a median BMI of 45.6 kg/m². The median %EWL at 6 months was 59.4% and significantly (p = 0.04) increased to 90.1% at 12 months. The weighted mean rate of improvement in diabetes mellitus was 99.1 (95%CI: 98.2-99.9, I² = 0). The crude percentages of patients with improvement in hypertension, hyperlipidemia, and gastroesophageal reflux disease were 51%, 76.6%, and 92%, respectively. The median operation time was 111.3, ranging between 75 and 148.4 min. Complications were recorded in 116 (12.3%) patients. Longer common limb was associated with less %EWL at 6 months and less complications whereas larger anastomosis size was associated with higher weight loss and greater improvement in hypertension.

CONCLUSIONS

SASI bypass was associated with good short-term outcomes in regard to weight loss and improvement in comorbidities, namely diabetes mellitus with an acceptably low complication rate.

Sleeve Gastrectomy, One-Anastomosis Gastric Bypass (OAGB), and Single Anastomosis Sleeve Ileal (SASI) Bypass in Treatment of Morbid Obesity: a Retrospective Cohort Study

PURPOSE

Bariatric surgery is the most effective treatment for morbid obesity. The present study aimed to assess three bariatric procedures with different mechanisms of actions; sleeve gastrectomy (SG), one-anastomosis gastric bypass (OAGB), and single anastomosis sleeve ileal (SASI) bypass, in terms of efficacy and safety.

METHODS

This was a retrospective cohort study on patients with morbid obesity who underwent SG, OAGB, or SASI bypass. The main outcome measures were weight loss and improvement in comorbidities at 6 and 12 months postoperatively, and complications.

RESULTS

A total of 264 patients (186 female) with mean preoperative body mass index (BMI) of 43.6 ± 9.9 kg/m²were included to the study. Significant weight loss was recorded at 6 and 12 months after the three procedures. At 6 and 12 months postoperatively, body weight and BMI were significantly lower after SASI bypass than after SG and OAGB. The %total weight loss (%TWL) and %excess weight loss (%EWL) were significantly higher after SASI bypass than after SG and OAGB. SASI bypass was associated with a significantly higher rate of improvement in DM than SG and OAGB (97.7% vs 71.4% vs 86.7%; p = 0.04) whereas improvement in other comorbidities was similar. The short-term complication rate was similar between the three procedures, yet SASI bypass was followed by higher long-term complication rate.

CONCLUSION

Based on retrospective review of data, SASI bypass was associated with more reduction in body weight and BMI, higher %TWL and %EWL, better improvement in T2DM, and more long-term nutritional complications than SG and OAGB.

Single-Anastomosis Sleeve Ileal (SASI) Bypass: Hopes and Concerns after a Two-Year Follow-up

BACKGROUND

Single-anastomosis sleeve ileal (SASI) bypass is a simplification of sleeve gastrectomy with transit bipartition. Both share a metabolic foundation through early postprandial ileal brake, and SASI bypass has the advantages of shorter operative time and less incidence of internal herniation. This study evaluates the safety and outcome of SASI bypass with 2-year follow-up.

METHODS

A retrospective cohort study of all patients who underwent SASI bypass in the period between June 2016 and January 2019. The primary outcome was weight loss and diabetic remission.

RESULTS

Three hundred twenty-two patients underwent SASI bypass with a mean age of 37.4 ± 15 years and a mean body mass index of 50.1 ± 7.7 kg/m². Thirteen patients (4%) had early major postoperative complications. The 1-year percentage of excess weight loss (%EWL) was 86.9 ± 9.2, and diabetic remission rate was 98.2%. The 2-year %EWL was 96.7 ± 5, and diabetic remission rate was 97.9%. Twenty-six patients had gastroesophageal reflux that improved in 21 (80.7%) patients, remained stationary in 4 (15.4%) patients, and worsened in one patient who required reversal. One patient (0.3%) had severe protein-energy malnutrition and is prepared for reversal. Technical variations had no significant impact on %EWL or diabetic remission.

CONCLUSION

SASI bypass had a promising outcome in terms of 2-year %EWL, diabetic remission, and improvement of preoperative GERD. However, stationary or progressive course of GERD is a substantial possibility. Although the double-outlet for the gastric content allows duodenal access, it may be an obstacle to the standardization of postoperative care. The double-outlet is not a guarantee for absence of malnutrition.