Revisional Laparoscopic SADI-S vs. Duodenal Switch Following Failed Primary Sleeve Gastrectomy: a Single-Center Comparison of 101 Consecutive Cases

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

One-Stage Vs. Two-Step One Anastomosis Duodenal Switch (OADS/SADI-S): A Safety and Efficacy Single-Center Propensity-Score Matched Analysis

INTRODUCTION

One Anastomosis Duodenal Switch (OADS/SADI-S) is used both as a one stage and a second-step procedure, either planned or revisional after a failed sleeve gastrectomy. However, there is lack of adjusted comparative evidence validating its use.

MATERIAL AND METHODS

Propensity-score matched comparison between patients submitted to one-stage vs. two-step OADS, adjusted by age, gender, and initial body mass index (BMI).

RESULTS

One hundred ninety-five patients (130 one-stage and 65 two-step OADS) were included, with mean initial BMI 52.4 kg/m2. Overall complication rate was 6.6% in the short-term (3.3% Clavien-Dindo ≥ III), and 7.3% in the long-term, with no differences between groups. Follow-up at 1 and 3 years was 83.6% and 61.5%. After one-stage OADS, total weight loss was 36.6 ± 8.2% at 1 year and 30.4 ± 10.3% at 3 years, vs. 30.2 ± 9.4% and 25.6 ± 10.2% after two-steps OADS (p = 0.021). Resolution rates of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea were 86.4%, 80.4%, 78.0%, and 73.3%, with no differences between groups.

CONCLUSION

One-stage OADS is a safe and effective bariatric technique for patients with grade III and IV obesity. The two-step strategy does not reduce postoperative risks and may compromise weight loss results at mid-term.

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.

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.

The Efficacy and Safety of Laparoscopic Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S) in Mid- and Long-Term Follow-Up: a Systematic Review

This systematic review of 10 studies aimed to investigate the mid- and long-term results of duodeno-ileostomy with sleeve gastrectomy (SADI-S) according to the PRISMA guideline. Related articles, which reported outcomes of laparoscopic SADI-S with follow-up ≥ 3 years, were selected and analyzed. The percentage of excess weight loss (EWL) was 70.9-88.7%, and 80.4% at 6, and 10 years, respectively. The more common late complications were malabsorption (6.3%) and gastroesophageal reflux disease (GERD) (3.6%). The remission rates of hypertension, diabetes, GERD, obstructive sleep apnea, and dyslipidemia were 62.9%, 81.3%, 53.2%, 60.9%, and 69.7%, respectively. In conclusion, SADI-S is a safe and effective surgical technique with durable weight loss and a high rate of comorbidity resolution in mid and long term.

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.

[Prevention and management of postinterventional weight regain]

Decreasing levels of patient motivation or compliance are far from being the only causes of postinterventional weight regain after lifestyle, psychological, pharmacological and surgical interventions. Weight regain originates from a complex and individually varying set of central and peripheral mechanisms, with the overall purpose of increasing food intake by both stimulating hunger and reducing satiety (mediated by gastrointestinal hormones) and decreasing the body's energy demands (via metabolic adaption). These mechanisms counteract any attempts to reduce or maintain body weight in today's increasingly prevalent adipogenic environments. The knowledge about the biological mechanisms of body weight regulation should be taken into consideration when planning treatment programs for long-term weight reduction, including follow-up treatment for the prevention and individualized treatment of postinterventional weight regain. Therapeutic measures as well as the frequency of medical follow-ups should be based on the extent of weight regain.

Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center

INTRODUCTION

Revisional bariatric surgery (RBS) is a challenging type of procedure for the surgeons due to its specific morbidity and efficiency. The RBS has a higher prevalence nowadays and this study may help to improve scarce data upon this specific topic.

METHODS

Data from 252 patients undergoing RBS after laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) between 2005 and 2019, were analyzed at 2 years of follow up. A subgroup analysis of third procedure was also performed.

RESULTS

Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p = 0.045). At 2 years of RBS, mean weight was 92.8 ± 26.7 kg, BMI was 33.1 ± 8.56 kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1 ± 20.7 kg and BMI was 32.5 ± 6.45 kg/m2. TWL for RBS performed after LSG was 12.7 ± 16.4% versus 25.5 ± 10.3% after LAGB (p < 0.001).

CONCLUSION

RBS after LSG seems to lead to higher overall morbidity whereas RBS after LAGB lead to more perioperative issues.

The analysis of factors increasing the odds for type 2 diabetes mellitus remission following re-do bariatric surgery after laparoscopic sleeve gastrectomy- cohort study

INTRODUCTION

Metabolic/bariatric surgery is the only proven treatment for type 2 diabetes mellitus (T2D) with curative intent. However, in a number of patients, the surgery is not effective or they may experience a relapse. Those patients can be offered re-do bariatric surgery (RBS).

PURPOSE

The study aimed to determine factors increasing the odds for T2D remission one year after RBS following primary laparoscopic sleeve gastrectomy.

METHODS

A multicenter retrospective cohort study was conducted between January 2010 and January 2020, which included 12 bariatric centers in Poland. The study population was divided into groups: Group 1- patients with T2D remission after RBS (n = 28) and Group 2- patients without T2D remission after RBS (n = 49). T2D remission was defined as HBA1c < 6.0% without glucose-lowering pharmacotherapy and glycemia within normal range at time of follow-up that was completed 12 months after RBS.

RESULTS

Fifty seven females and 20 males were included in the study. Patients who achieved BMI < 33 kg/m2 after RBS and those with %EBMIL > 60.7% had an increased chance of T2D remission (OR = 3.39, 95%CI = 1.28-8.95, p = 0.014 and OR = 12.48, 95%CI 2.67-58.42, p = 0.001, respectively). Time interval between primary LSG and RBS was significantly shorter in Group 1 than in Group 2 [1 (1-4) vs. 3 (2-4) years, p = 0.023].

CONCLUSIONS

Shorter time interval between LSG and RBS may ease remission of T2D in case of lack of remission after primary procedure. Significant excess weight loss seems to be the most crucial factor for T2D remission.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Mid-Term Outcomes After Conversion Procedures Following Laparoscopic Sleeve Gastrectomy

PURPOSE

In the long term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss (IWL), gastroesophageal reflux disease (GERD), and persistence or relapse of associated medical problems. This study's objective is to present mid-term results regarding weight loss (WL), evolution of associated medical problems, and reoperation rate of patients who underwent a conversion after SG.

METHODS

Retrospective single-center analysis of patients with a minimal follow-up of 2 years after conversion.

RESULTS

In this series of 549 SGs, 84 patients (15.3%) underwent a conversion, and 71 met inclusion criteria. They were converted to short biliopancreatic limb Roux-en-Y gastric bypass (short BPL RYGB) (n = 28, 39.4%), biliopancreatic diversion with duodenal switch (BPD/DS) (n = 19, 26.8%), long biliopancreatic limb Roux-en-Y gastric bypass (long BPL RYGB) (n = 17, 23.9%), and re-sleeve gastrectomy (RSG) (n = 7, 9.9%). Indications were GERD (n = 24, 33.8%), IWL (n = 23, 32.4%), IWL + GERD (n = 22, 31.0%), or stenosis/kinking of the sleeve (n = 2, 2.8%). The mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after conversion was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and long BPL RYGB (32.9%) compared to RSG (20.0%; p = 0.004; p = 0.049). In case of GERD, conversion to Roux-en-Y gastric bypass (RYGB) led to a resolution of symptoms in 79.5%. 16.9% of patients underwent an additional revisional procedure.

CONCLUSION

In the event of IWL after SG, conversion to BPD/DS provides a significant and sustainable additional WL. Conversion to RYGB leads to a reliable symptom control in patients suffering from GERD after SG.

Patient-Reported Outcomes and Quality of Life After Single-Anastomosis Duodeno-ileal Bypass with Sleeve Gastrectomy (SADI-S): a Cross-Sectional Study with 283 Patients from a Single Institution

INTRODUCTION

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a safe and effective technique with good short- and mid-term weight control and associated medical problems remission for patients with a body mass index (BMI) > 45 kg/m². The aim of this study was to analyze patient-reported symptoms, specifically symptomatic gastroesophageal reflux disease symptoms (GERD), depositional habit, and quality of life (QOL) following SADI-S, using telemedicine and validated tests.

METHODS

A prospective unicentric cross-sectional study was conducted including all patients submitted to SADI-S in the University Hospital of Bellvitge from May 2014 to September 2019. A baseline control group was composed of 67 patients who were planning to undergo SADI-S in the following 4 months. Patients were divided into four groups: pre-SADIS, < 2 years, 2-3 years, and > 3 years after surgery. The information gathered via a telematic questionnaire was analyzed and compared with its presence in patients' clinical history derived from the last presential visit.

RESULTS

The response rate to telematic tests was 86.9%. The mean BMI exhibited significant differences depending on the moment of evaluation: 50.8 kg/m², 30.0 kg/m², 31.1 kg/m², and 32.7 kg/m² at pre-SADIS, < 2, 2-3, and > 3 years follow-up, respectively (p < 0.001). The proportion of GERD symptoms increased over time (17.9%, 18.8%, 26.9%, and 30.2%, p = 0.320). After SADIS, the percentage of patients with loose stools was progressively higher (17.4% vs 25.4% vs 30.2%, p = 0.04). Patients with < 2-year follow-up presented an improvement in both physical component (PCS) and mental component (MCS) summaries compared to the baseline group (PCS = 51.3, and MCS = 49.4). The mean BMI of patients with PCS ≥ 50 was 31.9 kg/m², compared with 41.7 kg/m² in the PCS < 50 group (p < 0.001). In the MCS ≥ 50 group, there were more patients with a BMI < 35 kg/m² than the MCS < 50 group (66.7% vs 48.7%, p = 0.004). Telematic follow-up offered a more systemic and detailed information: in the last presential visit only, 13.9% of patients had complete data regarding weight evolution, remission of associated medical problems, GERD symptoms, and depositional habit in comparison with the 82.9% of patients with telematic follow-up (p < 0.001).

CONCLUSION

Weight control is the main factor related to long-term QOL after SADI-S. The incidence of GERD symptoms and diarrhea was up to 30% in patients with > 3-year follow-up. Monitoring postoperative patient-related symptoms with validated objective tests seems a feasible and useful resource for the long-term follow-up of patients submitted to SADI-S.

Duodenal Switch Conversion in Non-responders or Weight Recurrence Patients

INTRODUCTION

Several modalities have been proposed to tackle insufficient weight loss and weight regain after bariatric surgery; we aimed to evaluate efficacy and safety of duodenal switch conversion as a salvage procedure.

MATERIAL AND METHODS

Data from patients who underwent duodenal switch conversions (n = 50) were retrospectively studied. Excess weight loss % and total body weight loss % were compared between primary procedure and duodenal switch conversion. Overall complication, emergency department visits, readmissions, reoperation, and mortality rates were described, analyzed, and compared to the current literature.

RESULTS

Every excess weight loss % and total body weight loss % comparison at 6, 12, and 24 months, demonstrated a statistically significant superiority in weight loss after duodenal switch conversion (p < 0.05). The mean operative time of adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (1 and 2 stages) conversions to duodenal switch were 208, 146, 187, and 152 min, respectively, while the mean length of stay was 3.38 days. No statistically significant differences were perceived regarding the primary procedure. The overall complication rate was 18% (9 patients); 3 patients (6%) had 1 emergency department visit; readmissions accounted for 12% of cases (6 patients); the reoperation rate was 10% (5 patients); no fatal outcomes were recorded.

CONCLUSION

Duodenal switch conversions are an effective salvage procedure for insufficient weight loss and/or weight regain after adjustable gastric band, sleeve gastrectomy, and Roux-en-Y gastric bypass; it is also safe, associated to low readmission, reoperation, and mortality rates.

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

Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: A systematic review and network meta-analysis

BACKGROUND

revisional bariatric surgery is gaining increasing interest as long term follow-up studies demonstrate an elevated failure rate of primary surgery due to insufficient weight loss, weight regain or complications. This particularly concerns restrictive bariatric surgery which has been widely adopted from the '80s till present through different procedures, notably vertical banded gastroplasty, laparoscopic adjusted gastric banding and sleeve gastrectomy. The aim of this study is to define which revisional bariatric procedure performs the best after failure of primary restrictive surgery.

METHODS

a systematic review and network meta-analysis of 39 studies was conducted following the PRISMA guidelines and the Cochrane protocol.

RESULTS

biliopancreatic diversion with duodenal switch guarantees the best results in terms of weight loss (1 and 3-years %TWL MD: 12.38 and 28.42) followed by single-anastomosis duodenoileal bypass (9.24 and 19.13), one-anastomosis gastric bypass (7.16 and 13.1), and Roux-en-Y gastric bypass (4.68 and 7.3) compared to re-sleeve gastrectomy. Duodenal switch and Roux-en-Y gastric bypass are associated to an increased risk of late major morbidity (OR: 3.07 and 2.11 respectively) compared to re-sleeve gastrectomy while no significant difference was highlighted for the other procedures. Re-sleeve gastrectomy is the revisional intervention most frequently burdened by weight recidivism; compared to it, patients undergoing single-anastomosis duodenoileal bypass have the lowest risk of weight regain (OR: 0.07).

CONCLUSION

considering the analyzed outcomes altogether, single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are the most performing revisional procedures after failure of restrictive surgery due to satisfying short and mid-term weight loss and low early and late morbidity. Moreover, single-anastomosis duodenoileal bypass has low risk of weight recidivism.

Gastric Ischaemia After SADI with Right Gastric Artery Ligation

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

Bile Reflux After Single Anastomosis Duodenal-Ileal Bypass with Sleeve (SADI-S): a Meta-analysis of 2,029 Patients

BACKGROUND

Single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a novel bariatric surgery modified from the classic biliopancreatic diversion with duodenal switch (BPD-DS). These surgical modifications address most BPD-DS hurdles, but the risk of bile reflux may hinder SADI-S acceptance. We aimed to evaluate the event rate of bile reflux after SADI-S.

METHODS

PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were used to search English articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale and the JBI tool. Event rates were meta-analyzed using Comprehensive Meta-Analysis (CME) V3.

RESULTS

Out of 3,027 studies analyzed, seven were included. Studies were published between 2010 and 2020. Six out of 7 studies were retrospective. Three studies had a low risk of bias, three studies had a moderate risk of bias, and one had a high risk of bias. The mean follow-up was 10.3 months. The total number of patients was 2,029, with 25 reports of bile reflux, resulting in an incidence of 1.23%, with an event rate of 0.016 (95% CI 0.004 to 0.055).

CONCLUSIONS

Bile reflux has not been demonstrated to be problematic after SADI-S in this meta-analysis. Further long-term studies are needed.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database

INTRODUCTION

For patients with super obesity (BMI > 50 kg/m²), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS.

MATERIALS AND METHODS

The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m², and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes.

RESULTS

There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m², p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019).

CONCLUSIONS

Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Comparison of the Outcomes of Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S), Single Anastomosis Sleeve Ileal (SASI) Bypass with Sleeve Gastrectomy, and Sleeve Gastrectomy Using a Rodent Model with Diabetes

OBJECTIVE

Single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is a powerful form of bariatric surgery; however, it has a high risk of malnutrition. Single anastomosis sleeve ileal (SASI) bypass with sleeve gastrectomy may be used as an alternative procedure to avoid malnutrition associated with SADI-S; however, no comparison between the two procedures has been performed.

METHODS

Sprague-Dawley rats with diabetes (n = 32) were divided into four groups: SADI-S (n = 8), SASI (n = 8), SG (n = 8), and SHAM (n = 8). Body weight, food intake, and fasting blood glucose were measured, and the oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) were performed before and after surgery. Blood samples were collected before and after the surgery to assess the levels of glucagon-like peptide-1 (GLP-1), hemoglobin, albumin, vitamin B12, calcium, and iron.

RESULTS

The SADI-S and SASI groups showed significantly greater weight loss and better glucose control than the SG group postoperatively. The SADI-S and SASI groups showed similar improvements in glucose control throughout the study. The SADI-S and SASI groups had significantly higher GLP-1 levels than the SG group at 6 months. The SADI-S and SASI groups presented with various degrees of deficiencies, with the SADI-S group showing a higher risk for hypoalbuminemia and iron deficiency than the SASI group.

CONCLUSIONS

The SASI procedure may be a better alternative as it has excellent bariatric and metabolic results with lower risk for hypoalbuminemia and can be easily converted into either SADI-S or SG procedures. Nevertheless, further clinical results are needed.