The single anastomosis duodenal switch modifications: a review of the current literature on outcomes

Single Anastomosis Duodeno-Ileal bypass (SADI-S) as Primary or Two-Stage Surgery: Mid-Term Outcomes of a Single Canadian Bariatric Center

PURPOSE

Compare primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and two-stage SADI after sleeve gastrectomy (SG) in terms of weight loss, reduction/remission of comorbidities, and morbidity.

METHODS

Retrospective study including 179 patients treated laparoscopically between 2016 and 2020. A 50Fr bougie was used for the SG in the primary SADI-S (group 1) and 36/40Fr for the two-stage procedure (group 2). The duodeno-ileal anastomosis was performed at 250 cm from the ileocecal valve and at least 2 cm after the pylorus.

RESULTS

Mean age was 44.1 years old, and there were 148 women and 31 men. There were 67 (37.4%) patients in group 1 and 112 (62.6%) in group 2, with 67% completing the 4-year follow-up. Mean preoperative body mass index (BMI) was 51.1 kg/m2 and 44.6 kg/m2 for groups 1 and 2, respectively. Preoperative comorbidities were obstructive sleep apnea, hypertension, type 2 diabetes, and dyslipidemia in 103 (57.5%), 93 (52%), 65 (36.3%), and 58 (32.4%) of cases. At 4 years postoperatively, excess weight loss (EWL) was 67.5% in group 1 and 67% in group 2 (p = 0.1005). Both groups had good comorbidity remission rates. Early postoperative morbidity rate was 10.4% in group 1 and 3.6% in group 2. In group1, there were mostly postoperative intra-abdominal hematomas managed conservatively (n = 4). Two revisional surgeries were needed for duodeno-ileal anastomosis leaks. Postoperative gastroesophageal reflux disease (GERD), daily diarrhea, vitamin, and protein levels were similar in both groups.

CONCLUSION

Both types of strategies are efficient at short and mid-term outcomes. Preoperative criteria will inform surgeon decision between a primary and a two-stage strategy.

Evaluation study of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of Chinese obese patients based on efficacy and nutrition

To evaluate the efficacy and nutrition of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in Chinese obese patients in the first postoperative year. Clinical data of 66 obese patients who underwent SADI-S surgery at China-Japan Union Hospital of Jilin University from November 2018 to May 2022 were retrospectively collected. The weight, body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of total weight loss (%TWL) were recorded at 3, 6, and 12 months after surgery. Moreover, metabolic disease remission and nutrient deficiencies were assessed at 1 year postoperatively. Overall, 66 patients (38 males and 28 females) were recruited, with a mean age of 35 (18-61) years and an average preoperative BMI of 42.94 kg/m2. Before surgery, 38 patients had type 2 diabetes mellitus (T2DM), 46 patients had hyperuricemia (HUA), 45 patients had hypertension (HTN), 35 patients had hyperlipidemia, 12 patients had hypercholesterolemia, 12 patients had hyper-low-density lipoproteinemia, and 14 patients had gastroesophageal reflux disease symptoms (GERD). All patients had undergone a DaVinci robotic or laparoscopic SADI-S surgery, and none converted to laparotomy or died. Four patients developed postoperative complications and were cured and discharged after conservative treatment or surgical treatment. At 3, 6 and 12 months, the average %EWL was 62.07 ± 26.56, 85.93 ± 27.92, and 106.65 ± 29.65%, %TWL was 22.67 ± 4.94, 32.10 ± 5.18, and 40.56 ± 7.89%, respectively. Fasting blood glucose (FBG), glycated hemoglobin (HbA1c), uric acid (UA), triglycerides (TG), blood pressure (BP), and other indexes were significantly lower after one year post-surgery compared with the preoperative period (P < 0.05). The remission rates of T2DM, HUA, HTN, hypertriglyceridemia, hypercholesterolemia, and hyper-low-density lipoproteinemia 1 year after surgery were 100, 65.2, 62.2, 94.3, 100, and100%, respectively. One year after surgery, the remission rate of GERD was 71.4% (10/14), the rate of new occurrence of GERD was 12.1% (8/66), and the overall incidence rate was 18.2% (12/66). Except for vitamin B12(vit B12), the other nutrient indexes were significantly decreased after 1 year of surgery relative to levels before surgery (P < 0.05). The deficiency rates for vitamin A (vit A), vitamin E (vit E), zinc ion (Zn), and folic acid (FA) were higher (45.5, 25.8, 24.2, and 16.7%, respectively); however, there were no related clinical symptoms. SADI-S had significant effects on weight loss and metabolic disease remission. The main nutrient deficiencies after SADI-S were vit A, vit E, Zn, and FA deficiencies. The long-term efficacy and safety of SADI-S warrant further follow-up.

Single Anastomosis Duodenoileostomy with Sleeve: A Comprehensive Review of Anatomy, Surgical Technique, and Outcomes

PURPOSE OF REVIEW

Single anastomosis duodenoileal bypass with sleeve (SADI-S) is a recently endorsed metabolic and bariatric surgery (MBS) procedure in the US. Despite its favorable characteristics, the utilization of SADI-S remains limited, accounting for a mere 0.25% of all MBS procedures performed. This review aims to offer an updated examination of the technique, while also presenting the safety and outcomes associated with SADI-S on both the short and long term.

RECENT FINDINGS

The safety of SADI-S is well-established, with short-term complication rates as low as 2.6%. A common channel length of 300 cm has consistently shown a lower incidence of malabsorption complications compared to shorter lengths. Bile reflux after SADI-S is relatively rare with an incidence of only 1.23%. SADI-S demonstrated sustained total weight loss (%TWL) at 5 years (37%) and 10 years (34%) postoperatively. Resolution of weight-related medical conditions was also significant after SADI-S, with remission rates of diabetes mellitus as high as 86.6% with over 5 years of follow-up. SADI-S is a safe and effective MBS procedure that has shown impressive and sustainable results in terms of weight loss and improvement in obesity-related medical conditions. Careful limb length selection is essential in minimizing the risk of nutritional deficiencies. SADI-S holds great promise as a valuable option for individuals seeking effective weight loss and improvement in associated health conditions.

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.

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch

INTRODUCTION

Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications.

METHODS

A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared.

RESULTS

A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7 months in the pre-TBL group and 6.7 months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3 months (4.2 g/dL vs 3.5 g/dL, p < 0.001), 6 months (4.1 g/dL vs 3.6 g/dL, p < 0.001), and 12 months (4.2 g/dL vs 3.8 g/dL, p = 0.023) postoperatively when compared to the pre-TBL group.

CONCLUSION

Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Remission of Type II Diabetes Mellitus after Duodenal Switch: the Contribution of Common Channel Length

INTRODUCTION

The role of the common channel length in duodenal switch (DS) on remission of type II diabetes mellitus (DM), when stratifying patients based on diabetes severity, is not well understood.

METHODS

We retrospectively reviewed 341 consecutive patients with DM undergoing DS with one of three different common channel (CC) lengths (100 cm, 150 cm, and 200 cm), each with a fixed 300 cm alimentary limb (AL). Patients were stratified by insulin dependence (IDDM) versus non-insulin dependent diabetes (NIDDM). Data was collected at one year and at the last available follow-up.

RESULTS

The NIDDM group had a similar average HbA1c at last follow-up for each of the CC lengths. However, the IDDM group had lower average HbA1c with shorter CC lengths (100 cm = 5.4%, 150 cm = 6%, 200 cm = 6.4%, p < 0.05). Shorter CC lengths resulted in a greater proportion of patients achieving remission in the IDDM group (66%, 50%, 32% in the 100 cm, 150 cm, and 200 cm CC, respectively, p < 0.01). Improvements in HbA1c were independent of weight loss and average DiaRem scores were similar between CC lengths. Rates of nutritional deficiencies were higher in shorter common channel lengths. Revision for malnutrition was similar between common channel lengths (100 cm group: 3.7%; 150 cm group: 1.8%; 200 cm group: 0%, p = NS).

CONCLUSIONS

When the AL is fixed, shortening CC lengths results in improved glycemic control and remission of DM in patients with the need for insulin preoperatively. Milder forms of DM are treated well with any of the CC lengths.

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

Nutritional deficiencies following malabsorptive surgeries are a major concern.

PURPOSE

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

SETTING

Single private institute, Australia.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Medium-Term Nutritional and Metabolic Outcome of Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S)

INTRODUCTION

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S), like other hypoabsorptive procedures, could be burdened by long-term nutritional deficiencies such as malnutrition, anemia, hypocalcemia, and hyperparathyroidism.

OBJECTIVES

We aimed to report our experience in terms of mid-term (2 years) bariatric, nutritional, and metabolic results in patients who underwent SADI-S both as a primary or revisional procedure.

METHODS

One hundred twenty-one patients were scheduled for SADI-S as a primary or revisional procedure from July 2016 to February 2020 and completed at least 2 years of follow-up. Demographic features, bariatric, nutritional, and metabolic results were analyzed during a stepped follow-up at 3 months, 6 months, 1 year and 2 years.

RESULTS

Sixty-six patients (47 female and 19 male) were included. The median preoperative BMI was 53 (48-58) kg/m². Comorbidities were reported in 48 (72.7%) patients. At 2 years, patients had a median BMI of 27 (27-31) kg/m² (p < 0.001) with a median %EWL of 85.3% (72.1-96.1), a TWL of 75 (49-100) kg, and a %TWL of 50.9% (40.7-56.9). The complete remission rate was 87.5% for type 2 diabetes mellitus, 83.3% for obstructive sleep apnea syndrome and 64.5% for hypertension. The main nutritional deficiencies post SADI-S were vitamin D (31.82%) and folic acid deficiencies (9.09%).

CONCLUSION

SADI-S could be considered as an efficient and safe procedure with regard to nutritional status, at least in mid-term (2 years) results. It represents a promising bariatric procedure because of the excellent metabolic and bariatric outcomes with acceptable nutritional deficiency rates. Nevertheless, larger studies with longer follow-ups are necessary to draw definitive conclusions.

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

BACKGROUND

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

METHODS

SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

RESULTS

Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

CONCLUSIONS

Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

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

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

Long-Term (> 6 Years) Outcomes of Duodenal Switch (DS) Versus Single-Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S): a Matched Cohort Study

BACKGROUND

There are no comparative studies on the long-term outcomes after the primary traditional duodenal switch (DS) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S).

PURPOSE

This study aims to compare the long-term outcomes in a matched cohort.

SETTING

This study took place in a single private institute, in the USA.

MATERIALS AND METHODS

Data from 266 patients who underwent a primary laparoscopic traditional DS or primary laparoscopic SADI-S from September 2011 to December 2015 by four surgeons were used for a retrospective matched cohort. Data were obtained by matching every DS patient to a SADI-S patient of the same age, sex, and body mass index (BMI). In addition, only patients that were out at least 5 years and had a minimum 5-year follow-up were included in the study.

RESULTS

The matched cohort included 30 DS and 30 SADI-S patients. There were no statistically significant differences in the preoperative characteristics and baseline comorbidities between both groups. The SADI-S patients had significantly shorter operative time and length of stay. The overall long-term complications, especially the long-term Clavien-Dindo grade IIIb complications, were significantly fewer with SADI-S. At 6 years, the DS patients had statistically higher %EWL; however, the ending BMIs were statistically similar between both groups. There were no significant differences in the long-term comorbidity and nutritional outcomes of both groups. The long-term failure rates were comparable.

CONCLUSIONS

Most long-term outcomes of SADI-S were either similar or significantly better than DS. Part of the reasons could be the surgeon's learning curve and the small sample sizes of both groups.

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

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

Reluctance in duodenal switch adoption: an international survey among bariatric surgeons

BACKGROUND

Duodenal switch (DS) still comprises less than 1% of the overall primary procedures in the United States. Our aim is to explore the reasons behind surgeons' reluctance to DS adoption.

OBJECTIVES

To determine perceived reasons for the widespread lack of adoption of the DS.

SETTING

Worldwide survey of closed bariatric surgery social media groups.

METHODS

A standardized questionnaire was posted on 2 closed social media bariatric groups. DS was used as an umbrella term that includes traditional BPD with duodenal switch, single anastomosis duodeno-ileostomy (SADI) and loop DS. The questionnaire link was accessible to bariatric surgeons only for a period of 1 week.

RESULTS

Survey responses (n = 193) were analyzed. The majority (75%) were fellowship-trained bariatric surgeons, and 58% were practicing in the United States. Although 72.9% believed DS to be a good bariatric procedure, it was not being performed by 64% of the respondents. The main reasons behind DS nonadoption included a perceptible high long-term complication rate (43.5%), lack of training (38.1%), and procedure seldomly demanded by patients (31.5%). For surgeons who perform DS, 16.4% use it as a revisional procedure, mainly following sleeve gastrectomy (40.5%). Finally, 29.5% of surgeons believed that the American Society of Metabolic and Bariatric Surgery endorsement of SADI will encourage them to add DS to their practice. They are mostly planning to do so by visiting other surgeons and getting proctored (42.6%).

CONCLUSION

This survey will help guide bariatric societies and governing bodies in addressing the issues and concerns preventing surgeons from adopting DS in their practice by elucidating the chief reasons and circumstances behind this occurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and Drawbacks of Single-Anastomosis Duodeno-Ileal Bypass After Sleeve Gastrectomy in a Tertiary Referral Bariatric Center

Background

The need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18–36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery.

Materials and Methods

Data of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal.

Conclusion

SADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05323-y.

Primary SADI-S in Chinese with Diabetes and BMI < 35 kg/m2: a Retrospective Study with 2-Year Follow-up

BACKGROUND

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a bariatric procedure based on the standard duodenal switch surgery. It was first introduced in 2007 as a procedure for individuals with clinically severe obesity. Till date, primary SADI-S has not been used on Chinese with diabetes and body mass index (BMI) < 35 kg/m².

OBJECTIVES

Here, we account the use of this novel surgery in Chinese with diabetes and BMI < 35 kg/m².

METHODS

All relevant medical information, involving patients with diabetes and BMI < 35 kg/m², who received primary SADI-S at Beijing Shijitan Hospital from June 2017 to December 2018, was retrospectively assessed.

RESULTS

Twenty-six patients were selected for evaluation, and all of them completed a 2-year follow-up. The age, diabetic duration, and preoperative BMI were 35.5 (range 20-63) years, 3.5 (range 0.5-18) years, and 34.40 (range 28.74-34.96) kg/m², respectively. At 24 months, the percentage of total body weight loss (%TWL) and BMI were 26.26 (range 13.33-43.88) and 24.72 (range 17.96-29.07) kg/m², respectively. There were no serious complications or sequelae within a 2-year follow-up. In addition, for diabetes, 20/23 people achieved complete remission, whereas 3 achieved partial remission.

CONCLUSION

SADI-S is a highly effective and feasible bariatric surgery for Chinese having diabetes and BMI < 35 kg/m². However, care must be taken to follow a strict criteria for patient selection and to monitor patients carefully for the detection of postoperative nutritional sequelae.

The Effectiveness of Single-Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS): an Updated Systematic Review

Single-anastomosis duodenoileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) was developed as a bariatric operation with reduced overall morbidity and lasting weight loss results. We performed a systematic review of the literature, including 14 studies reporting on weight loss, comorbidity resolution, postoperative complications, and nutritional deficiencies following SADI-S. Twelve months after SADI-S, the mean total body weight lost ranged from 21.5 to 41.2%, with no weight regain being observed after 24 months. The comorbidity resolution rate was 72.6% for diabetes, 77.2% for dyslipidemia, and 59.0% for hypertension cases. The need for reoperation was the most common postoperative complication. While several patients developed nutrient deficiencies, SADI-S seems to be an overall safe and effective bariatric operation.

SADI-S 250 vs Roux-en-Y Duodenal Switch (RY-DS): Results of 5-Year Observational Study

PURPOSE

There are only a small number of studies providing a comparison between SADI-S and Hess-Marceau's BPD/Duodenal Switch (RY-DS) operations. We aimed to compare 5-year results of SADI-S 250 (common limb 250 cm) with RY-DS.

MATERIAL AND METHODS

Data of patients who underwent open SADI-S (n 226) and RY-DS (n 528) were retrospectively studied. EWL(%), EBMIL(%), TWL(%), antidiabetic effect, complications, and revision rate were compared between the two groups.

RESULTS

After the first 12 months, EWL% (77.0% vs 73.3%) and TWL% (39.4% vs 38.9%) were statistically significantly better after SADI-S (p < 0.01, and p < 0.05 respectively), but not EBMIL% (p > 0.05). At nadir to 24-36 months, EWL, TBWL, and EBMIL after SADI-S was comparable to the RY-DS group. Up to the fourth and fifth year, better weight loss (TBWL, EBMIL, EWL) was observed after RY-DS than after SADI-S. Early complication rate was less (2.65%) in the SADI-S group vs 5.1% in the RY-DS. Protein deficiency and small bowel obstruction rates were also lower after SADI-S. 93.4% of patients achieved total remission of their diabetes. 7.5% of patients in the SADI-S group had symptoms of bile reflux, which was a main indication for revisions.

CONCLUSION

SADI-S has many advantages over RY-DS. However, weight loss and antidiabetic effects after the third year were marginally lower after SADI-S compared to RY-DS. SADI-S is less dangerous in terms of malabsorption and looks to be a reasonable alternative to RY-DS as a metabolic operation. RY-DS could be implemented for weight regain and/or bile reflux after SADI-S.

Prospective multicentre randomised trial comparing the efficacy and safety of single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus Roux-en-Y gastric bypass (RYGB): SADISLEEVE study protocol

INTRODUCTION

Despite the non-negligible weight loss failure rate at midterm, Roux-en-Y gastric bypass (RYGB) remains the reference procedure in the treatment of morbid obesity with metabolic comorbidities. A recently emerged procedure, the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), could be more effective on weight loss with similar morbidity and lower weight loss failure rate than RYGB. We propose the first randomised, open, multicentre superiority trial comparing the SADI-S to RYGB (SADISLEEVE).

METHODS AND ANALYSIS

The main objective is to demonstrate the superiority at 2 years after surgery of the SADI-S compared with RYGB in term of excess weight loss percentage. The secondary objectives are the evaluation of nutritional status, metabolic outcomes, overall complication rates and quality of life, within 2 years after surgery. Key inclusion criteria are obese patients with body mass index (BMI) ≥40 kg/m² or ≥35 kg/m² with at least one comorbid condition and candidate to a first bariatric procedure or after failure of sleeve gastrectomy. Patients randomised by minimisation in two arms, based on centre, surgery as a revisional procedure, presence of type 2 diabetes and BMI >50 kg/m² will be included over 2 years.A sample size of 166 patients in each group will have a power of 90% to detect a probability of 0.603 that excess weight loss in the RYGB arm is less than excess weight loss in the SADI-S arm with a 5% two-sided significance level. With a drop-out rate of 10%, it will be necessary to include 183 patients per group.

ETHICS AND DISSEMINATION

The study was approved by Institutional Review Board of Centre Hospitalier Universitaire Morvan (CPP1089-HPS1). Study was also approved by the French national agency for drug safety (2018061500148). Results will be reported in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03610256.

Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures

PURPOSE

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss.

MATERIALS AND METHODS

Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1 years earlier.

RESULTS

Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids-leucine, isoleucine, and valine-were higher after SADI-S as compared with BPD-DS.

CONCLUSION

Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

Outcomes After Laparoscopic Conversion of Failed Adjustable Gastric Banding (LAGB) to Laparoscopic Sleeve Gastrectomy (LSG) or Single Anastomosis Duodenal Switch (SADS)

BACKGROUND

Inadequate weight loss following LAGB (laparoscopic adjusted gastric banding) requiring band removal and conversion to another bariatric procedure is common. There is a paucity of objective data to guide procedure selection. Single anastomosis modifications (SIPS, SADI, SADS) of the duodenal switch biliopancreatic division (DS-BPD) are being investigated. Laparoscopic sleeve gastrectomy (LSG) has become the most prevalent primary bariatric procedure and has been used for revision following LAGB.

PURPOSE

The purpose is to investigate single-stage LAGB removal to LSG SADS (single anastomosis duodenal switch). A matched cohort analysis compared each revision to a similar patient having a primary procedure. This was performed to understand the impact of prior banding on outcomes with each procedure.

MATERIALS AND METHODS

This is a retrospective study to investigate the outcomes of revision of LAGB for inadequate weight loss to LSG or SADS. To determine whether prior banding impairs results, a matched cohort was done comparing each revision to a patient that had a primary procedure.

RESULTS

As expected, patients who had SADS had greater weight loss than LSG. There was no difference in peri-operative and early complications. Both procedures resulted in weight loss. Importantly, with matched cohort, prior LAGB decreased weight loss outcomes in LSG, but not SADS.

CONCLUSION

Conversion of LAGB to LSG or SADS results in weight loss. The presence of LAGB decreases weight loss in LSG, but not in SADS. This can have important implications for long-term outcomes.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel

BACKGROUND

Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation.

OBJECTIVES

We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting.

SETTING

Data were gathered at an international conference with attendees from a variety of different institutions and settings.

METHODS

Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

RESULTS

Consensus was present in 10 of 16 lines of questioning, with several key points most prominent.

CONCLUSIONS

As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

Oral levothyroxine therapy postbariatric surgery: Biopharmaceutical aspects and clinical effects

BACKGROUND

Bariatric surgery can lead to changes in the oral absorption of many drugs. Levothyroxine is a narrow therapeutic drug for hypothyroidism, a common condition among patients with obesity.

OBJECTIVE

The purpose of this work was to provide a mechanistic overview of levothyroxine absorption, and to thoroughly analyze the expected effects of bariatric surgery on oral levothyroxine therapy.

METHODS

We performed a systematic review of the relevant literature reporting the effects of bariatric surgery on oral levothyroxine absorption and postoperative thyroid function. A PubMed search for relevant keywords resulted in a total of 14 articles reporting levothyroxine status before versus after bariatric surgery.

RESULTS

Different mechanisms may support opposing trends as to levothyroxine dose adjustment postsurgery. On the one hand, based on impaired drug solubility/dissolution attributable to higher gastric pH as well as reduced gastric volume, compromised levothyroxine absorption is expected. On the other hand, the great weight loss, and altered set-point of thyroid hormone homeostasis with decreased thyroid-stimulating hormone after the surgery, may result in a decreased dose requirement.

CONCLUSIONS

For patients after bariatric surgery, close monitoring of both the clinical presentation and plasma thyroid-stimulating hormone and T4 levels is strongly advised. Better understanding and awareness of the science presented in this article may help to avoid preventable complications and provide optimal patient care.

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.

OBJECTIVES

To compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.

SETTING

University Hospital, Canada.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.

RESULTS

Six retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, -17.46 to -2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.

CONCLUSION

SADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.

Single-anastomosis duodeno-ileal - new revision procedure in a patient with insufficient weight loss after sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is one of the most popular and effective bariatric surgical procedures worldwide. The effect of LSG is mostly dependent on the restrictive mechanism, which makes it more vulnerable to failure. Failing of bariatric procedure is not uncommon and occurs in 6% to 23%. In case of weight loss failure, there are no hard recommendations on the choice of the redo procedure. One of the most novel options, introduced in 2007, relatively simple to perform following LSG is single-anastomosis duodenoileal bypass. Herein we describe surgical technique and history of a patient with inadequate weight loss after laparoscopic sleeve gastrectomy, who underwent single-anastomosis duodenoileal bypass.