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248
Fig. 25.1 SADI-S
conguration
A. Ruano-Campos et al.
gastrectomy. Undoubtedly, as all surgical procedures, drawbacks have been encountered, although these side effects have been well tolerated and postoperative complications have appeared to be minimal [2–4].
25.2 Surgical Technique
25.2.1 Patient Preparation
Patients are thoroughly evaluated before the intervention by a team of specialized
endocrinologists, surgeons, and anesthetists, and they undergo a number of tests
including an upper gastrointestinal endoscopy, barium swallow, chest X-ray, electrocardiogram, and blood tests. Respiratory function tests and psychiatric evaluation are performed as well. Prior to surgery, patients are recommended to follow a
healthy, low-calorie diet in order to lose as much weight as possible before surgery,
as well as introducing them to a healthy lifestyle. This will not only reduce the possibility of postoperative complications, but it will also improve postoperative results.
The procedure can be divided into a two-step technique, starting with the sleeve
gastrectomy and continuing with a one-loop duodeno-ileostomy.
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25.2.2 Position ofthePatient andtheSurgical Team
The rst part of the operation is performed with the operating table under forced
reverse Trendelenburg position. The surgeon is positioned between the patient’s
legs, the rst assistant on the patient’s left side, holding the camera, and the second
assistant on the patient’s right side, holding the liver retractor (Fig.25.2).
For the second part of the surgery, namely, the duodeno-ileal bypass, the position
is changed. The patient is placed horizontally, and the surgeon moves from the initial position between the legs toward the left side of the patient, as well as the camera assistant, who will introduce the laparoscope through the left subcostal trocar,
leaving the upper umbilical and right midline trocars as working trocars (Fig.25.3).
Fig. 25.2 Initial trocar and surgical team positioning
250
A. Ruano-Campos et al.
Fig. 25.3 Final trocar and surgical team positioning
25.2.3 Trocar Position
The standard laparoscopic approach is performed by placing four trocars. A
10–12mm optical trocar (Optiview) is inserted above the umbilicus, slightly left
from the midline, and pneumoperitoneum is applied. A 10–12mm left subcostal
trocar is placed to introduce the harmonic scalpel for the surgeon’s right hand and
for the introduction of the stapler for the duodenal section during the second step. A
5mm trocar for the surgeon’s left hand initially, and subsequently for the hepatic
retractor, is placed in a subxiphoid position. Finally, a 10–12mm trocar is placed
right from the midline position for the surgeon’s left hand and to introduce the stapler during the sleeve gastrectomy (Figs.25.2 and 25.3).
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25.2.4 Procedure
25.2.4.1 Sleeve Gastrectomy andDuodenal Dissection
The rst step begins with the release of the fundus and dissection of the left crus
(Fig.25.4). This way, the need for an additional tensile clamp is avoided. Complete
devascularization of the greater curvature of the stomach is performed, and any
hiatal hernia is always searched. All vessels from the gastroepiploic arcade are
divided, from the fundus to the rst duodenal portion. Adhesions from the gastric
posterior wall to the pancreas are also divided with a harmonic scalpel.
To begin duodenal dissection, the antrum is raised with gentle traction of the
posterior gastric wall, leaving the duodenum in a vertical position. The duodenum
is dissected proximally, taking care not to injure the right gastric artery. A precise
circumferential dissection of the rst duodenal portion is performed, up until 3–4cm
from the pylorus, to facilitate an adequate mobilization for an easy and safe anastomosis, always making sure we prevent any devascularization (Fig.25.5). Dissection
of the duodenum from the pancreatic surface is carried out until the pancreaticoduodenal groove is reached and the gastroduodenal artery is identied (Fig.25.6). To
complete the duodenal dissection, the peritoneum overlying the hepatoduodenal
ligament is slightly opened, and a vessel loop or silk tape is passed (Fig.25.7).
ab
Fig. 25.4 Fundus mobilization (a) and dissection of the left crus (b)
252
A. Ruano-Campos et al.
ab
Fig. 25.5 Circumferential dissection of the rst duodenal portion (a) with the opening of the hepatoduodenal ligament (b)
Fig. 25.6 Gastroduodenal
and right gastric arteries
Fig. 25.7 A vessel loop or
silk tape is passed
surrounding the rst
duodenal portion
25 SADIS: Technical Details
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Fig. 25.8 Sleeve
gastrectomy is performed
over a 54 French bougie
using a black plated linear
stapler (Echelon Ethicon),
coated with Seamguard
(Gore) sheets for staple
line reinforcement
253
At this point, a vertical sleeve gastrectomy is performed over a wide 54 French
bougie starting 5cm from the pylorus, with a black plated linear stapler (Echelon
Ethicon), coated with Seamguard (Gore) sheets for staple line reinforcement
(Fig.25.8). The stapler is introduced through the right midline trocar. The suture
line is revised for bleeding points, placing titanium clips if required.
Once the gastrectomy is done, the duodenum is sectioned with a 60mm blue
cartridge linear stapler (Echelon Ethicon) as distal as possible from the pylorus,
introducing the stapler through the left subcostal trocar (Fig. 25.9). We nish this
part of the surgery by placing the rst stitch of the anastomosis. With this step, we
avoid confusion with any possible duodenal rotation during bowel measurement.
25.2.4.2 Duodeno-Ileal Bypass
The patient is placed horizontally, and the surgical team moves to the second position (Fig.25.3). The ileocecal junction is identied and 250–300cm, depending on
each case, is measured upward. Measurement of the bowel is performed, stretching
the loops at the anti-mesenteric border in 10 cm intervals, having administered
20 mg of hyoscine butylbromide (Buscopan) intravenously to obtain a complete
relaxation of the bowel wall and so gaining the maximum possible length. The
selected loop is ascended in an antecolic fashion, and an end-to-side, two-layer,
hand-sewn anastomosis to the proximal duodenal stump is carried out with running
sutures of V-Loc 3/0 (Covidien) and interrupted PDS 3/0 (Johnson & Johnson)
stitches for the second anterior layer (Fig.25.10).
Having nished the anastomosis, both the sleeve gastrectomy staple line and
duodeno-ileal anastomosis are checked for leaks by means of oral introduction of
methylene blue. The surgery is completed with the removal of the resected stomach
through the right midline trocar and the placement of a vacuum drain.
254
Fig. 25.9 The duodenum
is sectioned with a 60mm
blue cartridge linear stapler
(Echelon Ethicon) as distal
as possible from the
pylorus
A. Ruano-Campos et al.
ab
Fig. 25.10 An end-to-side, two-layer, hand-sewn duodeno-ileal anastomosis is carried out with
running sutures of V-Loc 3/0 (Covidien) (a) and interrupted PDS 3/0 (Johnson & Johnson) stitches
for the second anterior layer (b)
25.3 Postoperative Course
The patient is taken to a recovery unit for immediate postoperative care. Six to eight
hours postoperatively, the patient begins oral intakes of water on the surgical ward,
starting with a low-caloric liquid diet the following day. On the second day after
surgery, the patient starts with a low-caloric shake diet (Optifast). The abdominal
drain is removed on the third postoperative day, and patient is discharged the next
day if postoperative course is uneventful.
25 SADIS: Technical Details
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255
During follow-up, for the rst postoperative month, patients follow a low-caloric
diet based on self-prepared shakes (800kcal/day). Multivitamin supplements, calcium, and iron are initially prescribed and maintained depending on the results of
subsequent blood tests. The patient will continue with periodical visits to the endocrinologist and the surgeon for life, with three to four visits per year during the rst
2years and then once a year.
25.4 Technical Pitfalls
This bariatric technique entails four fundamental technical challenges, which are an
adequate sleeve gastrectomy conguration, careful duodenal dissection and division, a correct intestinal measurement, and duodeno-ileal anastomosis. Subsequent
errors may therefore be the following:
• Insufcient fundal dissection when performing the sleeve gastrectomy and/or
undertreatment of a hiatal hernia. A complete fundal mobilization has to be
performed when constructing the sleeve gastrectomy to avoid ending up with a
bicameral stomach. Hiatal hernias should be searched, especially when diag-
nosed preoperatively, to remove the fundus entirely in order to avoid problems
such as gastroesophageal reux disorders and/or weight regain.
• Insufcient duodenal dissection. Complete dissection of the rst portion of the
duodenum is crucial to facilitate its mobilization in order to perform an easy and
safe anastomosis, making sure we end up with 3–4cm from the pylorus. This
dissection should always be carried out above the gastroduodenal artery to avoid
damage both to the right gastric artery and to the bile duct. If this is not possible,
division of the right gastric artery should be done at its origin.
• Duodenal devascularization. This may consequently affect the duodeno-ileal
anastomosis.
• Inaccurate measurement of the common limb from the ileocecal valve. The mea-
surement of the common limb must be precise, as a short limb would put the
patients at risk of malnutrition. A less effective weight loss technique is prefera-
ble rather than a severe malnourishment, which could be fatal for the patient.
• Technical difculties concerning the duodeno-ileal anastomosis. The anastomo-
sis is usually undemanding to perform either mechanical or hand-sewn, as long
as it is done with care. An intraoperative test, with oral methylene blue, for exam-
ple, is recommended.
In particular situations, such as aged patients or those with liver or bowel diseases, 300cm is the preferred length of the common limb to avoid important nutritional complications.
256
A. Ruano-Campos et al.
25.5 Technical Advantages ofSADI-S
• Pyloric preservation is more physiologic and avoids biliary reux.
• Dismantling SADI-S is feasible in case of complications.
• No mesenteric defects are created; therefore, no internal hernias are expected.
• No anastomotic concerns such as strictures or ulcers have been observed regard-
ing the duodeno-ileal anastomosis.
• Easy, quick, and reproducible surgical technique.
25.6 Conclusions
SADI-S has become an easier, quicker, and more physiologic biliopancreatic diversion than the original duodenal switch, without jeopardizing weight loss or metabolic results after the reduction to one anastomosis.
References
1. Sanchez-Pernaute A, etal. Proximal duodenal-ileal end-to-side bypass with sleeve gastrec-
tomy: proposed technique. Obes Surg. 2007;17(12):1614–8.
2. Sanchez-Pernaute A, etal. Single anastomosis Duodeno–ileal bypass with sleeve gastrectomy
(SADI-S). One to Three-Year Follow-up. Obes Surg. 2010;20:1720–6.
3. Sanchez-Pernaute A, et al. Single- anastomosis duodenoileal bypass with sleeve gastrec-
tomy: metabolic improvement and weight loss in rst 100 patients. Surg Obes Relat Dis.
2013;9(5):731–5.
4. Sanchez-Pernaute A, etal. Single- anastomosis duodenoileal bypass with sleeve gastrectomy
(SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015;11(5):1092–8.
Chapter 26
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Technical Aspects ofSingle Anastomosis
Duodenal Switch: SIPS Version
MichaelMarchese, LaurenRincon, DonnaBahroloomi, andMitchellRoslin
Bariatric surgery is different than most surgical specialties where pathology is
addressed and corrected. Rather, bariatric surgery seeks to create a controlled abnormality in an effort to reduce hunger, achieve weight loss, and decrease a disproportionately high-fat percentage without excessive muscle loss. The latter objective is
a challenge with bariatric procedures that bypass the intestine, thus placing the
patient at risk for muscle wasting. How to best achieve these goals while minimizing complications is the unceasing objective of the bariatric surgeon.
The single anastomosis duodenal switch, specically the stomach intestinal
pylorus sparing (SIPS) modication, was rst introduced in the USA by Roslin and
Caban in 2009. Concurrently, a Spanish group led by Torres and Sánchez-Pernaute
described a single anastomosis duodenal switch modication, the single anastomosis duodenal ileostomy (SADI) [1]. The SIPS modication makes use of a smaller
sleeve gastrectomy (performed over a bougie size 40F–44 F) while maintaining
approximately 3m of the intestine for digestion. Contrarily, the SADI modication
makes use of a larger sleeve gastrectomy (performed over a bougie size 50F–55F)
while maintaining a shorter common channel of 200–250cm for digestion. Through
the utilization of both a gastric and intestinal approach, the single anastomosis duodenal switch-type procedures seek to provide sustained weight loss.
A drawback of gastric-only procedures (i.e., vertical sleeve gastrectomy) is adaptive thermogenesis [2]. Following surgical intervention, caloric intake decreases.
The resultant weight loss is associated with an increase in parasympathetic tone and
a decrease in sympathetic tone. The net effect of these adaptations is decreased
metabolism. At approximately 9 months postoperatively, the patient’s intake
M. Marchese · L. Rincon · D. Bahroloomi · M. Roslin (*)
Lenox Hill Hospital, New York, NY, USA
e-mail: lrincon1@northwell.edu; MRoslin@northwell.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_26
257
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