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M. Marchese et al.
increases matching their now decreased metabolic rate resulting in a weight loss
nadir. Nonadherent patients are prone to recidivism at this time. With the addition of
an intestinal conduit, maximal weight loss is increased, and some recidivism is
thwarted. Unfortunately, intestinal bypass is not without consequence. These ramications include decreased absorption of divalent cations, such as calcium and iron
(normally absorbed in the duodenum), and less frequently trace minerals (i.e., copper, selenium, and zinc). Further, the absorption of fat-soluble vitamins is reduced,
and the risk for protein malnutrition increased [3].
The technical aspects of the SIPS which seek to balance the benecial and detrimental effects of a gastric and intestinal-based bariatric procedure will be discussed.
The operation begins by locating the terminal ileum and the ileocecal valve.
Approximately 300cm of the small intestine is measured by counting back from the
ileocecal valve and fastened with a stay stitch. Although not exact, we employ
graspers to measure the bowel. Literature published by Torres and Sánchez-Pernaute
demonstrated that 250cm of the small intestine is sufcient for the common channel. However, when the common channel approached 200cm, numerous episodes
of diarrhea were common. Since our technique employs an imperfect method of
measurement, there is a signicant chance of error (approximately 25%) and a tendency to underestimate rather than overestimate the length. As a result, we advocate
for 300cm to account for this potential miscalculation and limit the risk of diarrhea.
Chronic diarrhea can be physiologically compensated for via the adaptive nature of
the small and large intestine; however, side effects are signicant and can be lifelimiting. Additionally, excess weight loss can exceed 100% when the small intensive isn’t adequate resulting in excess catabolism and muscle wasting [4].
After measuring the small intestine, we proceed with our sleeve gastrectomy by
entering the lesser sac. The epiploic branches and posterior adhesions of the stomach to the retroperitoneum are taken down. The resulting blood supply of the stomach should be based solely along the lesser curvature. We begin our dissection along
the greater curvature at the angularis and proceed proximally, ligating the epiploic
and short gastric vessels until the base of the left crus of the diaphragm is visualized.
If a hiatal hernia is encountered, we address it at this point. The area of the caudate
lobe is taken down and the distal esophagus mobilized resulting in the restoration of
an intra-abdominal segment of the esophagus. The crura are then re-approximated.
We then proceed distally along the greater curvature and past the angularis, removing any posterior adhesions. The distal extent of the dissection of the greater curvature is past the pyloric valve and the prepyloric vein of Mayo.
The pylorus can now be elevated, and via a plane superior to the gastroduodenal
artery, the duodenum is encircled. We use an articulating grasper to transverse this
plane and encircle the duodenum. Once the duodenum is encircled, we staple a
3–4cm duodenal cuff. This is facilitated via gentle traction to the stomach. We recommend using a blue or purple staple load with buttress material when transecting
the duodenum. It is our opinion that buttress material helps to decrease bleeding
along the duodenal stump staple line. Excessive difculty or visualization of the
pancreas may represent a distal dissection plane. In our practice, we have not
26 Technical Aspects ofSingle Anastomosis Duodenal Switch: SIPS Version
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259
encountered a duodenal stump leak without a concomitant pancreatic injury. To
avoid injuring the pancreas, it is essential to elevate both the antrum and pyloric
valve, thus ensuring the proper plane and facilitating encircling the duodenum.
We then perform our sleeve gastrectomy over a 40F–44F bougie [5]. The gastric
transection should be initiated approximately 5cm proximal to the pylorus. Key
technical aspects of sleeve gastrectomy include the preservation of some antrum
and avoidance of an excessively small sleeve which can exacerbate diarrhea.
Once the sleeve gastrectomy is performed, the stay stitch and previously measured small bowel are identied, and duodenal-jejunal anastomosis is performed.
We prefer a hand-sewn technique, utilizing barbed suture. Complete mobilization of
all posterior adhesions allows for a tension-free anastomosis. Although triple staple
techniques have been described, it is our belief that these techniques are both difcult and associated with an increased risk of damage to the pyloric area. We advocate for a hand-sewn anastomosis performed either laparoscopically with a standard
needle passer, via an endoscopic suturing device, or robotically.
With our hand-sewn technique, we rst address the posterior layer after creating
a 1.5–2cm enterotomy on both the duodenum and small bowel. The posterior layer
is sewn in a continuous fashion with barbed suture. We then pass an oral gastric tube
on top of the posterior layer and into the efferent limb. We start the anterior layer at
the inferior corner by tying the anterior stitch to the posterior stitch and running it
halfway along the anterior wall. In the superior corner, we start another suture meeting at the halfway mark and tying both together. We test our anastomosis with the
oral gastric tube that’s in place. Figure26.1 demonstrates the key technical aspects
Fig. 26.1 Technical
aspects of SIPS.Visual
representation of SIPS
including sleeve
gastrectomy performed
over a 40F–44F bougie
and a duodenal-jejunal
anastomosis performed
300cm proximal to
ileocecal valve
Sleeve gastrectomy
performed over a
40F -44F bougie
Duodenal-jejunal
anastomosis
300 cm of smal
intestine left for
absorption
260
M. Marchese et al.
of SIPS including a sleeve gastrectomy performed over a larger bougie than a sleeve
gastrectomy and a duodenal-jejunal anastomosis performed with a loop 300 cm
proximal to the ileocecal valve.
Proper technique while performing the SIPS-type procedure maximizes the benets of a combined gastric and intestinal procedure. Our goal of this operation is to
promote fat loss while maintaining adequate lean muscle mass. Essential technical
aspects to ensure this goal include performing an adequate sleeve gastrectomy and
maintaining 300cm of the small bowel for absorption.
References
1. Brown WA, Ooi G, Higa K, Himpens J, Torres A.On behalf of the IFSO-appointed task force
reviewing the literature on SADI-S/ OADS. Single anastomosis duodenal-ileal bypass with
sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) IFSO position state-
ment. Obes Surg. 2018;28:1207–16.
2. Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve
gastrectomy. Surg Obes Relat Dis. 2008;4(1):33–8.
3. Bal BS, Finelli FC, Shope TR, Koch TR.Nutritional deciencies after bariatric surgery. Nat
Rev Endocrinol. 2012;8(9):544.
4. Cottam A, Cottam D, Roslin M, et al. A matched cohort analysis of sleeve gastrectomy
with and without 300 cm loop duodenal switch with 18-month follow-up. Obes Surg.
2016;26(10):2363–9.
5. Helmy M.Bougie size 32 versus 40 French in laparoscopic sleeve gastrectomy. Egypt J Surg.
2018;37(2):200.
Chapter 27
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Duodenal Bipartition or Side-to-Side
Duodeno-Ileostomy: Rationale
andTechnical Details
MichelGagner andMaximeLapointe-Gagner
27.1 Rationale
Since the introduction of laparoscopic sleeve gastrectomy from 2000, there has
been a tremendous increase in bariatric surgical procedures worldwide, and this
technique is now most accomplished for severe obesity and type 2 diabetes [1].
According to a recent French national countrywide data, revisions of sleeve gastrectomy occur at more than 10% after 10years, with >87% concern of weight regain,
insufcient weight loss, or recurrence of type 2 diabetes [2]. Re-interventions have
also increased in the last 10years either due to weight regain or intractable gastroesophageal reux disease following the latter operation. As a last resort, severe
reux may be contained by Roux-en-Y gastric bypass following disappointment of
medical treatment, as other methods have not been fully approved in all countries
(magnetic collar beads, i.e., LINX from Torax, radiofrequency sphincter augmentation, i.e., STRETTA, ligamentum teres-plasty, etc.) [3]. For weight regain after
sleeve gastrectomy, especially in patients with a higher body mass index (BMI),
laparoscopic duodenal switch (DS) and its variants are increasingly suitable for
revisional surgery, since conversion to Roux-en-Y gastric bypass can produce relatively poor or fair results [4]. Single anastomosis duodenal switch, or single anastomosis duodeno-ileostomy (SADI), is a variant that has become more popular
because it is less technically complicated (avoidance of ileo-ileostomy) and results
M. Gagner (*)
Westmount Square Surgical Centre, Westmount, QC, Canada
Hôpital du Sacre Coeur, Montreal, Montréal, QC, Canada
M. Lapointe-Gagner
Department of Experimental Surgery, McGill University, Montreal, QC, Canada
e-mail: maxime.lapointe-gagner@mail.mcgill.ca
© 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_27
261
262
M. Gagner and M. Lapointe-Gagner
in comparable weight loss at 5years and resolution of comorbidities with fewer side
effects [5]. Interestingly, this procedure was rst proposed by Del Genio when he
was at the experimental surgery laboratory of Mount Sinai, several years before the
seminal paper of Sanchez-Pernaute and Torres [6]. For type 2 diabetes, similar
results may certainly be obtained with hypoabsorptive surgery, after sleeve gastrectomy [7, 8].
A recent variation of this procedure is the side-to-side duodeno-ileostomy or
“duodenal bipartition,” similar to gastric bipartition of Santoro [9]. Although a
Roux-en-Y limb is used in his original description, duodenal bipartition categorically avoids the risk of gastro-ileostomy marginal ulcers, and the connection is
small bowel-to-small bowel, with bile thwarting acid [9]. Mahdy personalized this
concept to create the SASI bypass (for single anastomosis sleeve ileal), where a
loop of the ileum at approximately 250cm from the ileocecal valve is anastomosed
to the antrum, but with lesser results than an end-to-side duodeno-ileostomy, contributing an extra 40% of EWL after sleeve gastrectomy [10].
Before human implementation, the duodenal bipartition has previously been
tested in a porcine model and has proven to be an effective weight loss procedure by
both creating an early stimulation of the distal ileum (with GLP-1 and PYY 3–36
release), the so-called ileal brake, and by continually providing absorption of nutrients, such as by progressing the normal pathway of the third duodenum and continuing distally to the jejunum and proximal ileum due to dual lumen pathways
(Fig.27.1) [11]. Hence, this assembly generates a lower risk of malnutrition and
hypoproteinemia compared to a full duodenal switch or even a single anastomosis
duodeno-ileostomy, where liver failure is still a possibility.
This procedure (duodenal bipartition) can be accomplished either with the rst/
second parts of the duodenum after the pylorus with an antecolic anastomosis or
with the third portion of the duodenum in a transmesocolic/infracolic approach
(described here). It is possibly easily reversed with one cartridge and a linear stapler
Fig. 27.1 Schematic
representation of a
side-to-side duodenoileostomy with a
transmesocolic approach.
The inferior third portion
of the duodenum and the
anti-mesenteric distal
ileum are approximated
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by laparoscopic approach if clinical situations require it in the future. One mesenteric defect is involved both ways and is closed laparoscopically with a running
nonabsorbable suture, most straightforwardly on the left side, between the transverse mesocolon and the mesentery of the ileum up to the transverse colon itself.
Postoperative care and follow-up are similar to a duodenal switch SADI, but you
can anticipate a lower risk of malnutrition and hypovitaminosis, lesser bleeding and
leakages, and a faster recovery [12]. Interestingly, a more radical concept has been
evaluated in the porcine model: a duodeno-colic bypass, side-to-side, reminiscent of
weight loss after colic stulas. This may never reach the stage of common clinical
applications [13].
27.2 Technique
Duodenal bipartition can be performed with sleeve gastrectomy (at the same time)
or as a second-stage procedure. In this chapter, I describe a technique for the second
stage as it is likely to be the most common condition. The technique is described,
and images are taken from a didactic video from the session “Emerging Techniques
in Bariatric Surgery– Laparoscopic Duodeno- Ileostomy,” from the Annual Congress
of the American College of Surgeons in 2009; hence, this technique of side-to-side
duodeno-ileostomy has been around for more than a decade and is available in the
Online video Library of the American College of Surgeons, as ACS-2771 [14, 15].
The side-to side anastomosis is most easily performed while the main operator is
on the left side of the patient. The left arm can lie on the side of the body, while a
camera or other assistant can be on the upper left side. Interchangeably, a betweenthe- leg position, the so-called French position, can also be used. The port positions
will be similar to a duodenal switch or SADI procedure, with a camera position in
the umbilicus or somewhat to the left paramedian area, superior to the umbilicus.
Since a linear stapler is required (if not doing a full hand-sewn anastomosis which
is a possibility), the stapler port is slightly higher and to the left of the camera port.
A retraction grasper is best in the upper subcostal left to lift the transverse colon and
greater omentum cephalad. Another 5mm port, either on the right of the umbilicus,
slightly inferior for the left hand, is required for suturing.
The rst maneuver is a diagnostic laparoscopy to assess the feasibility of the
approach, as previous surgeries may create signicant adhesions to the ileum (like
appendectomy, prior colectomy, or pelvic surgery in women) or adhesions near the
transverse colon and greater omentum from upper quadrant surgeries. If the ileum
is free (or needs to be freed from adhesions) and the transverse colon can be pushed
cephalad to expose its transverse mesentery, then the duodenum really becomes
apparent and visible, given that it is in the left retroperitoneum.
Figure 27.1 schematically represents this concept. In Fig.27.2, we attempt an
opening of the peritoneum lying over the third portion of the duodenum (which is
retroperitoneal) after lifting the transverse colon. An ultrasonic or bipolar dissector
creates a linear, transverse opening from left to right, enough to reach the
264
Fig. 27.2 Opening the
peritoneum over the third
portion of the duodenum
(which is retroperitoneal
after lifting the transverse
colon). An ultrasonic
dissector is making a linear
opening from left to right
enough to get the
anti-mesenteric border for
the anastomosis
Fig. 27.3 Exposed third
portion of the duodenum
M. Gagner and M. Lapointe-Gagner
anti- mesenteric border for the anastomosis (5–6cm). After exposing the third portion of the duodenum, we assess the mobility for a side-to-side anastomosis and
ensure that we have enough length, since the stapler itself is 60mm which is adequate for such anastomoses to remain patent long term (Figs.27.3 and 27.4).
Measurement of an adequate length of the ileum is necessary and has to be done
accurately, since the ileum that is too short will result in malnutrition. In a classical
DS and SADI, the distances are 250cm from the ileocecal valve (in SIPS, it will be
300cm), and in cases where the stomach has not been resected, a shorter distance is
possible. The length measurements are performed using a 50cm umbilical measuring tape and run with at traumatic forceps (laparoscopic Dorsey bowel forceps,
Storz, Tuttlingen, Germany). Enterotomies are made on both sides of the bowel on
the left side of the duodenum, as the stapler will be inserted from left to right. The
openings are not too large but are just wide enough to insert a linear stapler of
60mm in length (Figs.27.5 and 27.6). These openings can be made using either a
hook with monopolar energy or with the harmonic scalpel. The stapler is introduced
27 Duodenal Bipartition or Side-to-Side Duodeno-Ileostomy: Rationale and Technical…
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Fig. 27.4 Pulling and
assessing mobility for an
anastomosis
Fig. 27.5 Making an
enterotomy on the
ileal side
265
from left to right, with the anvil in the thinnest bowel (duodenum), using a white
cartridge in order to get good apposition and minimize bleeding (Fig.27.7). The
enterotomies are closed with running suture; I prefer a 3–0 absorbable monolament or equivalent (Fig.27.8).
A methylene blue test can be performed with a nasogastric tube in the stomach
using 200ml with the duodenum and ileum clamped with bowel forceps. This test
not only helps ensure that the anastomosis is not leaking but also importantly that
lumens are patent and no kinks have occurred. Running 2–0 nonabsorbable sutures,
on the left side, from top to bottom, uniting the mesocolon and the mesentery of the
ileum are used to close the mesenteric defect (Fig.27.9). This is closed on the left
side of the anastomosis, as closing on the right is more difcult and unnecessary.
Doing so will prevent an internal hernia and possible bowel obstruction in the future.
The ultrasonic blade should point upward when opening the peritoneum over the
duodenum to avoid burning the duodenal wall itself. The markings on the mesentery
266
Fig. 27.6 Making an
enterotomy on the left side
of the duodenum (with a
traction silk suture under)
Fig. 27.7 A linear stapler
is inserted in both
enterotomies, with the
largest end into the ileum
M. Gagner and M. Lapointe-Gagner
Fig. 27.8 Closing the last
centimeter on the
entero-enterostomy with
running suture
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267
of the ileum are done with metal clips or alternately with a suture on the antimesenteric side, which can also be used for traction during the entero-enterostomy
(Fig.27.10). When the stapler is inserted, it helps to place traction sutures underneath to pull the bowel toward the stapler. If the mesentery is not suitable for an
infracolic approach, then a supracolic route can be used, and a side-to-side anastomosis is performed the same way on the rst/second portion of the duodenum. The
mesenteric space is trickier to close and starts typically on the taenia of the transverse colon. Uniting the mesentery of the colon to the ileum, splitting the greater
omentum (in between the right third and left two-thirds), facilitates this maneuver
at the beginning of the case. Postoperative care is similar to a DS or SADI with
nutritional rapid progression, protein supplements, mineral, and multiple vitamins,
including fat-soluble vitamins which should be provided. Blood levels of
micronutrients are critical as well as regular follow-up visits to ensure excellent
nutritional health.
Fig. 27.9 Closing the
mesenteric defect with a
running nonabsorbable
suture, on the left side,
from top to bottom
Fig. 27.10 Marking with a
clip, the ileal
measurements from the
ileocecal valve
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