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280
A. I. Olano et al.
29.5 Points ofDiscussion
Restriction is performed by performing a vertical gastrectomy, and at this point,
there are several variables depending on the surgical groups. The main variables are
the distance at which the rst shot is made in the antrum and the caliber of the probe
with which the stomach is calibrated. In a recent study of 390 patients [3], it was
shown that starting the gastric sect. 3cm or less from the pylorus was signicantly
associated with greater weight loss, even though these patients presented more oral
intolerance in the immediate postoperative period. These data are conrmed by a
recent randomized study [4] comparing an antral resection 2cm from the pylorus
with a resection 6cm beyond, showing more weight loss in the group of patients
with a larger resection and without associated complications.
Another controversy is the size of the sleeve and whether the size of the tube used
to calibrate the gastrectomy has an impact on weight loss. In a recent meta- analysis
[5] comparing the results of weight loss and complications in patients operated with
thicker tubes compared to thinner ones, it is concluded that thinner tubes are related to
greater weight loss, but thicker tubes have fewer associated complications.
When these laparoscopic surgical procedures were described, serious postoperative complications were initially observed, which made it necessary to perform this
procedure in two stages, a rst restrictive stage and a second malabsorptive stage,
when the patient had already lost some weight and the surgical intervention was
safe. The decision to perform this surgery in one or two stages also varies according
to the patient’s BMI and the surgical team, but in a study carried out comparing the
results of surgery in one or two stages, no differences in total weight loss were
observed, but there were differences in the complications [6].
29.6 Summary
The circular stapler anastomosis is an easily reproducible anastomosis. There are
few points of discussion and variations. It is a safe and usually quite straightforward
anastomosis. When the OrVil can be introduced from the mouth, it is also a quick
anastomosis.
Even though there are just a few trials comparing the three different ways, they
all conclude that this kind of anastomosis is safe, with low risk of stenosis and
slightly higher risk of bleeding.
References
1. Burla L, Weibel P, Baum C, Huber M, Gürtler T, Weber M. Linear versus circular stapler
for gastrojejunal anastomosis in laparoscopic Roux-En-Y gastric bypass: an analysis of 211
cases. Surg Res Pract. 2020;2020:4090797. https://doi.org/10.1155/2020/4090797. PMID:
32802938; PMCID: PMC7414346
29 Circular Anastomosis inDuodenal Switch
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281
2. Major P, Janik MR, Wysocki M, Walędziak M, Pędziwiatr M, Kowalewski PK, Małczak P,
Paśnik K, Budzyński A.Comparison of circular- and linear-stapled gastrojejunostomy in lapa-
roscopic Roux-en-Y gastric bypass: a multicenter study. Wideochir Inne Tech Maloinwazyjne.
2017;12(2):140–6. https://doi.org/10.5114/wiitm.2017.66868. Epub 2017 Mar 29. PMID:
28694899; PMCID: PMC5502334
3. Avlanmis O, Isil RG, Burcu B. Effect of resection distance from pylorus on weight loss
outcomes in laparoscopic sleeve gastrectomy. Obes Surg. 2019;29(9):2731–8. https://doi.
org/10.1007/s11695- 019- 03923- 3.
4. Abdallah E, El Nakeeb A, Youssef T, Abdallah H, Ellatif MA, Lotfy A, Youssef M, Elganash
A, Moatamed A, Morshed M, Farid M.Impact of extent of antral resection on surgical out-
comes of sleeve gastrectomy for morbid obesity (a prospective randomized study). Obes Surg.
2014;24(10):1587–94. https://doi.org/10.1007/s11695- 014- 1242- x. Erratum in: Obes Surg
2015;25(10):1987. Yousef, Tamer [Corrected to Youssef, Tamer]
5. Chang PC, Chen KH, Jhou HJ, Chen PH, Huang CK, Lee CH, Chang TW.Promising effects of
33 to 36 Fr. Bougie calibration for laparoscopic sleeve gastrectomy: a systematic review and net-
work meta-analysis. Sci Rep. 2021;11(1):15217. https://doi.org/10.1038/s41598- 021- 94716- 1.
PMID: 34312476; PMCID: PMC8313581
6. Iannelli A, Schneck AS, Topart P, Carles M, Hébuterne X, Gugenheim J.Laparoscopic sleeve
gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal
switch for superobesity: case-control study. Surg Obes Relat Dis. 2013;9(4):531–8. https://doi.
org/10.1016/j.soard.2012.02.003. Epub 2012 Mar 3
Chapter 30
Duodenoileal Anastomosis withLinear
Stapler Technique
OscarGonzalezLopez, AmadorGarciaRuizde Gordejuela,
andMarcBeisaniPellise
30.1 Introduction
The duodenoileal anastomosis is considered to be the Achilles’ heel of the duodenal
switch and its variants. It is technically the most demanding stage of the operation
and the place where most postoperative complications arise. Different techniques
have been proposed, both stapled and hand-sewn. Initially, the use of circular stapled devices was the most common laparoscopic approach. However, this requires
to pass the anvil through the mouth, which is a time-consuming maneuver, and
increases the risk of surgical wound complications at the site where the stapler is
introduced into the abdomen. Later, a “right-angled” side-to-side linear stapled
anastomosis was described for the duodenal switch [1], which seemed to avoid the
problems related to the circular anastomosis without adding much technical
complexity.
One of the most common variations of the duodenal switch is the single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S), described by
Sanchez-Pernaute etal. in 2007 [2]. It is based on the principle that preserving the
pylorus would stop biliary reux to the stomach, thus making a Roux-en-Y conguration unnecessary. Although still a recent incorporation to the surgical arsenal against obesity, it has progressively gained popularity due to its greater
technical simplicity and has already been endorsed by the International Federation
O. G. Lopez (*) · A. G. R. de Gordejuela
Endocrine, Metabolic and Bariatric Surgery Unit, Vall d’Hebron University Hospital,
Autonomous University of Barcelona, Barcelona, Spain
M. B. Pellise
Bariatric Surgery Unit, General and Digestive Surgery Department, Moises Broggi Hospital,
CSI, Sant Joan Despi, Barcelona, Spain
© 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_30
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O. G. Lopez et al.
for the Surgery of Obesity and Metabolic Disorders (IFSO) [3] and the American
Society for Metabolic and Bariatric Surgery (ASMBS) [4] as an accepted alternative to the classic duodenal switch. In its original description of the laparoscopic
SADI-S, Sanchez-Pernaute etal. recommend the same “right angled” side-to-side
linear stapler technique previously introduced for the duodenal switch [5]. In this
chapter, we will elaborate on how to perform this anastomosis and highlight some
important technical aspects.
30.2 Procedural Approach
30.2.1 Common Limb Measurement
Although some groups prefer to perform this step after taking down the duodenum, we believe that it is a good practice to begin by measuring the future common limb, in order to discard any anomaly that could pose a contraindication to
the technique.
With the surgeon and the assistant in the left side of the patient, the ileocecal
valve is identied and the ileum counted back between 2 and 3m. There is controversy on the ideal length of the common limb, as the initial 200cm limb has been
associated with a hardly acceptable high rate of postoperative malnutrition.
However, limbs of more than 300cm may not obtain good weight loss outcomes. In
our practice, we perform the anastomosis at 270cm from the ileocecal valve if the
patient has previously undergone a conventional sleeve gastrectomy and may
shorten it to 250cm if the sleeve is performed by us in the same act and made intentionally “oppy.”
Once the selected ileal loop is identied, it is ascended antecolically and xed to
the gastrocolic omentum. Marking the efferent limb with a stitch may be convenient, in order to avoid twisting the loop later on.
30.2.2 Duodenal Dissection
The duodenal dissection is the most delicate part of the procedure. A thorough anatomical knowledge is mandatory, as important structures (i.e., the pancreaticoduodenal vessels and the hepatic hilum) lie around the working area. Moreover, the
vessels of the lesser curvature should be preserved at all costs to avoid compromising the gastric and pyloric blood supplies.
First, the gastroepiploic vessels should be taken down and the gastric antrum
lifted to the anterior abdominal wall and pulled to the left, in order to comfortably
30 Duodenoileal Anastomosis withLinear Stapler Technique
Fig. 30.1 Dissection of
the posterior aspect of the
duodenum. The asterisk
marks the window where
the stapler will go through,
in the space limited by the
gastroduodenal artery, the
right gastric artery, and the
duodenum
*
285
access the lesser sac and carefully dissect the subtle plane between the pancreas and
3–4cm of the posterior aspect of the duodenum. The gastroduodenal artery, which
will cross under the dissection plane, perpendicular to the duodenum, usually marks
the limit of that dissection. However, visualizing the gastroduodenal artery is not
mandatory. During this dissection, the pancreaticoduodenal vessels can be found
running parallel to the duodenal axis from the pancreas to the pylorus. The right
gastric vessels can be seen going upward, perpendicular from the gastroduodenal
artery and leaning to the duodenum (Fig.30.1). Gently retracting the liver cranially
may help to move away the hepatic hilum during this stage. When the posterior
aspect of the duodenum has been freed and the space limited by the gastroduodenal
artery, the right gastric artery, and the duodenum has been identied, the dissection
is completed. It may be useful to leave a gauze pad in the dissection bed, in order to
help with hemostasis and protect the hepatic hilum before moving to the anterior
aspect of the duodenum to nally open the window in the thin peritoneal layer of the
hepatoduodenal ligament.
After completing the duodenal dissection, it is then sectioned with a laparoscopic
linear stapler device passed through the window previously created. We recommend
the use of the white or blue cartridges of the Echelon (Johnson & Johnson, New
Jersey, USA) or the beige cartridge of the Endo-GIA (Medtronic, Minnesota, USA).
Attention must be paid only to include the duodenum when closing the device. In
normal conditions, neither the distal nor proximal duodenal stumps need additional
reinforcing.
When performing this linear stapled anastomosis, preserving the right gastric
artery is recommended for two main reasons:
• It xes the duodenal stump and facilitates later on the introduction of the linear
stapler through a small duodenal entrance.
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Fig. 30.2 “Right-angled”
side-to-side linear stapled
anastomosis
O. G. Lopez et al.
• After the duodenal section and the linear anastomosis are completed, there will
be a hypovascularized region between the two (Fig. 30.2) that can critically
depend on the blood supply arriving from the right gastric artery. That should be
specially kept in mind when performing a staged approach, if the integrity of the
left gastric artery from the previous sleeve surgery cannot be reassured.
30.2.3 Duodenoileal Anastomosis
After the selection of the suitable ileal segment and the section of the duodenum are
completed, a 2–3-cm-long side-to side duodenoileal anastomosis is performed. The
linear stapler is introduced parallel to the longitudinal axis of the small bowel and
parallel to the duodenal section line, through small incisions on the antimesenteric
aspect of the ileum and the lateroposterior aspect of the duodenum, approximately
1cm from the section line (Fig.30.2). A white or beige cartridge is usually used for
that stage, entering the thick stem through the ileum. When retrieving the stapler, it
should remain semi-closed to avoid stretching the orices, and any bleeder from the
stapled line should be carefully identied and controlled.
Finally, the orices are closed with a running suture. Also, the anterior aspect of
the anastomosis is reinforced with a running suture, including the section line of the
duodenal stump. We prefer using a 3-0 braided resorbable suture for the former and
resorbable auto-locking 3-0 suture for the latter, although other options could be
suitable as well (Fig.30.3). The anastomosis can then be tested for leaks with methylene blue introduced through an orogastric tube. Indocyanine green can also be
used to conrm an adequate blood supply.
30 Duodenoileal Anastomosis withLinear Stapler Technique
Fig. 30.3 Final
appearance of the
anastomosis, after closing
the orices and reinforcing
the anterior aspect
References
287
1. Sánchez-Pernaute A, Pérez-Aguirre E, Díez-Valladares L, Robin A, Talavera P, Rubio MA,
Torres García A. “Right-angled” stapled latero-lateral duodenojejunal anastomosis in the duo-
denal switch. Obes Surg. 2005;15:700–2.
2. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García Pérez JC, Cabrerizo L, Díez
Valladares L, Fernández C, Talavera P, Torres A.Proximal Duodenal–Ileal end-to-side bypass
with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17:1614–8.
3. Brown WA, Ooi G, Higa K, Himpens J, Torres A.Single anastomosis duodenal-ileal bypass
with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) IFSO position
statement. Obes Surg. 2018;28:1207–16.
4. Kallies K, Rogers AM, American Society for Metabolic and Bariatric Surgery Clinical Issues
Committee. American Society for Metabolic and Bariatric Surgery updated statement on
single- anastomosis duodenal switch. Surg Obes Relat Dis. 2020;16:825–30.
5. Cottam D, Cottam S, Surve A.Single-anastomosis duodenal ileostomy with sleeve gastrec-
tomy “continued innovation of the duodenal switch”. Surg Clin N Am. 2021;101:189–98.
Chapter 31
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Staged Duodenal Switch forHigh-Risk
Patients
AndrewCollins, GaryAghazarian, andAndreTeixeira
31.1 Introduction
In the USA, since the year 2000, the adult obesity rate has increased from 30.5% to
42.4% in 2018, with the subset of severely obese patients increasing rapidly.
Hispanic and non-Hispanic Black adults had the highest age-adjusted prevalence of
obesity [1]. This presents as a public health crisis, as the prevalence of obesity mirrors the prevalence and burden of many comorbid diseases, affecting several organ
systems. Despite several pharmaceutical, lifestyle, and public health measures
aimed to address the disease, the obesity epidemic in the USA continues to grow
[2]. In patients suffering from morbid obesity refractory to lifestyle change, bariatric surgery has demonstrated effective long-term treatment. Given the procedural
efcacy, safety, and utilization of laparoscopic methods, procedures such as laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy, Roux-en-Y gastric
bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD/DS)
have been increasingly utilized in the USA.
LAGB and RYGB are the most common bariatric procedures aimed for weight
reduction; however, the BPD/DS is the most effective procedure, resulting in the
greatest excess weight loss (EWL) among the various surgical options. Patients
undergoing BPD/DS often experience decreased hunger due to the reduction in gastric volume and further EWL through diminished nutrient absorption within the
alimentary limb. The procedure is technically intensive, requiring a skilled surgeon
with clinical expertise for choosing appropriate patients. As a result, BPD/DS
A. Collins
College of Medicine, University of Central Florida, Orlando, FL, USA
G. Aghazarian (*) · A. Teixeira
Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health,
Orlando, FL, USA
© 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_31
289
290
accounts for <1% of bariatric surgery, despite the powerful impact on weight and
improved resolution of obesity-related comorbidities, such as type II diabetes.
Increased perioperative morbidity and long-term nutritional adverse effects related
to the nature of the technique add to the disinclination of its use. However, BPD/DS
still maintains a critical role in the treatment of super-obese patients (BMI>50 kg/
m2), due to the effective management of their disease. In high-risk or super-superobese patient groups (BMI>60kg/m2), a two-stage procedure may be utilized to
limit procedure time, leading to a reduction in the perioperative morbidity and mortality. The rst stage consists of a sleeve gastrectomy, followed by duodenoileostomy and ileoileostomy approximately 6–18months after [3, 4]. The objectives of
this chapter will be to (1) provide an overview of the procedure, (2) describe indications and contraindications, (3) briey describe the surgical technique, and (4) outline surgical outcomes and complications related to staged BPD/DS.
A. Collins et al.
31.2 Procedure
By staging the BPD/DS into two stages, (1) sleeve gastrectomy and (2) duodenoileostomy and ileoileostomy, operation duration is decreased, and complications
related to increased time under anesthesia are reduced [4, 5]. Staging of procedures
may be planned preoperatively, or the decision can be made during the sleeve gastrectomy portion. Indications for intraoperative decision for procedure staging
include physiologic compromise of the patient or questionable technical feasibility
of the remaining maneuvers. The SG and BPD portions of the procedure have also
been reported using a robotic-assisted technique, with similar outcome to purely
laparoscopic procedures [6]. In other bariatric procedures, such as the RYGB, a
comparison of robotic-assisted surgery to laparoscopy demonstrated a potentially
increased leak rate at the gastric pouch or remnant stomach level [7].
31.3 Stage 1: Sleeve Gastrectomy
Commonly a stand-alone procedure, the sleeve gastrectomy is conducted laparoscopically and is the rst portion of the staged BPD/DS for high-risk or super-superobese patients. In this procedure, approximately 75–80% of the stomach is removed
in a vertical fashion to limit food volume intake. The stomach volume will be
reduced from 2L to 100–150 mL, and due to the removal of the fundus, the new
stomach is largely resistant to stretch and accommodation of large ingested volumes. With the patient in supine position and surgeon standing on the patient’s right
and working ports in the right subcostal and mid-abdomen, the camera is in the left
mid-abdomen. If the liver is enlarged and interfering with the procedure, a liver
retractor can be added through the extreme right-sided port to provide leeway. Using
an ultrasonic or bipolar energy device, the greater curvature of the stomach is
31 Staged Duodenal Switch forHigh-Risk Patients
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devascularized and mobilized approximately 4–6cm from the pylorus superiorly to
the left crus of the diaphragm. After mobilization, a 60 Fr bougie is passed to guide
gastric division. If a hiatal hernia is noted during the procedure, repair is indicated
to reduce postoperative gastroesophageal reux and retained elements of the stomach leading to impaired weight loss. Creation of the gastric sleeve utilizes a thick
tissue cartridge with a linear stapler. Stapling must be conducted in the same horizontal plane to avoid functional obstruction caused by a spiral-sleeve contour.
Stapling along the bougie should not be overly tight, as improper staple ring may
occur. The stapling will begin 4–6 cm above the pylorus to spare much of the
antrum. In a two-staged procedure, the gastric specimen can now be removed, and
the procedure is terminated. The weight loss goal for this rst stage in high-risk
patients is a 100–150 pound weight loss (or until weight plateau), often reached
within 6–18months after the sleeve gastrectomy.
31.4 Stage 2: Duodenoileostomy andIleoileostomy
31.4.1 Duodenal Transection
Excessive visceral fat may complicate the dissection, and bleeding can blur the tissue planes. Due to this, the duodenal transection can be technically demanding;
however, it is critical to minimize excessive duodenal devascularization and injury
to the duodenum and pancreas. With lateral retraction of the antrum to linearize the
rst portion of the duodenum, free the peritoneum on the inferior and superior portions of the duodenum, until the duodenum fuses posteriorly with the pancreas.
Either a curved or right-angle dissector can be used to create this retroduodenal
tunnel. Posteriorly through this window, a stapler cartridge can be applied to the
gastroduodenal artery. A suture is then placed at the inferior corner of the duodenal
cuff staple line, with its tail incised approximately 4cm to allow later proximal
anastomosis to the ileum. Another suture is placed to create the posterior anastomosis and is to remain while the alimentary limb is created.
31.4.2 Alimentary Limb Creation
The greater omentum is opened toward the patient’s right, allowing the ileum to be
connected with the duodenum. Moving to the patient’s left side, working through
the LUQ subcostal and lateral mid-abdominal ports, identify the terminal ileum at
the ileocecal junction. If the patient has a past abdominal surgery history, examine
the region for intra-abdominal adhesions before duodenal transection. Measuring
100cm from the cecum, mark the ileum at the site of later ileoileostomy. Another
150cm past this point, transect the ileum using a stapler. Mark this distal end of the
biliopancreatic limb to distinguish from the alimentary limb. The alimentary limb is
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