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38 Conversion ofSleeve Gastrectomy toDuodenal Switch andSADI-S
357
Leaving the outcomes on GERD aside, associating only an intestinal bypass and
keeping the sleeve intact can be a very simple and highly effective technical alternative for sleeve patients with IWL or obesity recurrence. In this scenario, both
BPD-DS and SADI-S/OADS should emerge as the natural options for conversion
(or second stage), since the SG comprises the original technique of these two procedures. According to the 32 members present in an international panel of experts to
dene the best practice guidelines in reoperative surgery after SG, the BPD-DS was
consensually considered superior to the RYGB in terms of improving weight loss.
In addition, consensus has also been reached that the SADI-S/OADS surgery can
additionally be a reasonable option for treating patients with failed SG [29].
Despite the favorable arguments aforementioned, both BPD-DS and SADI-S/
OADS do not seem to be the preferred procedure for failed SG.At the Fourth
International Consensus Summit on Sleeve Gastrectomy, 130 expert surgeons provided data of 46,133 procedures. Although many respondents denied observing signicant WR after SG at that time, if a second operation became necessary due to
weight loss failure, conversion to a BPD-DS was the second most common procedure (24%), behind the RYGB (46%). A small percentage of surgeons reported
opting for SADI-S/OADS (3%) at that time [30]. In sequence, at the Fifth
International SG Consensus, 120 expert surgeons provided data on 117,000 procedures. The percentage of conversions caused by failure in weight loss was 4.7%.
BPD-DS has been reported as the second most common choice for a rescue procedure, again behind the RYGB [31].
An online questionnaire-based survey attempted to obtain data on practices
related to revision bariatric surgery. Opinions of 460 surgeons around the world concerning revision after SG have identied the RYGB surgery as the preferred procedure, followed by OAGB-MGB. Both one- and two-anastomosis duodenal switch
surgeries came next, with a slightly higher percentage for choosing SADI-S/OADS
[32]. More recently, another online survey regarding global variations in periopera-
tive practices concerning SG gathered the responses of 863 bariatric surgeons from
67 countries with a cumulative experience of 520,230 procedures. The most common procedure offered to the patient for further weight loss after sleeve surgery was
RYGB (51%), followed by OAGB-MGB (25%). SADI-S/OADS and BPD-DS came
next, with 10% and 3.2% of the indications, respectively [33]. Interestingly, the
option for revision with SADI-S/OADS surpassed the classic BPD-DS in this survey.
In general, these data perhaps reect the greater familiarity of bariatric surgeons
with gastric bypass, either with the traditional Roux-en-Y or, more recently, with
that of one anastomosis, both considered technically less complex than the duodenal
switch approach. In this sense, the greater technical simplicity of SADI-S/OADS
can overcome this barrier and become a more chosen option in the SG revision due
to IWL/WR in the near future. However, both BPD-DS and SADI-S/OADS are
malabsorptive procedures with some difculty in postoperative nutritional management, which currently has not been viewed favorably by either surgeons or patients.
Recently, a consensus meeting applied debatable issues to 29 experienced bariatric surgeons to outline areas of further research on the role of BPD-DS as a secondstage or revision procedure. Expert surgeons considered BPD-DS surgery the most
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A. C. Ramos and E. L. D. S. Bastos
appropriate subsequent operation for a committed patient with IWL after SG (88.5%
agreement). Likewise, the SADI-S/OADS was also considered a reasonable option
to deal with SG failure (72.4%), but technically simpler. For sleeve patients with
WR and normal upper gastrointestinal series (without reux, without enlargement),
BPD-DS was the most common choice (43.3%), followed by RYGB (33.3%) and
SADI-S/OADS (13.3%) [34]. In this publication, the authors reported interesting
data from the Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP) in relation to the BPD-DS as a revision procedure. In 2017, the United States performed 1643 primary BPD-DS, an increase of
54.3% compared to 2years ago. Notably, during the same time interval (2015–2017),
the duodenal switch as a revision procedure grew 114.1%.
The rst consensus statement on revisional bariatric surgery gathered 70 expert
surgeons to vote on the agreement or disagreement of 39 pivotal questions regarding
general aspects of revisional surgery, disregarding the index procedure. Specically
for revision after sleeve, SADI-S/OADS achieved the highest percentage of agreement
(88.5%) as an acceptable option, followed by OAGB (84.3%) and BPD-DS (81.4%)
[35]. In this consensus-building vote, the reason for the revision was not up for debate.
Finally, an international panel of 32 expert bariatric surgeons was brought
together with the aim of providing guidelines on revisional surgery after sleeve
surgery. Several causes for interventions were addressed, but one of the most controversial topics was in regard to strategies to manage poor weight control. First of
all, multidisciplinary evaluation and treatment were considered mandatory before
considering a revisional surgical approach, especially in the absence of anatomic
abnormalities in the sleeve. For IWL or WR with sleeve enlargement/dilation or
disappointing responses to multidisciplinary clinical management, conversion to
standard BPD-DS has reached consensus as a safe and effective strategy. Likewise,
SADI-S/OADS has also achieved agreement as a reasonable revisional procedure
for treating patients with failed SG. Both procedures were deemed superior to
RYGB to restore or improve weight loss [29].
Thus, although two- and one-anastomosis duodenal switch has been repeatedly
pointed out as the best rescue option among expert surgeons, the general bariatric
community still seems to opt more frequently for conversion to RYGB in cases of
failure to control obesity after SG.The expected popularization in the coming years
of a procedure with less technical complexity (SADI-S/OADS) may eventually contribute to increasing the indications for a duodenal switch surgery after failed SG.
38.4 Conversion ofSG toBPD-DS andSADI-S:
Surgical Technique
If no anatomical abnormalities are found in the preoperative work-up, and conrmed in the intraoperative, the approach of the sleeve appears to be needless.
Indeed, it may not even be advisable, as the risk of complications related to the
38 Conversion ofSleeve Gastrectomy toDuodenal Switch andSADI-S
Fig. 38.1 Redundant
gastric fundus (dilated)
already dissected, ready for
the safe positioning of the
stapler (green load)
Fig. 38.2 Stapler well
positioned and closed,
ready for ring
359
procedure can potentially be increased. In some cases, whether due to pre- or intraoperative diagnosis, excision of the redundant fundus (fundectomy) may be necessary to boost further weight loss (Figs.38.1, 38.2, 38.3, and 38.4). In cases where
the entire sleeve is severely dilated, the surgeon who chooses to tighten should keep
in mind that the BPD-DS sleeve appears to have been originally designed also to
reduce stomach acid secretion, and not just to cause a signicant restrictive effect.
Therefore, the calibration of the diameter of the sleeve should be slightly looser
than when the SG is performed as a stand-alone procedure. After all, the association of a strong restrictive effect with malabsorption can be dangerous for nutritional balance.
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Fig. 38.3 Second ring
from the stapler to
complete the resection of
the redundant gastric
fundus (also green load). A
safe distance from the
abdominal esophagus must
be assured
Fig. 38.4 Reinforcement
of the fresh staple line by
means of transmural
running suture
A. C. Ramos and E. L. D. S. Bastos
Technical details necessary for conversion surgery such as trocar placement,
techniques for duodenal mobilization, approach to the right gastric artery, duodenoileostomy technique (hand-sewn/stapled), length of the common channel and Roux
limb in BPD-DS or the efferent loop in SADI-S/OADS, and closure of mesenteric
defects, among others, are properly covered in other chapters of this book.
38 Conversion ofSleeve Gastrectomy toDuodenal Switch andSADI-S
Although the conversion of a SG to BPD-DS or SADI-S/OADS can be less complex when compared with these same operations performed primarily, it is still a
reoperation, a revisional surgery. Complication rates are generally higher on revision procedures, and, therefore, they should preferably be performed by trained and
experienced hands at referral centers.
361
38.5 Results ofConversion fromSG into BPD-DS
or SADI-S/OADS
Some caution must be taken when analyzing the outcomes concerning further
weight loss after revisional procedure, since published studies with inadequate comparison between different postoperative follow-up times can be easily found. Most
patients who are reoperated for WR after SG have had satisfactory short-term
results. Therefore, it is not fair, nor scientically correct, to compare the long-term
WR of SG with the short- or mid-term outcomes of the revisional procedure.
Furthermore, duodenal switch surgeries, alongside OAGB-MGB, have become a
more attractive option for revising the sleeve due to weight loss failure only recently,
perhaps driven by the unsatisfactory long-term results of RYGB surgery. Therefore,
substantial mid- and long-term data is not yet available.
Outcomes of revisional duodenal switch procedures after sleeve have been frequently compared with other bariatric surgeries, especially gastric bypass. In this
comparison, both BPD-DS and SADI-S/OADS appear to provide higher weight
loss, most likely by adding a malabsorptive component to an essentially restrictive
surgery. On the other hand, malabsorption can lead to higher rate of nutritional side
effects that are not commonly seen in RYGB surgery, requiring strict surveillance,
especially when the efferent loop (common channel) is left less than 250 cm
in length.
A systematic review carried out to compare single- or double-anastomosis duodenal switch with RYGB for further weight loss in failed SG included six retrospective studies for meta-analysis. The primary outcome was the percentage of total
weight loss (%TWL). A total of 206 patients comprised the SADI-S/BPD-DS
group, and an average of %TWL of 30.75 was observed after a highly variable follow- up period (median of 24months). This weight loss was about 10% higher compared to the RYGB group. However, this signicantly favorable outcome concerning
weight loss seems to have occurred mainly at the expense of patients undergoing
classic BPD-DS, since the comparison only between SADI-S/OADS and RYGB
remained showing the superiority of the duodenal switch surgery, but without statistically signicant difference [36]. Nonetheless, the small sample size in each study
and lack of baseline equivalence in initial BMI between the groups before the second procedure observed in most of the studies are signicant factors of high risk of
bias to compare the duodenal switch procedures and gastric bypass in terms of
weight loss.
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One of the studies included in the meta-analysis formerly mentioned brought
together the largest casuistic to compare SADI-S/OADS (n = 66) with RYGB
(n=45) as rescue surgery for failed SG.At 24months following secondary surgery,
data were available in only about 50% of patients in both groups, but the percentage
of total body weight loss (%TBWL) was signicantly higher in patients undergoing
SADI-S/OADS (26.4%±10.4 vs. 6.9%±11.3, SADI-S/OADS vs. RYGB, respectively). Moreover, 72% of RYGB patients regained a part of their lost weight after
revisional surgery, whereas SADI-S/OADS patients seem to progressively lose
weight during the 2-year follow-up period. Nutritional deciency was found in
more than 60% of patients in both groups (64% vs. 62%, SADI-S/OADS vs. RYGB,
respectively), despite oral supplementation being directed to all patients. Within the
rst year of surgery, complications were observed with rates above 15% in both
SADI-S and RYGB (16.7% vs. 17.6%, respectively). Meanwhile, the authors
reported two SADI-S/OADS patients underwent re-sleeve because of IWL and one
additional patient underwent a duodenojejunostomy for enteral feeding due to
intractable severe chronic diarrhea [37].
A retrospective matched cohort study with short-term follow-up also compared
SADI-S/OADS (n=42) and RYGB as a revisional procedure after SG to achieve
additional weight loss. Although post-revisional percentage total weight loss
(%TWL) appeared to be slightly higher in the duodenal switch group (10.6 vs. 9.5,
SADI-S/OADS vs. RYGB, respectively), no signicant difference was found in
relation to the drop in BMI after 12months. Interestingly, failure in obesity control
was again observed after both procedures (three patients from SADI-S/OADS group
and nine from RYGB group), highlighting the relevance of patient selection before
going for revision [38].
Regarding the comparison with the also emerging OAGB-MGB surgery, a retrospective observational study of a prospectively collected database compared
SADI-S/OADS (n=42) with OAGB-MGB (n=49) as a rescue procedure for postsleeve weight recidivism. Drop in BMI and improvement in obesity-related comorbidities were similar for both procedures, although the percentage of total weight
loss (%TWL) was slightly higher in SADI-S/OADS patients (26.4 vs. 21.2, SADI-S/
OADS vs. OAGB-MGB, respectively) at 18-month follow-up. The complication
rate was slightly lower in the SADI-S/OADS group (19% vs. 27%), but without
statistical difference when compared to the OAGB-MGB group. Also, postoperative
nutritional deciencies were comparable in both groups, and no mortality was
reported. These similar global outcomes are quite reasonable, since OAGB-MGB is
seen as hypoabsortive operation by several bariatric surgeons. If, on the one hand,
gastrojejunostomy appears to be technically easier than a duodenoileostomy, preserving the pylorus can prevent side effects such as biliary reux and dumping syndrome. In addition, the technical design of OAGB-MGB is based on proximal
exclusion (usually 200cm), while SADI-S/OADS is based on distal inclusion (usually 250–300cm), making the lengths of the afferent and efferent loops very different in some cases. In this study, the efferent loop in SADI-S/OADS group was
250–300 cm in length, and the extent of the exclusion (afferent loop) remained
unknown. Conversely, in OAGB-MGB group, the afferent loop was 150–250cm in
length, no matter of the length of the efferent loop. Interestingly, the authors reported
38 Conversion ofSleeve Gastrectomy toDuodenal Switch andSADI-S
363
two OAGB-MGB patients underwent a second revisional surgery due to WR, specically the SADI-S/OADS [28].
Another interesting comparison is between planned and unplanned duodenal
switch surgery after SG.A retrospective matched study with a minimum follow-up
of 2years (mean of almost 5 years) showed that the staged BPD-DS for management of poor weight loss after SG had similar outcomes regarding weight loss,
obesity-related comorbidity control, and complications than primary
BPD-DS.Revisional surgery after SG was considered when patients were meeting
one of the following criteria: excess weight loss (EWL) less than 50%, weight
regain of 25% of EWL, for the management of a potentially reversible comorbidity,
or reached a weight plateau at an unsatisfactory level. The same limb lengths were
used for one- and two-stage duodenal switch, that is, alimentary limb of 150cm and
common channel of 100cm. After conversion, an additional 41% EWL and 35% of
remission rate for diabetes were obtained in this group of patients, reaching similar
rates as primary BPD-DS.Although the loss of a statistically signicant difference
between EWL rates has been achieved after 2years of conversion, the weight loss
curves of the two procedures equaled at the 81% EWL level at 72months postoperatively. In this period, data were only available in 28% of the patients who underwent staged BPD-DS.There was no signicant difference in protein malnutrition
and nutritional deciency rates between the two groups. Likewise, no signicant
difference in complication rates was observed between the different approaches,
including for the overall complication rate for staged BPD-DS [39].
Similar safety and effectiveness rates also seem to be also applicable when comparing planned and unplanned SADI-S/OADS.A multicenter retrospective study
compared ninety-three 2-stage SADI-S/OADS patients, or because of weight loss
failure after SG (n = 64; unplanned) or as a surgical strategy for super obesity
(BMI>50kg/m2) (n=29; planned). The time elapsed since SG was predictably
shorter in planned than unplanned surgical group (8.9months vs. 46months, respectively), and the planned patients were obviously heavier at baseline (48.6kg/m2 vs.
40.1kg/m2, respectively). Prior to conversion, none of the patients with failed SG
had apparent dilation of sleeve seen in the armed assessment; therefore, only the
intestinal step was performed in the entire series. After 24months of the second
stage, data on weight loss were available in just over half of the patients (52.9%).
Nonetheless, about 65% of EWL was observed in both groups, with no statistically
signicant difference between planned and unplanned two-stage SADI-S/
OADS.Similar rates of resolution of comorbidities and low rates of complications
have also been observed [40].
38.6 Summary
The conversion (or second stage) of the SG into duodenal switch surgery, whether
by one- or two-anastomosis, appears to be quite safe and provides sustained obesity
control. Accordingly, duodenal switch surgery should be considered the natural rescue procedure for a failed sleeve, mainly because the sleeve is already part of the
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A. C. Ramos and E. L. D. S. Bastos
original surgical technical design. The limited acceptance among bariatric surgeons
so far may be explained by the feared postoperative side effects of malabsorption
and the greater technical demand. In this regard, the promising widespread use of
SADI-S/OADS may partially overcome this barrier and increase the accomplishment of duodenal switch surgery as a suitable option for failed SG in the near future.
Key Learning Points
• Both BPD-DS and SADI-S should be naturally seen as following procedure after
failed SG, since the sleeve gastrectomy is already part of the original technical
design of the duodenal switch surgery. The sleeve can be left untouched in most
cases, saving operative time and reducing the rate of sleeve staple-line-related
complications.
• Conversion (or second stage) from sleeve to BPD-DS or SADI-S for inadequate
weight loss or weight regain seems to have encouraging outcomes in the short-
and mid-term. However, robust long-term data is still lacking.
• Unplanned BPD-DS and SADI-S in sleeved patients with failure to control obe-
sity disease appear to be as safe and effective as primary or planned two-stage
duodenal switch surgery.
• Despite the consensus among expert surgeons regarding the higher effectiveness
of duodenal switch surgery over gastric bypass, the general bariatric community
seems more comfortable with gastric bypass as a rescue procedure for failed SG.
• The less technical demand of the one-anastomosis duodenal switch (SADI-S/
OADS) can potentially help to increase the acceptance of this technical option by
bariatric surgeons in the near future.
• Revision of failed SG to the different modalities of duodenal switch surgeries
should preferably be performed by trained and experienced surgeons at referral
centers.
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