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38 Conversion ofSleeve Gastrectomy toDuodenal Switch andSADI-S
38. Ceha CMM, van Wezenbeek MR, Versteegden DPA, Smulders JF, Nienhuijs SW.Matched shortterm results of SADI versus GBP after sleeve gastrectomy. Obes Surg. 2018;28(12):3809–14.
https://doi.org/10.1007/s11695- 018- 3415- 5.
39. Biertho L, Thériault C, Bouvet L, Marceau S, Hould FS, Lebel S, etal. Second-stage duodenal switch for sleeve gastrectomy failure: a matched controlled trial. Surg Obes Relat Dis.
2018;14(10):1570–9. https://doi.org/10.1016/j.soard.2018.05.008.
40. Zaveri H, Surve A, Cottam D, Ng PC, Enochs P, Billy H, etal. A multi-institutional study
on the mid-term outcomes of single anastomosis Duodeno-ileal bypass as a surgical revision
option after sleeve gastrectomy. Obes Surg. 2019;29(10):3165–73. https://doi.org/10.1007/
s11695- 019- 03917- 1.
367
Chapter 39
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Gastric Band Revision toDuodenal Switch
MohitBhandari, ManojReddy, ShashankTrivedi, SusmitKosta,
andWinniMathur
39.1 Introduction
In 1993, Belachew etal. rst described the laparoscopic placement of an adjustable
gastric band (LAGB). After approval by the FDA in 2001, Lap-Band, a laparoscopic
adjustable gastric band (LAGB), became very popular as weight loss procedure
across the globe, by the end of the rst decade of the century. With the time, the
research-proven complications, risks associated with procedure, and limited benets in the long term are the reason for decline in following decade. Complications
encountered after LAGB include band slip, band erosion, complications with the
port or tubing and, more often, failure to achieve required weight loss along with
resolution of co-morbidities, requiring removal and revision.
Compared with other obesity operations, failure rates for LAGB are reported to
be as high as 40–50% with revision rates of 20–30% [1–3]. One such study of Asian
population has reported reoperation rate of 25% after LAGB [4]. Inadequate weight
loss and surgical complications are main indications for reoperation following primary LAGB.Many options for conversion procedure are available and studied, such
as laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass
(LRYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).
In 1987, DeMeester and colleagues described the duodenal switch procedure
(DS), as a surgical resolution for bile reux, primary or post gastrectomy/gastroduodenostomy. Further, Hess introduced this procedure with Scopinaro’s BPD, as
restrictive and malabsorptive procedure for morbid obesity by performing 75%
M. Bhandari (*) · M. Reddy · S. Trivedi · S. Kosta
Mohak Bariatrics and Robotics Surgery Center, Sri Aurobindo University,
Indore, Madhya Pradesh, India
W. Mathur
© 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_39
369
370
longitudinal gastrectomy (to reduce acid secretion and to reduce volume) and extension of the Roux limb (to decrease absorption).
Although BPD/DS showed promising results, high technical expertise required
to perform laparoscopy and feared metabolic complication (protein-calorie malnutrition and other nutrient deciencies) due to malabsorptive property of the procedure remain the reason for slow popularity, contrary to LAGB, which gained
widespread and speedy popularity.
As a primary bariatric procedure when combined. BPD/DS) is the most effective
procedure concerning the mean percentage of excess weight loss (70%) and decrease
in obesity-related co-morbidities (80%) [5–8]. The results of conversion after LAGB
failure have been studied by different authors. A study of laparoscopic revision from
Lap-Band to duodenal switch showed that it is a safe and more effective alternative
to gastric bypass who have failed Lap-Band procedure [9], whereas another such
study concluded that weight reduction was not more benecial than with laparoscopic RYGB, although procedure-specic nutritional problems were more common after BPD/DS [10]. This chapter aims to share our data outcomes and experience
of BPD/DS as a revision procedure after failed LAGB as primary procedure.
M. Bhandari et al.
39.2 Materials andMethods
At our centre, post LAGB, revision procedures were considered for patients who
had failed to attain 25% excess weight loss (%EWL) at the end of 3years. Patients
who had complications related to band were excluded from the study. Patients who
were not operated at our centre, but presented with failure after LAGB, were also
included in this study.
The BPD/DS was chosen as a revision procedure, after discussion with patients,
because it shows promising results in terms of weight reduction and resolution of
obesity-related co-morbidities.
All patients were evaluated preoperatively and postoperatively by the multidisciplinary team (nutritionists, endocrinologist, surgeons, physician, pulmonologist,
anaesthetist and psychiatrist).
Factors that were taken into account for deciding BPD/DS as a revisional procedure
were age of the patient, BMI at the time of the primary procedure (i.e. gastric banding),
related co-morbidities, absence or presence of a large hiatal hernia, the ability to take
multivitamin and mineral supplements on a long-term basis and having type 2 diabetes
mellitus with C-peptide levels below 3 or history of diabetes more than 10years.
39.3 Preoperative Preparation
Patients were assessed for pre-LAGB BMI and associated co-morbidities. Post
LAGB nadir weight loss achieved BMI Prior to revision. All patients received counselling for success rate of revisional procedure and their compliance post
BPD-DS.Along with blood screening, plain radiographs and contrast studies of the
39 Gastric Band Revision toDuodenal Switch
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371
upper abdomen were done, and we performed intra-op upper GI endoscopies with
carbon dioxide for insufations. Deep vein thrombosis (DVT) prophylaxes were
given to all patients, as a routine protocol, either in the form of compression stockings, DVT pumps and low molecular weight heparin.
39.4 Surgical Technique
The technique starts with band removal involving full dissection of the band.
Mobilization of greater curvature of the stomach starts rst towards OGJ.The mobilization continues further down to the gastroduodenal artery or 3cm from the pylorus (whichever comes rst). In order to avoid any bleeding or tears, meticulous and
careful dissection is necessary around the duodenum. After mobilization, the duodenum is transected using a stapling device. After the transection procedure, it continues with gastric resection to create a loose sleeve with the bougie size 38 and
over. The common limb (CL) measurement starts at the ileocecal junction without
stretching the bowel. A suture marker is placed at 350cm, indicating what is to
become the CL.The small bowel is transected using a linear cutter stapler 150cm
from the ligament of Treitz indicating BP limb. The mesentery is partially divided
with the harmonic scalpel. The biliopancreatic limb (BPL) and AL are joined by a
side-to-end anastomosis at the 350cm marker. Now an alimentary limb is brought
up for hand-sewn duodeno-ileal anastomosis. Hernial spaces are closed.
39.5 Results
Nine patients underwent BPD/DS) after unsuccessful LAGB was 3years. Mean age
was 44.3 ± 3.4 years (range, 25–62), with 22.2% men. Their pre-LAGB mean
weight was 132±4.5 and mean preoperative BMI was 51.4±4.3kg/m
and the mean excess weight was 63±13kg. The pre-BPD/DS mean body weight
was 125± 19 kg, the mean BMI was 47.1 ± 6kg/m2, and the excess weight was
58± 12kg. Two patients (22.2%) were lost to follow-up. The number of patients
with complete follow-up at 6 six years was seven patients. The reasons for the loss
to follow-up were migration for one and unknown for one patient.
The primary endpoint was the mean %EWL as a measure of the efcacy of BPD/
DS after LAGB failure. Concurrently, the BMI decreased from 42.5±6kg/m2 to
30 ± 4.9 kg/m2 in 6 years. The initial mean body weight before LAGB was
Table 39.1 Demographic data
Age (years) 44.3±3.4
Gender M:F 9 (77.8%): 2 (22.2%)
Weight (kg) 132±4.5
BMI (kg/m
Characteristic
2
) 47.1±6
2
(Table39.1),
372
140
120
100
Pre OP WT
42.5 kg (71.2%)
After LAGB WT After BPD/DS
80
Years
%EWL
M. Bhandari et al.
132±4.5kg and had decreased to 125±19kg after LAGB, for a %EWL of 18%.
The body weight decreased further after BPD/DS to 89.5 ± 11 kg after 6 years
(Fig.39.1). The total weight loss calculated from the period before BPD/DS to years
after BPD/DS was 35.5kg and corresponded to an additional %EWL of 55%. After
LAGB and subsequent band removal plus BPD/DS resulted in a total weight loss of
42.5kg with a %EWL of 71.2% (52.2%, 61.5%, 75.3%, 74.4%, 72.3% and 71.2%
at six, respectively shown in Fig.39.2). These results show that patients unsuccess-
fully treated with LAGB still responded well to BPD/DS.
132
80
60
40
20
0
7 kg (18 %)
125
Fig. 39.1 Weight loss pattern (after LAGB and after BDP/DS)
75
70
65
60
55
50
45
52.2
61.5
75.3
74.4
35.5 kg (55 %)
72.3
89.5
71.2
40
1yr 2yr 3yr
Fig. 39.2 After BPD/DS %EWL pattern
4yr 5yr 6yr
39 Gastric Band Revision toDuodenal Switch
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Table 39.2 Co-morbidities
Pre-OP LAGB BPD/DS
Resolution of
N N
T2D 3 1 2 (66%) 3 100%
HTN 4 2 2 (50%) 3 2 (66.6%)
OSA 7 5 5 (71%) 7 100%
DLS 6 5 5 (83.3%) 5 4 (80%)
OA 6 3 3 (50%) 4 2 (50%)
co-morbidities N
Resolution of
co-morbidities
373
Preoperatively, 33.3% (n = 3) had diabetes, 44.4% (n = 4) had hypertension,
77.7% (n= 7) had OSA, and 66.6% (n =6) had dyslipidaemia and OA.Weight
reduction after post-LAGB and BPD/DS, however, showed a clear tendency towards
a reduction in co-morbidities (Table39.2).
References
1. Gagner M, Gentileschi P, De Csepel J, Kini S, Patterson E, Inabnet WB, Pomp A.Laparoscopic
reoperative bariatric surgery: experience from 27 consecutive patients. Obes Surg.
2002;12(2):254–60.
2. Mittermair RP, Obermüller S, Perathoner A, Sieb M, Aigner F, Margreiter R. Results and
complications after Swedish adjustable gastric banding: 10 years’ experience. Obes Surg.
2009;19:1636–41.
3. Suter M, Calmes JM, Paroz A, Giusti V. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates. Obes Surg.
2006;16(7):829–35.
4. Wong SKH, Mui WLM, Ng EKW.Development of bariatric surgery: the effectiveness of a
multi-disciplinary weight management programme in Hong Kong. Ann Acad Med Singap.
2009;38:9–6.
5. Marceau P, Hould FS, Simard S, etal. Biliopancreatic diversion with duodenal switch. World
J Surg. 1998;22:947–54.
6. Buchwald H, Avidor Y, Braunwald E, etal. Bariatric surgery: a systematic review and metaanalysis. JAMA. 2004;292:1724–37.
7. O’Brien PE, McPhail T, Chaston TB, Dixon JB.Systematic review of medium-term weight
loss after bariatric operations. Obes Surg. 2006;16:1032–40.
8. Strain GW, Gagner M, Pomp A, etal. Comparison of weight loss and body composition
changes with four surgical procedures. Surg Obes Relat Dis. 2009;5:582–7.
9. Amit Surve MD, Daniel Cottam MD, Hinali Zaveri MD, Christina Richards MD, Walter
Medlin MD, Samuel Cottam CNA.Weight loss after conversion from laparoscopic band to
loop duodenal switch. Surg Obes Relat Dis. 2015;11:S56–S211.
10. Schouten R, Japink D, Meesters B, Nelemans PJ, Greve JW. Systematic literature review
of reoperations after gastric banding: is a stepwise approach justied? Surg Obes Relat Dis.
2011;7:99–109.
Chapter 40
Endoscopic Treatment ofWeight Regain
inDuodenal Switch
EduardoGrecco, ThiagoFerreirade Souza, ManoelGalvaoNeto,
LuizGustavode Quadros, andFernandaOliveiraAzor
40.1 Introduction
Obesity is a complex multisystemic disease with negative health implications, being
associated with comorbidities such as type 2 diabetes mellitus (DM2), arterial
hypertension, cardiac diseases, asthma, and obstructive sleep apnea, being the fth
risk factor for mortality in the world [1].
Lifestyle and dietary changes are ineffective in controlling obesity in the long term,
and bariatric surgery (BS) is more effective in maintaining weight loss [1]. However,
a degree of weight regain (WR) is common after patients reach their lowest weight,
with up to 20–25% of them facing an important struggle with WR after surgery—with
loss of quality of life and return of associated comorbidities. Despite this, insufcient
weight loss (IWL) is more frequent in the indication of revision surgeries [2].
E. Grecco · M. G. Neto
Instituto EndoVitta, São Paulo, Brazil
Faculdade de Medicina do ABC, Santo André, Brazil
T. F. de Souza
Instituto EndoVitta, São Paulo, Brazil
Faculdade de Medicina do ABC, Santo André, Brazil
Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
L. G. de Quadros (*)
Faculdade de Medicina do ABC, Santo André, Brazil
Kaiser Clínica, São José do Rio Preto, Brazil
Hospital Benecência Portuguesa, São José do Rio Preto, Brazil
F. O. Azor
Kaiser Clínica, São José do Rio Preto, Brazil
© 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_40
375
376
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E. Grecco et al.
It is essential to dene the difference between WR and IWL.IWL occurs when
the loss of excess weight (% EWL) is less than 50% in the 18 months after
BS.Weight regain is the progressive weight gain that happens after an initial weight
loss success. However, there is no consensus on these denitions, and further studies are needed to more uniformly delineate the clinical signicance of WR, indicating when an intervention would become necessary [2].
Among the several BS available, biliopancreatic deviation (BPD) is considered
the most effective, producing marked weight loss and reducing associated comorbidities [1].
Biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal
switch (BPD-DS) are bariatric surgeries used effectively in morbid obesity and
metabolic disorders composed of a restrictive and a disabsorptive mechanism.
However, they are techniques with prolonged operative time and a high rate of postoperative complications [3]. BPD was designed to be performed in a single step to
decrease the absorption of fats in a long-lasting manner, avoiding weight regain. In
BPD-DS, distal gastric resection was replaced by a vertical sleeve with preservation
of the pylorus, reducing possible side effects, such as rapid emptying. In the early
days, surgery was considered difcult to be performed in a single stage in very
obese patients, leading doctors to perform it in two stages, initially with resection of
the gastric sleeve without making the anastomosis, a technique that became popular.
Marceau etal. compared separate components of BPD-DS, including 48 DS and 53
vertical gastrectomies, studying the role of each component of the BPD-DS, and
concluded that each step contributes independently to a metabolic improvement [4].
BPD-DS preserves the antrum and pylorus, in addition to the rst part of the duodenum, avoiding initial complications associated with Scopinaro surgery such as marginal ulcers, vomiting, diarrhea, and micronutrient deciency [1].
To simplify the BPD-DS, in 2007, the single-anastomosis duodeno-ileal bypass
with sleeve gastrectomy (SADI-S) was created, a technique with a single anastomosis but maintaining the results and principles of the BPD-DS [3]. A non-randomized
study that followed the results of patients undergoing BPD-DS or SADI-S for
2 years demonstrated similar rates of diabetes remission, with similar metabolic
improvement and weight loss [3].
The rate of weight regain is low in these procedures, as they have a disabsorptive
component that is very difcult to circumvent. However, over time, intestinal adaptation can increase the absorption of carbohydrates with villous hypertrophy.
However, the cumulative incidence for IWL is very low compared to other techniques. Strain etal. evaluated 284 patients undergoing BPD-DS, and after 9years of
surgery, about 10.9% had IWL, with a rate of 2.2% in the rst year of follow-up [5].
The reasons for a new weight gain involve investigating psychological and nutritional issues, alcohol consumption, and new habits on the part of patients. This
context results in obesity but with nutritional complications, especially in the overweight [6].
Revisionary surgery in those with inadequate weight loss undergoing BPD-DS is
controversial, and there is no consensus on whether the joint loop should be reduced
or the volume of the gastric pouch. Due to the difculty of revising the distal
40 Endoscopic Treatment ofWeight Regain inDuodenal Switch
377
anastomosis, one option is to reduce the volume of the gastric sleeve. The revision
of the common loop length can lead to weight loss, however, at the expense of poor
protein nutrition. Weight loss may not occur and still cause complications. Studies
of weight regain in BPD-DS are scarce because, often, the performance of revision
surgery occurs due to protein malnutrition and excessive weight loss. Despite this,
Gagner etal. reported a case of revision surgery in a 47-year-old morbidly obese
woman (BMI=67kg/m2) who had undergone a laparoscopic BPD-DS, losing 80%
of her excess weight, with a resolution of several comorbidities after 17months.
However, she regained weight after this period (BMI=29kg/m2). After nding a
dilated pouch in a contrast examination, she underwent revision surgery to create a
new gastric sleeve with a 60F bougie. The patient evolved with weight loss, maintaining a BMI of 22kg/m2 and 61kg, 10 months after revision surgery, without
postoperative complications [7].
Revision surgery is helpful in patients with insufcient weight loss and those
with weight regain, but it can be a difcult task [8]. Endoscopic sleeve gastroplasty
(ESG) is a minimally invasive procedure that arises in this context and may be a less
invasive therapeutic alternative to reduce gastric pouch. Laparoscopic re-suture is a
valid option after an initial failure in LSG, and further studies are needed to analyze
the efcacy of the endoscopic technique and its importance in cases of WR associated with DS and SADI-S.
Topart and Becouarn, in a literature review, found sparse literature correlating
WR with BPD and BPD-DS, probably due to the low incidence of this adverse
event, with rates of 0.5–2.78% in BPD.In revision surgery, there is no consensus on
the size of the common loop. However, the common loop can be shortened as an
option, resulting in a smaller loop in contact with the ingested food or a reduction in
the gastric pouch [9].
Nedelcu etal. analyzed 61 patients who underwent laparoscopic re-sleeve after a
mean interval of 37.5months after the primary laparoscopic sleeve. Patients were
selected due to insufcient weight loss (28 patients), weight regain (29 patients),
and gastroesophageal reux disease (GERD) (4 patients). The re-sleeve was proposed after volumetric analysis of the gastric pouch, with cases of primary dilation
(dilated pouch in barium examination) and secondary (residual volume above
250mL after volumetric computed tomography study) being selected. All were submitted to laparoscopic re-sleeve without intraoperative complications. The average
BMI decreased from 39.4kg/m2 to 29.2kg/m2, with an average percentage of excess
weight loss (% EWL) of 58.3% (P<0.0004) [10].
In patients already submitted to previous LSG, reLSG can be indicated when the
CT scan volume method demonstrates a volume greater than 250cm3 of the remaining stomach. In smaller volumes, malabsorptive surgeries are indicated [11]. Thus,
in cases of BPD-DS and SAID-S, although there is no consensus, in the future, this
volumetric measure could guide the indications for endoscopic suture in the control of WR.
In a multicenter international cohort evaluated in 9 services, from 2014 to 2019,
Maselli etal. evaluated the data of 82 patients with weight regain after LSG who
underwent a revision endoscopic sleeve gastroplasty (R-ESG) with an OverStitch
378
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E. Grecco et al.
device (Apollo Endosurgery, Austin, Texas, USA). Of the sample, 92.7% were
women with an average age of 42.8 years and an average weight of 128.5 kg
(±57.5kg). The average number of sutures performed was four. After re-suturing,
the TBWL rate was 6.6%, 3.2% of which in the rst month, with 10% TBWL being
reached in 72.5% of the patients. Thus, it is concluded that R-ESG can assist in WR
after LSG before choosing more invasive revision surgeries [12].
In a prospective study by Neto etal., 233 patients from 4 bariatric centers in
Brazil, submitted to ESG using OverStitch, with grade I and II obesity, were evaluated for post-procedure weight loss, resulting in a 17.1% TWL in 6months and
19.7% in 12months [13].
In ESG, the endoscope is introduced to assess the dilated areas of the remaining
stomach, outlining the site to be sutured. The OverStitch system (Apollo
Endosurgery, Austin, Texas, USA) is then coupled to a double-channel endoscope.
The suture starts at the anterior wall, at the level of the anterior notch. Sutures start
from the distal body at the angular incisure to the proximal body. The procedure is
performed with the patient under general anesthesia [12, 13].
40.2 Conclusion
Weight regaining is not frequent in surgeries with a disabsorptive component such
as BPD, BPD-DS, and SADI-S because the disabsorption component is challenging
to transpose. However, even at low rates, it deserves attention and studies to nd the
best treatments.
ESG appears as an option in cases of remaining dilated stomachs, which may
contribute to the treatment of weight regain. It is a feasible alternative to revision
surgery, being a less invasive technique, avoiding new changes in the intestinal
loops already reorganized.
Further studies are needed to reach a consensus on the denitions of IWL and
WR—necessary to guide the diagnosis and better conduct in the presence of these
complaints in the postoperative period of bariatric surgeries.
Despite the weight regain, which occurs mainly in superobese, these patients,
because they have a disabsorptive component as a component of the bariatric surgery performed, may be at the same time obese due to a caloric increase ingest
however with a lack of essential nutrients, which may result in patients with high
weight but with nutritional problems. Thus, the investigation of psychological
causes, multidisciplinary assessment, and nutritional monitoring are fundamental in
the desired treatment.
ESG comes as a promising technology in cases of weight regains in disabsorptive surgeries. Studies involving the technique in the cases of WR and IWL of these
surgeries should be carried out to evaluate the benets of this therapeutic choice.
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