Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 541 - файл
.pdf
2 Duodenal Switch: Mechanisms ofFunctioning
19
In the rst years of the present century, the sleeve gastrectomy was reborn as a
single standing weight loss operation [3]. Some reasons contributed, and probably
the most important was its simplicity. But another important reason was that the
observed weight loss was greater than expected; greater than that obtained with
similar operations performed in the past, as it was the vertical banded gastroplasty
or the Magenstrasse and Mill operation introduced by Johnston [4, 5]. The achieved
weight loss with a sleeve gastrectomy was quite close to that obtained after a Rouxen- Y gastric bypass. The main difference between the sleeve gastrectomy and those
old operations was the removal of the fundus instead of leaving it separated from the
new gastric pouch. The fundus of the stomach is one of the places where the orexigen hormone ghrelin is secreted. It is true that ghrelin is also produced in the small
intestine, the testicles, placenta, liver, or central nervous system, but when the fundus is removed, the levels of ghrelin are shown to drop drastically, and this seems to
be related to early satiety and successful weight loss [6].
The decrease in ghrelin levels is a direct effect of the fundus resection. However,
there are other hormonal effects not directly related to resection of its production area,
as is the rise in glucagon like peptide-1 (GLP-1) secretion in patients submitted to
sleeve gastrectomy. This has been demonstrated by Vives etal. [7] and appears to be
related to the acceleration of gastric emptying after the sleeve resection combined
with the poor processing of ailments in the operated stomach. On one hand, the gastric resection decreases the rst processing of food, as there is no antral mill where the
particles are sieved into small ones that can be absorbed. In the other one, the rapid
gastric emptying delivers this poorly processed food into the distal small bowel, stimulating the secretion of GLP-1 which, among different actions, accelerates satiation.
The gastric resection decreases nutrient absorption at least partially. This is secondary to the limitation in the gastric phase of digestion. Secretion of pepsinogen,
pepsin, hydrochloric acid, etc., is reduced, and this limits the initial gastric digestion
of proteins and other nutrients, thus decreasing its absorption in the distal parts of
the small bowel. The decrease in acid secretion also decreases the reduction of cations into absorbable ions in the duodenum and proximal ileum, so iron and calcium
absorption is expected to be substantially reduced.
2.3 Pyloric Preservation
The preservation of the pylorus is an extremely important part of the operation. To
achieve a correct functioning of the valve we advocate a complete vascular and
neural preservation, what means avoiding dissection at the lesser curve of the
antrum and duodenum, leaving the right gastric artery untouched. The motor
branches of the vagus nerve to the pylorus typically arise from the hepatic branch,
which is a division of the anterior vagus nerve, and accompany the right gastric
artery to reach the pylorus and innervate both this muscle and the proximal part of
the duodenum [8]. Division of the right gastric artery will, invariably, also sever
pyloric innervation.
20
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. Sánchez-Pernaute et al.
To improve mobilization of the duodenum with preservation of the lesser omentum, a full detachment of the posterior wall from the pancreatic surface must be
achieved, while dissection should go beyond the gastroduodenal artery down to the
common bile duct level. At this point is where the lesser omentum has to be incised
to warrant full mobilization of the proximal duodenal stump without eliminating
vascularization or innervation (Fig.2.2).
Empirically we speculate that if the pylorus regulates gastric emptying, and if
gastric emptying regulates the incretinic response, the preservation of a normally
functioning pylorus has to be important in the regulation of the metabolic syndrome,
especially in diabetic patients [9]. The regulation of gastric emptying has the great
advantage of the elimination of the dumping syndrome, which has been linked to
bariatric operations since the very rst development of the gastric bypass. Dumping
syndrome has been considered an adjuvant effect for weight loss, helping patients
to abandon sweet-eating due to the unpleasant effect of the rapid gastric emptying.
The post pyloric anastomosis eliminates this undesired complication improving the
quality of life without affecting weight loss.
Another advantage, that is not empiricism, and has been thoroughly demonstrated, is the great benet in terms of long-term complications of a postpyloric
anastomosis. The alkaline mucous secretion of the duodenum protects the anastomosis from ulceration and stricture, complications seen frequently in the gastrojejunal anastomosis of the Roux-en-Y gastric bypass. Even in heavy smokers no
such complications are observed affecting the proximal anastomosis of the duodenal switch. The duodenal mucous secretion tamponade is not the only protection
against anastomotic problems, as was demonstrated by the group of DeMeester in
1992, when they reported that a postpyloric anastomosis favored gastric emptying
and maintained a normal gastric acid secretion, while on the other hand, a prepyloric one was related to a delay in gastric emptying and a greater—probably secondarily—gastric acid secretion with frequent anastomotic ulcer formation [10].
Fig. 2.2 Complete
duodenal dissection with
preservation of lesser curve
vascularization and
innervation. CBD common
bile duct; RGA right gastric
artery; GDA
gastroduodenal artery
2 Duodenal Switch: Mechanisms ofFunctioning
21
2.4 Biliopancreatic Diversion
The term biliopancreatic diversion is referred to the separation of bile and pancreatic juices from the area of the intestine where the aliments pass initially. The limb
carrying these secretions will come together with the limb transporting the aliments
distally in the small bowel, thus differing absorption to the distal intestine. Scopinaro
introduced this concept of division of the small bowel to reduce the problems
derived from the presence of a long blind limb, by anastomosis this one to the proximal stomach. In this way three different limbs could be distinguished: the alimentary one, the biliopancreatic, and the common channel, this last one being where
absorption will mainly take effect [11–13]. This diversion was applied also to the
Mason’s gastric bypass at the end of the 1970s by Ward O Griffen [14]. The difference between both types of surgery laid on the long biliary limb and short common
channel characterizing the biliopancreatic diversion.
Duodenal switch, as was Scopinaro’s operation, consists on a limited, usually
200–250cm, alimentary limb in which only a short amount of starch and proteins is
absorbed, while water, electrolytes, and hydrosoluble vitamins absorption is maintained. As the alimentary limb commences usually at the level of the proximal
ileum, little if any hexose receptors are present at the mucosal surface, so absorption
of hexoses is drastically reduced, what appears to be an early control mechanism of
glycemia in diabetic patients.
Bile and pancreatic juices circulate through all the jejunum, losing part of their
power to contribute in the absorption of proteins and fat, and come together with the
ingested nutrients at 60–100cm from the ileocecal valve, where the common channel starts. The length of the common channel warrants the maintenance of the
entero-hepatic cycle, and, on the other hand, limits caloric absorption to not more
than 1500 Kcal per day, independently of the amount of the intake [15].
The duodenal switch is possibly the most powerful metabolic operation, along
with the Scopinaro procedure, as it gathers most of the mechanisms implied in the
remission of diabetes: the bypass of the duodenum and pancreatic regions (foregut
hypothesis); the emptying of the rst duodenal portion directly into the ileum, what
causes early satiety and cooperates with gastric restriction, but also avoids contact
of glucose with sodium glucose transport protein (SGLT) receptors; the stimulation
of Takeda receptors in the intestinal L cells, what increases GLP-1 secretion; and
the selective fat malabsorption, which secondary depletes liver fat deposits and also
intra-myocyte fat, both related to insulin resistance and diabetes.
GLP-1 is probably the most amazing hormone related to obesity and obesity
surgery. Its study has helped to develop powerful drugs currently used to treat obesity and diabetes or as adjuvant therapy to bariatric surgery. GLP-1 secretion is
directly related to the amount of calories ingested, mainly carbohydrates. It is
22
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. Sánchez-Pernaute et al.
degraded by dipeptidyl peptidase-4 (DPP4). It enhances glucose-dependent insulin
release and inhibits gastric emptying. It probably also has a direct effect on appetiteregulating centers in the central nervous system, as it also has an effect during starvation. A rise in postprandial levels of GLP-1 is detected in patients submitted to
duodenal switch, as well as in patients submitted to other types of malabsorptive
operations [16]. Other intestinal peptides related to weight loss and metabolic
improvement after duodenal switch and other bariatric surgeries are oxyntomodulin, which acts as GLP-1 inhibiting gastric emptying and reducing food intake, peptide YY (3–36), also liberated by the L cells in the ileum, but not so potent as
GLP-1, and neurotensin, which is directly related to lipid absorption and insulin
sensitivity and increases higher after biliopancreatic diversions than after the standard Roux-en-Y gastric bypass [17].
Malabsorption-based operations do not enjoy a good press, in some respects
deservedly; wrongly selected patients and non-compliant patients can have a highly
impaired quality of life, mainly because of diarrhea and malnutrition. In a large
series of experienced groups, these represent less than 5% of the cases, and those are
because patients are thoroughly selected and followed, and supplementation is
maintained from the early postoperative period [18]. Nutritional recommendations
for patients undergoing duodenal switch include at least a total daily protein intake
between 60 and 120g of pure protein, 1–1.5g/kg of ideal weight; fat should never
exceed 30–35% of total caloric amount, as 20g daily is enough to warrant the
absorption of essential fatty acids and an adequate function of the gallbladder.
Vitamin D, calcium, and iron are the usually recommended supplementation, and
sometimes also vitamins A and E.
2.5 Conclusion
Duodenal switch includes virtually all mechanisms involved in weight loss and
metabolic improvement after a bariatric operation. Intake restriction, changes in
bile acids and peptide secretion, and a controlled limitation to absorption are all
present in this highly effective operation. Selection of patients and an adequate performance of the surgical technique to decrease postoperative and long-term complications should warrant a satisfactory and maintained long-term effect.
2 Duodenal Switch: Mechanisms ofFunctioning
23
References
1. Hess DS, Hess DW, Oakley RS. The biliopancreatic diversion with the duodenal switch:
results beyond 10 years. Obes Surg. 2005;15:408–16.
2. DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrck TC, Marcus JN.Experimental and
clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric
reux. Ann Surg. 1987;206:414–26.
3. Regan JP, Inabnet WB, Gagner M, Pomp A.Early experience with two-stage laparoscopic
Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg.
2003;13:861–4.
4. Mason EE.Vertical banded gastroplasty for obesity. Arch Surg. 1982;117:701–6.
5. Johnston D, Dachtler J, Sue-Ling HM, King RF, Martin IG.The Magenstrasse and Mill operation for morbid obesity. Obes Surg. 2003;13:10–6.
6. Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX, Zacherl J, Wenzl E, Schindler
K, Luger A, Ludvik B, Prager G.Sleeve gastrectomy and gastric banding: effects on plasma
Ghrelin levels. Obes Surg. 2005;15:1024–9.
7. Vives M, Molina A, Danús M, Rebenaque E, Blanco S, París M, Sánchez A, Sabench F, Del
Castillo D.Analysis of gastric physiology after laparoscopic sleeve gastrectomy (LSG) with or
without antral preservation in relation to metabolic response: a randomised study. Obes Surg.
2017;27:2836–44.
8. Skandalakis LJ, Gray SW, Skandalakis JE.The history and surgical anatomy of the vagus
nerve. Surg Gynecol Obstet. 1986;162:75–85.
9. Roslin M, Damani T, Oren J, Andrews R, Yatco E, Shah P.Abnormal glucose tolerance testing
following gastric bypass demonstrates reactive hypoglycemia. Surg Endosc. 2011;25:1926–32.
10. Welch NT, Yasui A, Kim CB, Barlow AP, Hinder RA, DeMeester TR, Polishuk PV, Adrian
TE.Effect of duodenal switch procedure on gastric acid production, intragastric pH, gastric
emptying, and gastrointestinal hormones. Am J Surg. 1992;163:37–45.
11. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V.Bilio-pancreatic bypass for obesity: I.An experimental study in dogs. Br J Surg. 1979;66:613–7.
12. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V.Bilio-pancreatic bypass for obesity: II.Initial experience in man. Br J Surg. 1979;66:618–20.
13. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V.Two years of clinical experience
with biliopancreatic bypass for obesity. Am J Clin Nutr. 1980;33:506–14.
14. Griffen WO Jr, Young VL, Stevenson CC.A prospective comparison of gastric and jejunoileal
bypass procedures for morbid obesity. Ann Surg. 1977;186:500–9.
15. Scopinaro N.Biliopancreatic diversion: mechanisms of action and long-term results. Obes
Surg. 2006;16:683–9.
16. Hellström PM.Satiety signals and obesity. Curr Op Gastroenterol. 2013;29:2222–7.
17. Von Loeffelholz C, Castagneto Gissey L, Schumann T, Henke C, Kurzbac A, Struck J,
Bergmann A, Hanefeld M, Schatz U, Bornstein SR, Casella G, Mingrone G, Birkenfeld
AL.The anorexigenic peptide neurotensin relates to insulin sensitivity in obese patients after
BPD or RYGB metabolic surgery. Int J Obes. 2018;42:2057–61.
18. Biertho L, Lebel S, Marceau S, Hould FS, Julien F, Biron S.Biliopancreatic diversion with duodenal switch: surgical technique and perioperative care. Surg Clin North Am. 2016;96:815–26.
Chapter 3
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Duodenal Switch andIts Derivatives
Yen-YiJuo andRanjanSudan
3.1 Introduction
Despite the relative popularity of Roux-en-Y gastric bypass and sleeve gastrectomy
[1], DS results in both the greatest magnitude of excess weight loss and the most
reliable resolution of comorbidities, especially type II diabetes [2].
However, duodenal switch is currently not widely practiced. As of 2019, DS
accounted for only 0.9% of all bariatric surgeries performed in the USA [3]. This is
likely a result of factors such as the performance of DS requires both advanced laparoscopic technical skills, expert judgement in patient selection, and reliable follow up for nutritional parameters. Also, the procedure is generally perceived as having
higher peri-operative complications as well as increased risks of long-term nutritional deciencies [4].
Nevertheless, DS is recently enjoying a resurgence of clinical interest, partly due
to the spread of advanced laparoscopic skills, and, perhaps most importantly, the
rising prevalence of super morbid obesity (BMI>50kg/m2) [5] and weight recidivism after sleeve gastrectomy [6]. Due to these reasons, we believe that DS should
continue to be in the arsenal for high-volume bariatric surgeons.
In this chapter, we seek to provide an in-depth overview of the pre-operative,
procedural, and post-operative clinical management of patients undergoing DS surgery or one of its derivative procedures.
Y.-Y. Juo · R. Sudan (*)
Department of Surgery, Duke University School of Medicine, Durham, NC, USA
e-mail: yenyi.juo@duke.edu; ranjan.sudan@duke.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_3
25
26
Y.-Y. Juo and R. Sudan
3.2 History
Biliopancreatic diversion was initially described by Scopinaro etal. as a combination of two procedures: a partial gastrectomy and distal intestinal bypass. The partial gastrectomy involves a creation of a 250 mL gastric pouch and the distal
intestinal bypass creates a 50cm common channel and a 250 cm alimentary limb
[7]. This procedure was subsequently modied due to the relatively high rate of
dumping and marginal ulcers. The modernized version of this procedure, also
known as biliopancreatic diversion with duodenal switch (BPD-DS), involves the
creation of a sleeve gastrectomy, thereby preserving the pylorus, and the creation of
a duodenal-ileal anastomosis [8]. This would allow preservation of the pylorus and
reduce the parietal cell mass, leading to decreased rates of dumping and ulcer
formation.
3.3 Derivative Procedures ofDuodenal Switch
While early reports of BPD-DS were of open surgery, Ren etal. described the earliest laparoscopic BPD-DS [9] and our group reported the rst report of roboticassisted BPD-DS in 2000 [10]. With the evolution and advancement of robotic
technology, this technique has evolved from a hybrid procedure to a totally robotic
technique. By docking the robot one time, there is less dependence on a bedside
assistant and improved efciency within the operation. This book chapter describes
and illustrates the robotic-assisted BPD-DS technique utilized by our group since
November 2011.
Besides the advance in minimally invasive surgical approaches, the recent evolution of BPD-DS has developed several derivative procedures. The most popular
derivative procedure is the adoption of sleeve gastrectomy as a standalone bariatric
procedure, the details of which will be described in a separate chapter in this book.
One other variation of BPD-DS that has gained increasing attention is the SADI-S
(single-anastomosis duodeno-ileal bypass with sleeve gastrectomy), also known
simply as “SADI,” “loop DS,” or “SIPS” (stomach intestinal pylorus sparing). SADI
was rst described by Sanchez-Pernaute etal. in 2007 [11]. The main differences
between SADI and a formal BPD-DS are the omission of the ileo-ileal anastomosis,
thus converting the Roux-en-Y conguration of the duodeno-ileostomy into a loop
conguration and the alimentary limb lengths.
Whether it is appropriate to abandon the Roux construction is one of the most
contentious debate subjects among bariatric surgeons. Many surgeons are concerned about the potential for bile reux from a loop duodeno-ileostomy. In fact,
3 Duodenal Switch andIts Derivatives
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
27
duodenal switch was initially described as a treatment for bile reux gastritis [12].
On the other hand, some argue that SADI anatomy actually reduces bile reux gastritis in comparison with normal anatomy, because bile will rst be diluted and
partially absorbed as it travels through several meters of the small intestine before
reaching the area of the anastomosis. Furthermore, bile must resist the forward peristalsis of the small intestine and reux through the anastomosis and the pylorus
before reaching the gastric mucosa. Currently there is no strong evidence supporting the claim that bile reux from SADI anatomy could cause gastric dysplasia and
esophageal cancer [13].
On the other hand, SADI is attractive to modern surgeons due to the creation of
a longer common limb, lessening the fears of some regarding the malabsorptive
risks of formal BPD-DS.In fact, many see it as a “milder” version of BPD-DS.It
has been endorsed by american society of metabolic and bariatric surgery (ASMBS)
as an appropriate metabolic bariatric procedure, with caution advised regarding
concerns about intestinal adaptation, nutritional issues, optimal limb lengths, and
long-term outcomes [14]. Short-term weight loss efcacy appears comparable
between SADI and BPD-DS, but recent studies are demonstrating signicantly
inferior total body weight loss and excess weight loss for SADI than formal
BPD-DS.On the other hand, there is also a lower incidence of protein deciency
and bowel obstruction after SADI than formal BPD-DS [15].
3.4 Pre-operative Consideration
3.4.1 Indications forSurgery
No consensus indications for BPD-DS exists outside that of those for bariatric surgery based on the 1992 National Institutes of Health Consensus Development
Conference Statement, namely, BMI greater than or equal to 40kg/m2 or a BMI of
35kg/m2 or greater with signicant medical comorbidities [16]. However, BPD-DS
is often reserved for patients with BMI over 50kg/m2 [17] or poorly controlled
metabolic diseases [18].
As with any bariatric procedure, a multidisciplinary evaluation is necessarily
pre-operatively. This includes a medical, nutritional, and psychological evaluation.
The medical evaluation includes a comprehensive laboratory evaluation, preoperative electrocardiogram, and chest X-Ray. Additional preoperative tests are performed on an individualized basis and beyond the scope of this chapter but the
readers are referred to a detailed publication on the subject [19]. Pre-operative
weight loss is frequently recommended with either the patient’s primary care physician or with the bariatric surgeon.
28
Y.-Y. Juo and R. Sudan
3.4.2 Contraindications
Some contraindications to BPD-DS are similar to bariatric surgery in general, such
as inability to tolerate general anesthesia, non-correctable coagulopathy, preexisting
malabsorptive disorder such as inammatory bowel disease or celiac disease, or
active malignancy.
Relative contraindications to BPD-DS include severe gastroesophageal reux,
which may be worsened by the sleeve gastrectomy anatomy, according to some
[20]. Furthermore, due to the relatively higher incidence of malnutrition after surgery, a higher standard for psychosocial ability to comply with postoperative
instructions is necessary. BPD-DS candidates need to demonstrate adequate social
support, full understanding of nutritional consequences of the procedure, ability to
maintain close follow-up, and absolutely no active alcohol or substance abuse.
Furthermore, the patient needs to demonstrate willingness and nancial ability to
obtain the necessary nutritional supplementations on a long-term basis after surgery.
3.5 Procedural Details
3.5.1 Patient Positioning andPort Placement
The patient is placed in a supine with position, with the arms spread out at right
angles and the legs together. Secure strapping of the patient and a footboard is mandatory, as a steep reverse-Trendelenburg position will be necessary during portions
of the procedure involving the upper abdomen. Extremities are padded meticulously
to prevent skin breakdown or neuropathy from pressure. The operating surgeon
stands to the patient’s right side for the majority of the case while the assistant
stands to the patient’s left. The scrub nurse stands at the foot of the bed next to the
assistant.
Peritoneal access is obtained based on surgeon preference. In our practice, we
routinely create pneumoperitoneum with a Veress needle (Medtronic, Norwalk, CT)
at the Palmer’s point before entering the peritoneal cavity under direct visualization
with an 8mm optical trocar in the supraumbilical midline, approximately 15cm
below the xiphoid process. Port positions are described for the Xi version of the
Intuitive Surgical robot. A 12mm accessory laparoscopic port for the bedside assistant is placed in the left and right subcostal area. Additional 8mm robotic ports are
placed in the left anterior axillary line (arm 1), right midclavicular line (arm 3), and
the right anterior axillary line (arm 4). The camera is in the supraumbilical position
and docked to arm 2 (see Fig.3.1).
3 Duodenal Switch andIts Derivatives
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 3.1 Port position
illustration. Arm 1 at the
right anterior axillary line,
arm 2 at the right
midclavicular line, and arm
4 at the left mid clavicular.
Arm 3, the camera port, is
in the midline. Liver
retractor (LR) is at the
subxiphoid area slightly
left of midline. An assistant
port for laparoscopic
instrument access is placed
in the left subcostal area
between arm 3 and 4
29
3.5.2 Laparoscopic Portion
The patient is rst placed in Trendelenburg position to allow identication of the
terminal ileum. With laparoscopic instruments, the ileum is measured in a retrograde manner from the ileocecal valve, until marking stitches could be placed at 100
and 250cm from the ileocecal valve. We then anchor the small bowel at the 250cm
mark to the anterior abdominal wall, in the right upper quadrant, in proximity to the
duodenum. This allows it to be easily identied when fashioning the duodeno-ileal
anastomosis later (see Fig.3.2).
We then place the patients in a steep reverse-Trendelenburg position for placement of a Nathanson retractor before docking the robot from the patient’s right ank.
3.5.3 Cholecystectomy
Due to the anticipated dramatic weight loss and the wasting of bile, patients often
have cholelithiasis or choledocholithiasis after BPD-DS [21], therefore, we have
adopted it as standard practice to perform concomitant cholecystectomy during BPD-DS.
Соседние файлы в папке @xirurgi_2025