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43 Duodenoileal Anastomosis Testing
401
Its sensibility may be increased by occluding the distal aspect of the duodenoileal anastomosis with an atraumatic clamp. The inated ileal loop not only conrms
that the dye has effectively gone through the pylorus but also allows an adequate
pressure to be applied to the anastomosis. Injecting air through the tube after the
blue and placing a clean gauze all along the suture lines before the injection can also
increase the sensibility of the test, especially on the posterior aspect of the anastomosis, where leaks can be harder to detect.
43.3 Water-Air Leak Test (Fig.43.1a andb)
The water-air leak test requires a little more preparation than the blue test, as water
needs to ood the supramesocolic space, covering the anastomosis. It is recommended to position the patient in forced Trendelenburg to minimize the water
required to completely cover the suture lines. This way, bubbles escaping from the
lumen after air injection through a nasogastric tube would be easily identied.
As air escapes easily than liquid, air tests are believed to be more accurate than
blue tests, although there is no good-quality data to support that impression. On the
other hand, the exact location of the leak may be harder to identify.
Fig. 43.1 (a and b)
Water-air leak test
a
b
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R. Vilallonga et al.
43.4 Intraoperative Endoscopic Direct Visualization
Intraoperative endoscopic exploration allows to simulate an air test with the insufation of the endoscope and also to directly visualize the suture lines. It offers the
advantage to not only rule out the presence of a leak but also intraoperative bleeding
or any anastomotic stenosis or mucosal ischemia. On the down side, it requires the
equipment to be readily available in the operating room, as well as the proper
training.
43.5 Indocyanine Green Test andCombination ofBlend
andEndovascular Test (Fig.43.2a andb)
More recently, bariatric surgeons have been including a novel leak agent blend.
This novel blend is done with 2mL of methylene blue and 5mg of ICG [5]. This
blend is mixed in 100mL of sterile water and placed into a syringe. Then, the
anesthesiologists can inject all the content through a previously placed nasogastric
tube, at the level of the antrum of the stomach, blowing the stomach and the duodenoileal anastomosis. At this time of the procedure, ICG cameras must be
Fig. 43.2 (a and b)
Indocyanine green test and
a combination of blend and
endovascular test
a
b
43 Duodenoileal Anastomosis Testing
403
activated to detect any leaks coming from the lumen of the gastrointestinal tract at
the level of the anastomosis. After injecting all the content, another 50mL of air
could be injected, adding pressure to the test (Fig.43.2a). ICG should only be
detected inside the lumen of the gastrointestinal tract. Then the surgeon needs to
switch to a normal view of the camera, looking for blue on the surgical eld
(Fig.43.2b).
There is little experience with this kind of blend test in bariatric surgery. Hagen
etal. [5] reported 95 blend tests in RYGB, nding no test-related adverse event.
They observed four patients (4.2%) with an abnormal ICG leak, but not blue extravasation. However, the interpretation of these ndings is controversial. More data is
necessary to clarify if the use of the ICG camera adds some value when testing for
intraoperative leaks.
Another interesting characteristic of ICG is that it allows us to observe the
blood supply of the tissues. In that line, an interesting variation of the previously
described test would be adding 4mg of ICG intravenously, which would conrm
the adequate vascular supply of the duodenoileal anastomosis, that could be compromised in case of section of the right gastric artery (Fig.43.3). There is currently no meaningful data on using the ICG to check the vascularization of this
anastomosis, but this type of transoral and vascular test has been described previously in colorectal and esophagogastric surgery [10, 11] and seems to offer some
benet.
Nowadays, there is still a lack of technology when measuring ICG uorescence. It would be useful to quantify the emission, in order to objectively evaluate tissue vascularization and especially to determine if an anastomosis could be
in risk of postoperative leak according to the observed intraoperative images.
Novel technology of ICG uorescence in many elds is arising to determine its
utility in the future. Moreover, clinical aspects and biological parameters would
need to be estimated according to the general status of each patient [12, 13].
Fig. 43.3 Methylene
blue test
404
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R. Vilallonga et al.
References
1. Yolsuriyanwong K, Ingviya T, Kongkamol C, Marcotte E, Chand B.Effects of intraoperative
leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis
of the MBSAQIP database. Surg Obes Relat Dis. 2019;15(9):1530–40.
2. Al Zoubi M, Khidir N, Bashah M.Challenges in the diagnosis of leak after sleeve gastrectomy:
clinical presentation, laboratory, and radiological ndings. Obes Surg. 2021;31(2):612–6.
3. Burgos AM, Braghetto I, Csendes A, etal. Gastric leak after laparoscopic-sleeve gastrectomy
for obesity. Obes Surg. 2009;19(12):1672–7.
4. Csendes A, Braghetto I, León P, Burgos AM.Management of leaks after laparoscopic sleeve
gastrectomy in patients with obesity. J Gastrointest Surg. 2010;14(9):1343–8.
5. Hagen ME, Diaper J, Douissard J, Jung MK, Buehler L, Aldenkortt F, Barcelos GK, Morel
P.Early experience with intraoperative leak test using a blend of methylene blue and indocyanine green during robotic gastric bypass surgery. Obes Surg. 2019;29(3):949–52. https://doi.
org/10.1007/s11695- 018- 03625- 2. PMID: 30607685.
6. Sethi M, Zagzag J, Patel K, Magrath M, Somoza E, Parikh MS, etal. Intraoperative leak
testing has no correlation with leak after laparoscopic sleeve gastrectomy. Surg Endosc.
2016;30(3):883–91.
7. Nelson L, Moon RC, Teixeira AF, Jawad MA.Methylene blue or upper GI, which is more
effective for detecting leaks in gastric bypass patients? Surg Laparosc Endosc Percutan Tech.
2015;25(5):451–4. https://doi.org/10.1097/SLE.0000000000000191.
8. Causey MW, Fitzpatrick E, Carter P.Pressure tolerance of newly constructed staple lines
in sleeve gastrectomy and duodenal switch. Am J Surg. 2013;205(5):571–4. https://doi.
org/10.1016/j.amjsurg.2012.12.008; discussion 574–5. PMID: 23592165.
9. Pennestrì F, Prioli F, Sessa L, Gallucci P, Ciccoritti L, Giustacchini P, Barbaro B, Brizi MG,
Princi P, Bellantone R, Raffaelli M. Early routine upper gastrointestinal contrast study following bariatric surgery: an indispensable postoperative care or a medicolegal heritage? Obes
Surg. 2019;29(6):1995–8. https://doi.org/10.1007/s11695- 019- 03850- 3. PMID: 30945153.
10. Trastulli S, Munzi G, Desiderio J, Cirocchi R, Rossi M, Parisi A.Indocyanine green uorescence angiography versus standard intraoperative methods for prevention of anastomotic leak
in colorectal surgery: meta-analysis. Br J Surg. 2021;108(4):359–72. https://doi.org/10.1093/
bjs/znaa139. Epub ahead of print. PMID: 33778848.
11. Duprée A, von Kroge PH, Izbicki JR, Wipper SH, Mann O. Fluoreszenzangiographie bei
Ösophagusanastomosen: Perfusionsbeurteilung des Magenschlauchs mit Indocyaningrün
[Fluorescence angiography for esophageal anastomoses: perfusion evaluation of the gastric conduit with indocyanine green]. Chirurg. 2019;90(11):875–879. German. https://doi.
org/10.1007/s00104- 019- 01021- 9. PMID: 31471660.
12. de Tudela AC, Vilallonga R, Ruiz-Úcar E, Pasquier J, Balibrea Del Castillo JM, Nedelcu A,
Fort JM, Carrasco MA.Management of leak after single anastomosis duodeno-ileal bypass
with sleeve gastrectomy. J Laparoendosc Adv Surg Tech A. 2021;31(2):152–60. https://doi.
org/10.1089/lap.2020.0798. Epub 2020 Dec 21. PMID: 33347794.
13. Schiesser M, Guber J, Wildi S, Guber I, Weber M, Muller MK. Utility of routine versus
selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric
bypass. Obes Surg. 2011;21(8):1238–42. https://doi.org/10.1007/s11695- 010- 0284- y. PMID:
20872254.
Chapter 44
Closing theMesenteric Defects
PhilVourtzoumis, FrancoisJulien, andLaurentBiertho
44.1 Introduction
Bariatric procedures that involve alterations in gastrointestinal absorption do so
through bypassing a predetermined length of the small intestine. There are a variety
of intestinal congurations that widely depend on the type of procedures performed
(e.g., Roux-en-Y vs. loop). However, these intestinal anastomoses share a common
theme of creating a “space” within the abdominal cavity known as a mesenteric
defect. These defects are usually formed when two opposing edges of intestinal
mesenteries are in close proximity, as a result of a new gastrointestinal anastomosis.
In the advent of laparoscopic bariatric surgery and the popularity of malabsorptive or hypoabsorptive procedures, there has been an ongoing debate regarding the
management of mesenteric defects at the index operation [1–3]. The major concern
that evolves around these defects has been the association with an increased rate of
internal hernias [4]. Factors such as absence of adhesions, loss of mesenteric fat,
and variety in surgical techniques can be attributed to this increasing likelihood [5].
Small bowel obstructions secondary to an internal hernia through mesenteric defects
are sometimes difcult to diagnose and can be a dreaded postoperative complication
that can eventually progress to small bowel ischemia.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 25828- 2_44.
P. Vourtzoumis (*) · F. Julien · L. Biertho
Institut Universitaire de Cardiologie et de Pneumologie de Québec—Université Laval,
Québec City, QC, Canada
e-mail: phil.vourtzoumis@mcgill.ca; francois.julien.med@ssss.gouv.qc.ca;
laurent.biertho.med@ssss.gouv.qc.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_44
405
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This chapter will focus on the management of mesenteric defects during a laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) and its derivatives, the single anastomosis duodeno-ileal bypass with sleeve gastrectomy
(SADI-S) and the stomach intestinal pylorus-sparing (SIPS) procedures.
44.2 Experience fromtheRoux-en-Y Gastric Bypass
In order to further discuss the management options, it is important to highlight
where most of our understanding of this topic has evolved from.
The breadth of the literature surrounding the experience of mesenteric defects in
bariatric and metabolic surgery mostly stems from the laparoscopic Roux-en-Y gastric bypass (LRYGB). The two most common spaces created during an antecolic
approach are known as the Petersen defect (space created between the Roux limb
and the transverse mesocolon) and the defect at the jejunojejunostomy. An additional third potential defect can also be encountered through the transverse mesocolon during a retrocolic approach.
Internal hernia rates after LRYGB can range from anywhere between 0.2
and 9% [6]. Currently, there is no clear standardized consensus toward the
technical management of mesenteric defects (closure vs. non-closure), and
given the heterogeneity of clinical practice, comparisons of surgical outcomes
are difficult. There are many non-comparative studies in the literature describing less internal hernia rates with the closure of mesenteric defects. There are
also studies advocating that closure of mesenteric defects can be facultative, as
there is no difference between groups [7]. Some believe that a wide open mesenteric defect will actually decrease the risk of strangulation secondary to an
internal hernia.
A recent comprehensive systematic review and meta-analysis examined closure vs. non-closure of mesenteric defects in LRYGB [8]. They identied a total
of 12,640 patients from 2 randomized controlled trials (RCTs) and 6 retrospective cohort studies. Their analysis concluded that closure of mesenteric defects
was associated with lower risks of internal hernia and reoperation for suspected
small bowel obstruction compared with non-closure of mesenteric defects.
Observational studies demonstrated a lower risk, 2% vs. 10%, in the closure
group compared to the non-closure group. Also, the two RCTs showed a lower
risk as well, 2% vs. 7%, in the closure groups [9, 10]. Interestingly, there may be
an associated higher risk of small bowel obstruction not related to an internal
hernia and early small bowel obstruction in the closure groups. This last observation was from only two studies, of which one showed no difference between
groups; therefore, this remains to be studied further given the low level and
uncertainty of the evidence.
44 Closing theMesenteric Defects
407
44.3 Experience inDuodenal Switch/Derivatives
The BPD/DS and its derivatives are very effective malabsorptive procedures that
offer sustained weight loss and provide impressive reversal of obesity-related
comorbidities. Although these procedures only make up roughly 1% of the total
procedures performed worldwide, there has always been a great interest in their
promising long-term results from experienced centers [11]. In order to discuss the
associated mesenteric defects, it is important to highlight the differences encountered anatomically in these procedures compared to the LRYGB.
The standard BPD/DS is a combination of a sleeve gastrectomy and a Roux-en-Y
intestinal bypass. In this procedure, there is a common channel of 100cm and a total
alimentary limb of 250cm. The alimentary limb is connected via an end-to-side
duodeno-ileal anastomosis, roughly 2–3cm distal to the pylorus. Given this anatomic conguration, we expect to encounter a mesenteric defect at the common
channel anastomosis with the biliary limb (ileo-ileostomy defect) and a Petersen
defect from an anti-colic Roux limb duodeno-ileal anastomosis. Similar to LRYGB,
most technique descriptions discuss the closure of the ileo-ileostomy defect; however, the Petersen defect closure is often still debated. It seems, though, that ndings
from the experience in LRYGB may have most likely been translated over to these
procedures and have convinced surgeons on the routine closure of these defects.
On the other hand, the SADI-S and the SIPS are fairly new procedures. They are
believed to be simplied alternatives to the BPD/DS with less potential malabsorptive/malnutrition complications and, of course, one less anastomosis. The SADI-S
was rst described by Sanchez-Pernaute and Torres in 2007 and has now evolved to
consist of a sleeve gastrectomy with a common channel of 250–300cm via a loop
duodeno-ileal anastomosis [12]. In 2013, Cottam and Roslin described the SIPS
procedure, which consists of a similar anatomical conguration; however, the common channel is longer, measuring 300cm [13, 14]. Generally speaking, these procedures claim to minimize and/or eliminate the risk of an internal hernia given the
single “loop” anastomosis conguration. Torres describes that, after a one-loop
reconstruction, the rate of internal hernia is reduced to almost nil [12]. In their
series, there was no single case of internal hernia; however, they lacked long-term
follow-up. Bekuzarov etal. recently published a series comparing SADI-S 250cm
vs. standard BPD/DS and reviewed their 5-year results [15]. They observed a lower
rate of small bowel obstructions in SADI-S vs. BPD/DS; however, there was never
any mention of complications secondary to internal hernias. They simply state that
there was never a need to close the mesenteric defect to prevent internal hernias. It
is believed that since there is no division to the small bowel and/or mesentery, the
loop duodeno-ileal anastomosis provides a large open contiguous “space” which
makes it rare for the occurrence of an internal hernia.
Over the years, there has been a multitude of publications debating the importance of mesenteric defect closure in LRYGB [1–3, 6, 9, 10]. However, there is very
limited data in the literature regarding the same for laparoscopic BPD/DS and its
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derivatives. This may be a reection of the highly specialized nature of this procedure. When reviewing the literature, for BPD/DS and its derivatives, there are a few
case reports discussing internal hernias through mesenteric defects. There are no
available randomized controlled trials, systematic reviews, or meta-analyses.
Khwaja etal. reported a case series of four patients who underwent laparoscopic
BPD/DS and who presented with symptomatic Petersen hernias [16]. Prior to this
case series, their group always closed the ileo-ileostomy defect, but did not close the
Petersen defect. They reported 4 out of 158 patients (2.5%) with Petersen hernias
that required surgery. One of these cases unfortunately resulted in a laparotomy and
resection of an ischemic alimentary limb. They since then now advocate on the
routine closure of all mesenteric defects and describe this as simple and pragmatic.
Other reported rates of internal hernias post-laparoscopic BPD/DS in the literature have been from Silecchia etal., whereby 2 of 27 (7.4%) patients were operated
for an internal hernia [17]. However, details regarding operative technique of defects
and the type of hernia were not mentioned. Comeau etal., in 2004, highlight their
experience with symptomatic internal hernias in patients having undergone LRYGB
and laparoscopic BPD/DS [18]. Their internal hernia rate was 3.3% (35/1064), and
from this, 6/248 patients (2.4%) had undergone a BPD/DS.Interestingly enough,
94.3% of the internal hernias were in patients who did not have primary closure of
their mesenteric defects. The authors therefore recommend that the best course of
management in prevention is to routinely close all mesenteric defects. Another prospective review by Al-Tai etal. observed a 5% internal hernia rate in patients undergoing BDP/DS and all of these patients did not have primary closure of their
mesenteric defects [19].
One of the reasons why many advocate for the SADI-S is because of the single
loop anastomosis that theoretically eliminates the risk of an internal hernia [20].
Recently, Surve etal. published, in 2020, a case report of the very rst reported
Petersen internal hernia in a SADI-S patient [21]. This hernia was reduced and the
Petersen defect was closed. Although it may be a rare occurrence indeed, the possibility of this complication is still present. Another interesting case report by
Summerhays etal., in 2015, described a case of an internal hernia after a revisional
laparoscopic SADI-S [22]. In this case, there was an adhesion causing the afferent
limb of the loop to rotate 180° in a counterclockwise fashion toward the right side
of the abdominal cavity creating a small bowel obstruction. Though this was not a
typical Petersen hernia, some may express that if the mesenteric space underneath
the anastomosis was closed, this may have prevented this volvulus type of twisting
from the anastomosis.
44.4 Closure Techniques
Given the evidence, most surgeons can agree that closure of mesenteric defects at
the initial operation can help minimize the risk of potential future postoperative
internal hernia complications. Although it does not absolutely eliminate the risk, at
least everything was done initially to prevent this. It is unclear, however, on the
44 Closing theMesenteric Defects
409
long-term integrity of these closures over time given the signicant weight loss
patients experience, which is associated with less mesenteric fat, and the possibility
of space opening. There is a denite learning curve involved in closing these defects,
all while also ensuring minimal complications secondary from the closures themselves. Most studies have mentioned that in experienced hands, routine closure is
safe [2]. There is no signicant addition to operative times, and there is also no
signicant difference in complication rates such as bleeding from the mesentery,
bowel obstruction related to kinking at the anastomosis, or possible stitch bezoar/
abscess [3].
Closure of mesenteric defect techniques may vary from surgeon to surgeon, and
for the most part, these techniques strongly depend on training experiences. Over
the years, given the rise in bariatric surgery cases, especially the LRYGB, we have
seen a diverse set of described closure methods, such as closure of mesenteric
defects with an absorbable or non-absorbable suture, the type of suture material
used, whether it is an interrupted or running fashion, closure with clips, and closure
with staplers or topical adhesive compounds [8, 23]. Given the art of surgery, these
various techniques may vary from surgeon to surgeon and therefore so do respective
surgical outcomes. In order to better understand the effectiveness of each technique,
there needs to be ongoing self-assessment of surgeon/center outcomes. With that
said, this heterogeneity in the literature may make it rather difcult to declare a
“standard of care.” Currently, there is no standard when it comes to mesenteric
defect closures; however, the majority of the evidence aims to recommend that routine closure of all mesenteric defects with a non-absorbable running suture is safe
and minimizes the risks of internal hernia postoperatively [8].
In our institution, our policy has been to close all mesenteric defects, whether in
a laparoscopic RYGB, BPD/DS, or SADI-S procedure. We are a bariatric and metabolic surgery center, specializing in a high volume of laparoscopic BPD/DS. In
2013, Biertho etal. published a consecutive series of 1000 BPD/DS [11]. Since the
1990s, the procedure of choice was an “open” BPD/DS, and in 2006, there was the
introduction of the laparoscopic BPD/DS.There was a total of 772 laparotomies
and 228 laparoscopic BPD/DS.Of these cases, there was a total of four patients that
were operated on for a repair of an internal hernia.
With regard to the closure of the mesenteric defects during a laparoscopic BPD/
DS, the following principles are usually taken into consideration. Given some variability between surgeons in our institution, the agreed-upon standard for our closures is the use of a 2.0 non-absorbable suture in a running fashion. The suture
material can vary from a Prolene, barbed, or Ethibond.
44.5 Ileo-ileostomy Defect (See Video 44.1)
The ileo-ileostomy defect closure is performed, from a caudad to cephalad direction, after a stapled side-to-side anti-peristaltic anastomosis is created and handsewn closure of the common enterotomy. This anastomosis usually lies in the
patient’s right mid-abdominal cavity. Typically, our patients are operated in a split
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leg position with the option of having the left arm tucked to their side if possible.
For the creation of the ileo-ileostomy, we are usually on the patient’s left side, and
the same goes for the closure of the mesenteric defect. The assistant, on the left side
as well, will typically retract the anastomosis toward the right upper quadrant using
the stay suture, initially placed to line up and expose the small bowel for the anastomosis. The common channel and the biliopancreatic limb are then retracted laterally on either ends to expose the root of the mesentery, like opening a book. Once
the defect is exposed, the suture is started at the root of the mesentery, ensuring that
no opening at this area is left. This part of the closure is crucial in order to avoid a
potential small space for herniation. The closure is then completed in the direction
toward the small bowel, all while avoiding deep suture bites into the mesentery and
ensuring equal symmetrical distances along the way. Care must be taken to ensure
one is not travelling too posteriorly, in order to avoid twisting of the small bowel.
Some surgeons may also choose to complete this closure in a purse-string fashion.
Once we have reached the top of the small bowel, one or two serosal bites are taken
to approximate both ends of the small bowel in order to completely close the defect.
The suture is then tied to itself, or a small metal clip is placed if using a barbed
suture. Careful inspection of the anastomosis is recommended to ensure no kinking,
twisting, or narrowing of the lumen.
44.6 Petersen Defect (See Video 44.2)
The Petersen defect during a laparoscopic BPD/DS is closed using a very similar
approach. This space is usually found in the right upper quadrant of the patient. It is
directly beneath the anti-colic duodeno-ileal anastomosis, between the alimentary
limb and the transverse mesocolon. The closure can be addressed from the patient’s
left side or in between the legs. In order to gain adequate exposure, the omentum to
the right of the anastomosis is reected upward and over the transverse colon, taking
care to not pull more transverse colon through the space than necessary. The assistant
will grasp the transverse mesocolon to expose the base of the Petersen defect within
the mesocolon and small bowel mesentery. The rst bite of the suture is generally
anchored on the lateral edge of the mesocolon then traveling toward the base and onto
the alimentary limb mesentery. The closure is completed in a running fashion, moving toward the transverse colon and alimentary limb junction. Sometimes, incorporation of the omentum is needed to ensure the complete closure of the space at the apex.
In our center, we also use the same principles when closing the SADI-S Petersen
defect. This space can sometimes be wider depending on the base of the mesentery
and transverse mesocolon given the nature of the loop anastomosis. In our experience with Petersen defect closures for BPD/DS, we are comfortable closing this
space in a SADI-S; even though the theoretical risk for an internal hernia is minimal, it has not been shown to be zero (see Video 44.3).
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