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44 Closing theMesenteric Defects
411
44.7 Tips andTricks
All mesenteric defect closures are never the same from patient to patient. In order to
ensure success during these closures, adequate exposure is key, along with the skillful coordination from your assistant. Familiarity and operative experience will also
allow you to judge the variable integrity of the mesentery available for your closures
from patient to patient. Difcult mesenteric closures can be expected in some morbidly obese patients with large amounts of intra-abdominal fat or with friable mesentery that tears in diabetic patients. What is crucial in these cases is taking all the
time necessary to perform a proper and long-lasting closure.
The following are some technical tips that can help along the way. When using a
non-barbed suture, in order to avoid tying a knot initially, we place a knot at the end
of the suture with a clip in order to secure the suture within the mesentery and avoid
it ripping through. If there is tension or a heavy mesentery, you can use a clip to
keep the closure snug as you sequentially travel upward. If you encounter bleeding
within the mesentery due to a deep suture bite, it is best to securely snug the defect
closed at the area and place a clip at the site of bleeding. This will usually control
any bleeding and avoid an expanding hematoma. Lastly, depending on the position
of the ileo-ileostomy, sometimes it can be possible and easier to approach the closure of the defect from posteriorly, if easily presented.
44.8 Summary
The complications of internal hernias in bariatric surgery are sometimes difcult
to diagnose and can be catastrophic. Over the years, there has been convincing
evidence highlighting the routine closures of mesenteric defects in laparoscopic
malabsorptive surgeries. Most of this knowledge stems from the LRYGB; however, it can and should be easily translated over to laparoscopic BPD/DS and its
derivatives. There has denitely been a trend of rising internal hernia rates since
the switch of these surgeries being done laparoscopically. Even though we cannot
predict the long-term integrity of mesenteric defect closures, most bariatric surgeons will agree that they nd comfort knowing they have done everything technically to minimize the risk of postoperative complications for their patients. We also
realize the heterogeneity in surgical practice from surgeon to surgeon. This chapter
does not by any means declare these recommendations as a standard of care.
Rather, we aim to highlight the importance of all mesenteric defect closures. We
also recommend surgeons to actively self-assess their outcomes and share their
experience with others. This will eventually allow us to better understand the intricacies and subtleties of techniques and can further help us stride toward possibly
developing a standard of care when dealing with mesenteric defects in bariatric
surgery.
412
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P. Vourtzoumis et al.
References
1. Thomas R, Olbers T, Barry JD, Beamish AJ.Closure of mesenteric defects during Roux-en-Y
gastric bypass for obesity: a systematic review and meta-analysis protocol. Int J Surg Protocol.
2019;15:1–4.
2. Magouliotis DE, Tzovaras G, Tasiopoulou VS, Christodoulidis G, Zacharoulis D. Closure
of mesenteric defects in laparoscopic gastric bypass: a meta-analysis. Obes Surg.
2020;30(5):1935–43.
3. Kristensen SD, Floyd AK, Naver L, Jess P.Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications? Surg Obes Relat Dis. 2015;11(2):459–64.
4. Stenberg E, Näslund I, Szabo E, Ottosson J.Impact of mesenteric defect closure technique on
complications after gastric bypass. Langenbecks Arch Surg. 2018;403(4):481–6.
5. Nuytens F, D’Hondt M, Van Rooy F, Vansteekiste F, Pottel H, Abasabassi M, etal. Closure
of mesenteric defects is associated with a higher incidence of small bowel obstruction due to
adhesions after laparoscopic antecolic Roux-en-y gastric bypass: a retrospective cohort study.
Int J Surg. 2019;71:149–55.
6. Wang E, Shope T.Alternative method of mesenteric defect closure after Roux-en-Y gastric
bypass. Obes Surg. 2019;29(2):751–3.
7. Madan AK, Menzo Lo E, Dhawan N, Tichansky DS.Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2009;19:549–52.
8. Hajibandeh S, Hajibandeh S, Abdelkarim M, Shehadeh A, Mohsin MM, Khan KA, et al.
Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a
systematic review and meta-analysis. Surg Endosc. 2020;34:3306–20.
9. Stenberg E, Szabo E, Agren G, Ottosson J, Marsk R, Lonroth H, etal. Closure of mesenteric
defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial.
Lancet. 2016;387:1397–404.
10. Rosas U, Ahmed S, Leva N, Garg T, Rivas H, Lau J, et al. Mesenteric defect closure in
laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial. Surg Endosc.
2015;29(9):2486–90.
11. Biertho L, Lebel S, Marceau S, Hould FS, Lescelleur O, Moustarah F, etal. Perioperative
complications in a consecutive series of 1000 duodenal switches. Surg Obes Relat Dis.
2013;9(1):63–8.
12. Sanchez-Pernaute A, Rubio MA, Cabrerizo L, Ramos-Levi A, Perez-Aguirre E, Torres
A.Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015;11:1092–8.
13. Mitzman B, Cottam D, Goriparthi R, Cottam S, Zaveri H, Surve A, et al. Stomach Intestinal
Pylorus Sparing (SIPS) surgery for morbid obesity: retrospective analyses of our preliminary
experience. Obes Surg. 2016;26:2098–104.
14. Surve A, Cottam D, Sanchez-Pernaute A, Torres A, Roller J, Kwon Y, etal. The incidence
of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience. Surg Obes Relat Dis.
2018;14(5):594–601.
15. Yashkov Y, Bordan N, Torres A, Malykhina A, Bekuzarov D. SADI-S 250 vs Roux-en-Y
Duodenal Switch (RY-DS): results of 5-year observational study. Obes Surg. 2020;31:570–9.
16. Khwaja HA, Stewart DJ, Magee CJ, Javed SM, Kerrigan DD. Petersen hernia complicating
laparoscopic duodenal switch. Surg Obes Relat Dis. 2012;8(2):236–8.
17. Silecchia G, Casella G, Fioriti M, Basso N.Two-stage laparoscopic biliopancreatic diversion
with duodenal switch as treatment of high-risk super-obese patients: analysis of complications.
Surg Endosc. 2009;23:1032–7.
18. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A.Symptomatic internal
hernias after laparoscopic bariatric surgery. Surg Endosc. 2005;19:34–9.
19. Al-Tai SS, Axer SS, Hoffmann L.Internal hernia after duodenal switch. Surg Obes Relat Dis.
2018;14(Supplement):S120.
44 Closing theMesenteric Defects
20. Finno P, Osorio J, García-Ruiz-de-Gordejuela A, Casajoana A, Sorribas M, Admella V, etal.
Single versus double-anastomosis duodenal switch: single-site comparative cohort study in
440 consecutive patients. Obes Surg. 2020;30:3309–16.
21. Surve A, Cottam D, Medlin W, Richards C, Belnap L, Horsley B, etal. Long-term outcomes
of primary single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). Surg
Obes Relat Dis. 2020;16(11):1638–46.
22. Summerhays C, Cottam D, Cottam A.Internal hernia after revisional laparoscopic loop duodenal switch surgery. Surg Obes Relat Dis. 2016;12(1):e13–5.
23. Yang J, Guan B, Huang S, Peng J, Chong TH, Wang C, et al. Different surgical techniques
that inuenced internal hernia prevalence rate after laparoscopic Roux-en-Y gastric bypass: a
retrospective analysis of 331 cases. BMC Surg. 2020;20(48):1–6.
413
Chapter 45
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Preventing Surgical Complications
CatherineChung andRanaPullatt
Duodenal switches comprise about 0.9% of bariatric surgeries across the United
States and are quickly gaining popularity [1]. Performing these operations whether
traditional duodenal switch or single anastomosis duodeno-ileal bypass is not without complications; however, there are ways to mitigate these complications during
preoperative care, intraoperative technique, and postoperative care. Reducing complications, particularly gastrointestinal leaks, can reduce the rates of readmission,
reoperation, and associated mortality. Gastrointestinal leaks occur at about 0.5–5%.
Leaks most commonly occur at the duodeno-ileostomy at a rate of 2.6% [2, 3].
45.1 Preoperative Prevention
Identifying patients who qualify for a duodenal switch is of utmost importance to
ensure proper patient selection to undergo a major lifestyle-changing operation. A
duodenal switch calls for a sleeve gastrectomy as the rst step of the operation. An
esophagogastroduodenoscopy is recommended for all patients being considered for
a duodenal switch to evaluate for gastroesophageal reux disease and Barrett’s
esophagus. Having either may require more follow-up in patients undergoing a duodenal switch.
Many bariatric surgery candidates have cardiovascular disease comorbidities and
obstructive sleep apnea (OSA). Attaining cardiac and pulmonary clearance to
undergo anesthesia is necessary to prevent intraoperative and postoperative complications such as deep venous thromboembolism (DVT), pulmonary embolism (PE),
C. Chung (*) · R. Pullatt (*)
Medical University of South Carolina, Charleston, SC, USA
e-mail: chungc@musc.edu; pullattr@musc.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_45
415
416
C. Chung and R. Pullatt
and myocardial infarction [4]. Almost all patients have OSA, and patients should
have testing completed to evaluate for CPAP requirements. Patients should be
instructed to know their settings and bring their CPAP masks to be used
postoperatively.
This patient population is frequently inactive with low exercise tolerance, giving
them a higher chance for having a DVT.During the initial clinic visit, ruling out a
DVT should be done with history and physical exam, and if clinical suspicion is
high, then a bilateral lower extremity ultrasound would be advisable. To aid with
intraoperative retraction of the liver, a low-calorie diet for at least 2–3weeks is recommended to reduce the size of the liver [5]. By having a smaller and lighter weight
liver, it is easier to reach the angle of His to complete the sleeve gastrectomy and
also perform the dissection around the duodenum to enable duodenal transection.
45.2 Intraoperative Techniques
The single anastomosis duodeno-ileal bypass with sleeve gastrectomy procedure,
rst illustrated by Sanchez-Pernaute etal., was able to simplify the duodenal switch
[6]. This operation eliminated the ileo-ileostomy and lengthened the common channel compared to the traditional BPD-DS.This approach reduces long-term malabsorption and malnutrition by providing increased absorptive capability [3] and
eliminates a mesenteric space that could cause internal hernia and potential bowel
necrosis when not managed in a timely fashion. Patients exhibit decreased nutritional deciencies and malnutrition compared to traditional duodenal switch and
comparable outcomes to gastric bypass [7, 8]. These morbidly obese patients with
massive visceral obesity have limited intra-abdominal space for insufation and
working space causing difculty in creating the ileo-ileostomy during a traditional
duodenal switch. By creating only a single anastomosis in the SADI, it can result in
lower incidence of bowel injury given there is less tissue handling and manipulation
of the stapler.
Creating a generous sleeve volume reduces the risk of staple line leak of the
sleeve gastrectomy as the sleeve of a DS is a lower-pressure system than a narrow
gastric conduit in a stand-alone sleeve gastrectomy. The larger gastric conduit in a
BPD-DS also allows patients to also eat an adequate volume of food and receive
sufcient protein to reduce rates of protein-calorie malnutrition.
A duodenal leak is a feared complication given the morbidity and mortality associated. This can be prevented by improving surgical technique in tissue handling
and reducing tension. In performing the duodenal dissection, reducing the amount
of cautery used can help prevent a thermal injury and a delayed leak. If it is deemed
that the reach of the ileum to the duodeno-ileal anastomosis is difcult, then dividing the right gastric artery may relieve tension at the duodeno-ileal anastomosis, and
the gastric conduit is sufciently supplied by the left gastric artery and the rich
submucosal plexus of the stomach. This strategy of dividing the right gastric artery
can be used on a case-by-case basis. It must be noted that dividing the right gastric
45 Preventing Surgical Complications
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417
artery may result in a temporary dusky appearance of the divided duodenum, and
this usually resolves by the end of the case, and the conduit can be safely anastomosed. A second strategy is to divide the greater omentum and bring the ileum in a
loop fashion and construct the anastomosis in an omega loop fashion and then convert the omega loop conguration to a Roux conguration. The third strategy which
is used in rare cases is to create the anastomosis in a retrocolic fashion. The nal
strategy to reduce tension at the duodeno-ileal anastomosis is to mobilize the terminal ileal mesentery from the retroperitoneum, and placing the patient in a
Trendelenburg position facilitates this.
There are several methods to construct the DI anastomosis: stapled, hand sutured,
robotically assisted, single layer, or two layered. Care must be taken to perform an
adequate caliber anastomosis if any of the techniques are used. The author’s preference is to use a single-layer hand sutured technique. In the conventional duodenal
switch, the caliber of the bowel is narrow for the ileo-ileostomy unlike a jejunojejunostomy in a gastric bypass as the proximal jejunum has a much larger caliber than
the ileum. This may result in a higher incidence of obstruction at the ileo-ileostomy,
especially when the common enterotomy closure is achieved in a stapled fashion.
We recommend that the common enterotomy closure be performed sutured to avoid
obstruction at the ileo-ileostomy. The author’s preference for creating this anastomosis is with a bidirectional staple re with white loads after enterotomies are performed and the common enterotomy is closed perpendicular to the bidirectional
res of the stapler, resulting in an H-shaped anastomosis. In creating the duodenoileal anastomosis in a SADI, care must be taken to prevent kinking of the loop
duodeno-ileal anastomosis at the afferent limb by placing sutures anchoring the
afferent limb of the loop DI to the gastric conduit.
Internal hernias are a common complication postoperatively. These can be prevented by closing the mesenteric spaces at the ileo-ileostomy and at Petersen’s
space, between the Roux limb mesentery, the transverse colon, and the retroperitoneum. Failure of closure of these spaces contributes signicantly to the increased
rates of internal hernias [9]. We recommend closure of all mesenteric spaces with a
running permanent suture in accordance to other studies as well [10, 11].
Bleeding is another common complication both intraoperatively and postoperatively that can be prevented. The rate of acute postoperative blood loss anemia is
0.99% [12]. Postoperative bleeding carries the highest risk of requiring ICU admission and reoperation and is the source of the second highest risk of mortality [13].
The sleeve gastrectomy staple line is the most common source of postoperative
bleed in a duodenal switch patient. Reinforcing the staple line with suture, clips, or
peristrips helps reduce this risk [14]. In performing the duodenal dissection, taking
care to identify the gastroduodenal artery (GDA) is necessary to prevent major
intraoperative bleeding. The GDA can be injured as a result of excessive dissection
during division of the proximal duodenum or postoperatively from an anastomotic
leak. During this dissection, it is again recommended to reduce the use of thermal
energy devices to prevent ischemia and delayed thermal injuries to the duodenum
and to use gauze sponges introduced laparoscopically to control minor bleeds. Care
must also be taken to prevent inadvertent injury to the head of the pancreas by
418
C. Chung and R. Pullatt
overzealous and aggressive dissection much to the right of the gastroduodenal artery
in an attempt to gain more duodenal length. This could result in a pancreatic leak
which can cause signicant postoperative morbidity. It is very important to take care
not to injure the spleen when performing the sleeve gastrectomy; this can be very
difcult to control in these super obese patients. Care must be taken to obtain proper
exposure of the short gastric arteries before division, and this is greatly aided by
placing the patient on a low-calorie diet preoperatively to reduce the size of the liver.
Trocar placement must be done carefully to avoid injury to the epigastric vessels. At
the end of the case, ensuring adequate port site hemostasis is recommended.
The duodenal dissection can result in injury to the bile duct especially in super
morbidly obese patients. During this dissection, direct visualization is recommended, taking care to not blindly push an instrument to encircle the duodenum.
Using ICG intraoperatively may aid in delineation of the bile duct. Intraoperative
recognition is critical to assist in timely repair if a bile duct injury does occur.
Biliary injury or cystic stump leak can happen during duodenal switches and in
SADI patients if a cholecystectomy is routinely performed. This procedure is difcult to accomplish given the retraction of the liver and fatty inltration. This is
where a low-calorie diet introduced preoperatively can be benecial. We recommend performing the duodenal switch or SADI procedure alone and perform a cholecystectomy after signicant weight loss is achieved, when clinically indicated.
Pancreatitis can result from excessive or aggressive dissection during the duodenal
dissection around the head of the pancreas. This can occur when the fusion planes
of the rst portion of the duodenum are not recognized. Care should be exercised in
identifying these planes.
45.3 Postoperative Care
During the immediate postoperative days, patients are recommended to have adequate oral intake of about 64oz of uids and over 80g of protein to ensure adequate
nutrition. DVTs are the highest risk of mortality in the duodenal switch patients
[13]. Low-molecular weight heparin is indicated for all patients in addition to early
ambulation to prevent DVTs. A shorter length of stay, allowing patients to return to
their home environments is important in reducing this risk as well.
If leaks are identied early, stenting is recommended for traditional duodenal
switches with the addition of IR-guided drain or surgical washout and drainage
when indicated clinically. These stents need to be secured possibly by taking fullthickness bites proximally with an endoscopic suturing system to prevent stent
migration. For leaks that occur after a SADI, we recommend oversewing of the leak
if small and identiable or conversion to a Roux-en-Y conguration traditional duodenal switch if it is a large defect to divert the bile from the anastomosis. Stenting is
not feasible after a SADI given the new anatomy with two lumens at the duodenoileostomy. An afferent loop obstruction in a SADI if a patient has abdominal pain
and a CT scan shows dilation of the afferent limb, this must be treated expeditiously
45 Preventing Surgical Complications
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419
as ignoring this may result in a disastrous duodenal stump blowout and potential
mortality. If an afferent limb obstruction is diagnosed, then an attempt can be made
to see if the anastomosis can be unkinked by placement of anti-obstruction sutures,
and this must be conrmed by on table endoscopy. If this is unsuccessful, then the
safest strategy would be to convert this patient to a traditional DS.
45.4 Conclusion
As duodenal switches and SADI become increasingly performed, it is of paramount
importance to use the techniques described during each phase of care to minimize
preventable complications.
References
1. Estimate of bariatric surgery numbers, 2011–2019. American Society of Metabolic and
Bariatric Surgery; 2021.
2. Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, et al. Duodenal switch:
long-term results. Obes Surg. 2007;17(11):1421–30.
3. Surve A, Cottam D, Sanchez-Pernaute A, Torres A, Roller J, Kwon Y, etal. The incidence
of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience. Surg Obes Relat Dis.
2018;14(5):594–601.
4. Tognolini A, Arellano CS, Marfori W, Sayre JW, Hollada JL, Goldin JG, etal. Cardiac dualsource CT for the preoperative assessment of patients undergoing bariatric surgery. Clin
Radiol. 2013;68(3):e154–63.
5. Schwenger KJP, Fischer SE, Jackson TD, Okrainec A, Allard JP. Non-alcoholic fatty liver
disease in morbidly obese individuals undergoing bariatric surgery: prevalence and effect of
the pre-bariatric very low calorie diet. Obes Surg. 2018;28(4):1109–16.
6. Sanchez-Pernaute A, Rubio Herrera MA, Perez-Aguirre E, Garcia Perez JC, Cabrerizo L, Diez
Valladares L, etal. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8.
7. Enochs P, Bull J, Surve A, Cottam D, Bovard S, Bruce J, etal. Comparative analysis of the
single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) to established
bariatric procedures: an assessment of 2-year postoperative data illustrating weight loss, type
2 diabetes, and nutritional status in a single US center. Surg Obes Relat Dis. 2020;16(1):24–33.
8. Finno P, Osorio J, Garcia-Ruiz-de-Gordejuela A, Casajoana A, Sorribas M, Admella V, etal.
Single versus double-anastomosis duodenal switch: single-site comparative cohort study in
440 consecutive patients. Obes Surg. 2020;30(9):3309–16.
9. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A.Symptomatic internal
hernias after laparoscopic bariatric surgery. Surg Endosc. 2005;19(1):34–9.
10. Blockhuys M, Gypen B, Heyman S, Valk J, van Sprundel F, Hendrickx L.Internal hernia after
laparoscopic gastric bypass: effect of closure of the Petersen defect—single-center study. Obes
Surg. 2019;29(1):70–5.
11. Yang J, Guan B, Huang S, Peng J, Chong TH, Wang C, et al. Different surgical techniques
that inuenced internal hernia prevalence rate after laparoscopic Roux-en-Y gastric bypass: a
retrospective analysis of 331 cases. BMC Surg. 2020;20(1):48.
420
12. Sudan R, Maciejewski ML, Wilk AR, Nguyen NT, Ponce J, Morton JM. Comparative
effectiveness of primary bariatric operations in the United States. Surg Obes Relat Dis.
2017;13(5):826–34.
13. Daigle CR, Brethauer SA, Tu C, Petrick AT, Morton JM, Schauer PR, etal. Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts
to improve national outcomes. Surg Obes Relat Dis. 2018;14(5):652–7.
14. Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in ve
staple-line reinforcement options: a systematic review. Surg Endosc. 2020;34(1):396–407.
C. Chung and R. Pullatt
Chapter 46
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Malabsorptive Complications
DonnaBahroloomi, SharonZarabi, AmandaBecker, andMitchellRoslin
46.1 Introduction
The duodenal switch (DS) was developed in the 1980s as a modication of the biliopancreatic diversion (BP) procedure and combines elements of restriction and
malabsorption to achieve weight loss [1]. This procedure is one of the most complex
in bariatric surgery and has demonstrated the highest reported weight loss in longterm studies and meta-analysis [2, 3]. BPD/DS has also been highly effective in
treating comorbid conditions, including hypertension, diabetes, lipid disorders, and
obstructive sleep apnea [4].
On the other hand, the DS has some of the highest rates of nutritional complications when compared to gastric bypass, sleeve gastrectomy, and other restrictive
procedures [2–4]. The nutritional effects of the DS depend on the length of the alimentary limb and the common channel. The length of the alimentary limb correlates
with protein absorption, while increased size of the common channel reduces fat
malabsorption [5]. Important factors to consider in DS patients include
D. Bahroloomi · S. Zarabi
Lenox Hill Hospital, New York, NY, USA
e-mail: Dbahroloomi@northwell.edu; Szarabi@northwell.edu
A. Becker
Northwell Health, New York, NY, USA
e-mail: Abecker6@northwell.edu
M. Roslin (*)
Lenox Hill Hospital, New York, NY, USA
Northern Westchester Hospital, Mt. Kisco, NY, USA
Barbra and Donald Zucker School of Medicine, Hempstead, NY, USA
e-mail: mroslin@northwell.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_46
421
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