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53 Diarrhea After Duodenal Switch: Medical andSurgical Management
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References
1. Wasserberg N, Hamoui N, Petrone P, Crookes PF, Kaufman HS.Bowel habits after gastric
bypass versus the duodenal switch operation. Obes Surg. 2008a;18:1563–6.
2. Elias K, Hedberg J, Sundbom M.Prevalence and impact of acid-related symptoms and diarrhea in patients undergoing Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic
diversion with duodenal switch. Surg Obes Relat Dis. 2020;16:520–7.
3. Pitombo C, Jones KB, Higa KD, Pareja JC.Obesity surgery principles and practice. NewYork:
McGraw Hill Medical; 2008.
4. ASBS Public/Professional Education Committee. American Society for Metabolic and
Bariatric Surgery. 2008. https://asmbs.org/app/uploads/2014/05/bariatric_surgery_postopera-
tive_concerns1.pdf.
5. Barkun AN, Love J, Gould M, Pluta H, Steinhart H.Bile acid malabsorption in chronic diarrhea: pathophysiology and treatment. Can J Gastroenterol. 2013;27:653–9.
6. Born P. Carbohydrate malabsorption in patients with non-specic abdominal complaints.
World J Gastroenterol. 2007;13:5687–91.
7. Vujasinovic M, Valente R, Thorell A, Rutkowski W, Haas SL, Arnelo U, Lohr J-M.Pancreatic
exocrine insufciency after bariatric surgery. Nutrients. 2017;9:1241.
8. Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Still CD. AACE/
TOS/ASMBS/OMA/ASA clinical practice guidelines for the perioperative nutritional,
metabolic, and nonsurgical support of the bariatric surgery patient—2020 update. 2020.
ASMBS.org: https://asmbs.org/app/uploads/2020/04/Mechanick- 2020- AACE- TOS- ASMBSGuidelines.pdf.
9. Rana SV, Malik A.Hydrogen breath tests in gastrointestinal diseases. Indian J Clin Biochem.
2014;29:398–405.
10. Mason JB. Overview of the treatment of malabsorption in adults. 2020. UpToDate.com:
https://www.uptodate.com/contents/overview- of- the- treatment- of- malabsorption- in- adults.
11. Pimentel M, Saad RJ, Long MD, Rao SS.ACG clinical guideline: small intestinal bacterial
overgrowth. Am J Gastroenterol. 2020;115:165–78.
12. Woodard GA, Encarnacion B, Downey JR, Peraza J, Chong K, Hernandez-Boussard T, Morton
JM.Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: a prospective randomized trial. J Gastrointest Surg. 2009;13:1198–204.
13. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg.
1998;8(3):267–82.
14. Wasserberg N, Hamoui N, Petrone P, etal. Bowel habits after gastric bypass versus the duodenal switch operation. Obes Surg. 2008b;18(12):1563–6.
15. Fysekidis M, etal. Prevalence and co-occurrence of upper and lower gastrointestinal symptoms in patients eligible for bariatric surgery. Obes Surg. 2012;22:403–10.
16. Sovik TT, Karlson J, Aasheim ET, etal. Gastrointestinal function and eating behaviors after
gastric bypass and duodenal switch. SOARD. 2013;9(5):641–7.
17. Appresai O, Murr M.Laparoscopic revision of common channel length for chronic diarrhea
and malnutrition complicating distal gastric bypass. SOARD. 2011;8(5):119–20.
18. Nelson WK, Fatima J, Houghton SG, etal. The malabsorptive very, very long limb Roux-en-Y
gastric bypass for super obesity: result in 257 patients. Surgery. 2006;140:517–23.
19. Horsley B, Cottam D, Cottam A, etal. Bowel reconstruction to treat chronic diarrhea and
hypoproteinemia following single anastomosis duodenal-ileal bypass with sleeve gastrectomy:
a single site experience. Obesity Surgery. 2019;29:2387–91.
Chapter 54
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Endoscopic Treatment ofComplications
LuizGustavode Quadros, NathaliaGuarnetti, ThiagoFerreirade Souza,
andIdibertoJoseZotarelliFilho
Highlights
• Among surgeries with a mixed functioning component, the duodenal switch
(DS) is important because it can provide considerable weight loss.
• The DS procedure is associated with greater short- and long-term morbidity than
any contemporary bariatric procedure.
• More than a third of DS patients require readmission for a related procedure.
Complication is 50% more than that associated with the Roux-en-Y laparoscopic
gastric bypass (RYGB) gold standard.
• Nutritional abnormalities due to malabsorption after DS are 2.5 times more
likely to occur compared to after a laparoscopic RYGB.
• Liver abnormalities after DS are 7 times more likely to develop than after lapa-
roscopic RYGB.
• Complications related to stenosis and stulas can be managed endoscopically.
L. G. de Quadros (*)
Kaiser Clinica, São José do Rio Preto, Brazil
Hospital Benecência Portuguesa, São José do Rio Preto, Brazil
Faculdade de Medicina do ABC, Santo André, Brazil
Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil
N. Guarnetti
Kaiser Clinica, São José do Rio Preto, Brazil
Hospital Benecência Portuguesa, São José do Rio Preto, Brazil
T. F. de Souza
Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
Instituto Endovitta, São Paulo, Brazil
I. J. Z. Filho
FACERES-Medical School of Sao Jose do Rio Preto, Sao Jose 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_54
505
506
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54.1 Introduction
Obesity stands out as an important predictor of several public health problems,
which can cause serious comorbidities [1]. Currently, about 30% of the world’s
population is overweight or obese. In 2020, over 60% of the world population
reached overweight or obesity, with a prevalence in 2030 of 11% [1]. It is estimated
that by 2025 Brazil will nd itself in fth place in the world ranking, with 18.0 million people [2].
In this scenario, bariatric and metabolic surgery can contribute to reducing the
impacts of obesity and its comorbidities [3, 4]. Among the procedures, four are currently recognized in the United States by national health agencies, insurance companies, and medical societies. These procedures include the adjustable gastric band,
the Roux-en-Y gastric bypass (RYGB), the duodenal switch (DS) with biliopancreatic bypass, and, the most recent procedure, vertical gastrectomy. All procedures are
generally performed by laparoscopy or robotically [4, 5].
In this context, Marceau and colleagues [6] published the rst DS report in 1993.
Rabkin and colleagues [7] and later Ren and colleagues in 2000 described the laparoscopic approach [8]. The rst long-term report with a large series of 701 patients
operated on at the University of Southern California was published in 2003 [9]. It is
universally accepted that DS is the most effective procedure to achieve weight loss
and has the best results among all four operations, with sustained results in the long
term of more than 70% (EBWL) [10, 11]. This is also the most effective procedure
for resolving the main comorbidities, such as type 2 diabetes mellitus, sleep apnea,
hypertension, and dyslipidemia [10–12].
Despite this, the DS did not gain popularity. The reasons include the massive
malabsorption component, which has major metabolic side effects, including protein malnutrition, nutrient and vitamin deciencies, and the relative technical complexity of the procedure [13, 14]. Also, multiple anastomoses, including the complex
duodenoileal anastomosis and the long-staple lines of the associated vertical gastrectomy, have not facilitated its laparoscopic adoption [15].
Also, the DS procedure is associated with greater short- and long-term morbidity
than any contemporary bariatric procedure. More than a third of DS patients require
readmission due to a procedure-related complication that is 50% more than that
associated with the Roux-en-Y laparoscopic gastric bypass (RYGB) gold standard
[16]. Nutritional abnormalities due to malabsorption after DS are 2.5 times more
likely to occur compared to after a laparoscopic RYGB.Liver abnormalities after
DS are 7 times more likely to develop than after laparoscopic RYGB [16].
In this context, in an attempt to reduce DS complications, a variant of biliopancreatic deviation with a duodenal switch (BPD-DS), called a single anastomosis
duodenal switch (SADS), has been popularized worldwide, but the number of published reports has small compared to other bariatric surgical procedures [16]. SADS
procedure is a type of duodenal switch that involves a loop anastomosis instead of
the traditional Roux-en-Y reconstruction. This modication simplies the procedure, decreases the complication rate, and combines the physiological factors [16].
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Recently, surgery to preserve the intestinal pylorus of the stomach (SIPS) was
introduced as a simpler and potentially safer variation of the DS.It is a single proximal duodenal-ileal end-to-side anastomosis with vertical gastrectomy [14–16].
Although safe and effective, DS surgery can course with serious complications such
as stulas [5, 17].
54.2 Major Approaches ontheDuodenal Switch
54.2.1 General Information: Duodenal Switch
The biliopancreatic deviation was rst described by Scorpinaro in 1979. This procedure combined a horizontal gastric resection with the closure of a duodenal stump,
gastroileal anastomosis, and an ileoileal anastomosis, to create a common 50cm
canal and a 250cm alimentary canal [18]. Patients undergoing this procedure suffered from biliary gastritis, which is why it was changed to the DeMeester duodenal
exchange procedure in 1987 [18]. The DS evolved into a modern biliopancreatic
bypass with a duodenal switch procedure that includes a vertical gastrectomy, the
transection of the duodenum distal to the pylorus, and the creation of a 200–250cm
long food tube [19, 20].
The surgical technique of DS is a variation of intestinal bipartition (BDP)
designed to combat bile reux [21, 22]. It was established when Hess and colleagues associated a vertical gastrectomy with pyloric preservation to intestinal
deviation [23]. Currently, it corresponds to less than 5% of the procedures performed in Brazil, and weight loss can exceed 70% of the total body weight [21].
Biliopancreatic diversion with a duodenal switch can be performed using an open or
laparoscopic approach.
54.2.2 Major Complications
Biliopancreatic deviation with DS complications can be divided into early and late
complications. Common early complications are anastomotic leak and hemorrhage.
The main complications are listed below [24, 25].
54.2.2.1 Leak
The incidence of gastric or duodenal leakage after biliopancreatic diversion with a
duodenal switch is 1.14% vs. 1.12% for Roux-en-Y gastric bypass [24]. The location of the leak appears to be more common in the duodenoduodenal anastomosis
[25]. The risk of leakage of the longitudinal gastric staple line is minimal compared
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to the leakage rate of the gastric staple line in the gastric bypass procedure. These
patients may be asymptomatic, but they often have tachycardia, which is usually the
rst sign. They may also have tachypnea and be feverish. The diagnostic test of
choice for an anastomotic leak should be a computed tomography scan with oral
and IV contrast, high sensitivity, and specicity. If the leak is acute (<5days), they
may return to the operating room for exploration with repair and placement of a
distal feeding tube [26]. When there is adequate drainage of the abdominal cavity,
endoscopic treatment may be indicated.
Computed tomography is the best imaging method for the diagnosis of stula
and helps to guide the management of the need or not for abdominal drainage,
although it is questioned for the diagnosis of stula in patients with a BMI greater
than 50 due to the size of the waist, abdominal [27]. Also, in patients in whom the
cavity drain remains in place, methylene blue administered orally can be very helpful in conrming the stula [28].
The use of endoscopic treatment represents a surgical treatment option. From the
use of the self-expanding prosthesis, the endoscopic treatment appeared, initially,
for malignant stulas and spontaneous perforation of the esophagus (Böerhaave
syndrome), and, later, it was proposed for postoperative stulas [28–30]. Besides,
dilation and septotomy allow earlier resolution of chronic stulas [31].
54.2.2.2 Endoscopic Treatment
Conventional surgical treatment of stulas brings high morbidity and mortality, due
to the high complexity of the proposed procedures, such as total gastrectomy and
stulojejunostomy. Thus, the endoscopic approach has been gaining popularity and
encompasses internal drainage methods: septotomy, balloon dilation, double pigtail
stents (DPS), and vacuum endoscopic therapy. Some methods of intraluminal leak
block are also proposed, such as placement of an endoscopic prosthesis, endoscopic
suture, and clips apposition, with variable results. The choice of treatment is related
to the chronicity of the stula. More acute conditions, with intense leakage of gastric content, require immediate blockage of the stula to control intracavitary contamination. Chronic cases, with intense brosis, require some sessions of septotomy
and dilation, to reverse the stenosis and allow internal drainage of the abscess [31].
54.2.2.3 Blocking Methods: Self-Expanding Metal Prosthesis
One of the most common endoscopic strategies is external drainage (surgical or
percutaneous) associated with the placement of a self-expanding metallic prosthesis, self-expandable metallic stents (SEMS). The prosthesis aims to occlude the
stulous orice and promote a deviation of the ow of the intraluminal content, in
addition to correcting any stenoses linked to the perpetuation of the stula.
The technique is based on the intragastric placement of an esophageal or bariatric prosthesis with the aid of a guidewire, under the endoscopic vision and radioscopic control. This strategy has good results for cases of acute and early stula,
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together with control of leakage of secretion into the abdominal cavity and reduction of sepsis. However, in late and chronic cases, success rates are lower, due to the
extensively brotic tissue and chronic stenosis. Also, some complications can happen, such as migration, stenosis, ulceration, and intolerance [32].
Thus, this treatment must be performed in centers with an advanced bariatric
endoscopy service with experienced professionals. The prosthesis must be removed
early to avoid complications, usually between 2 and 4weeks.
54.2.3 Internal Drainage Methods
54.2.3.1 Septotomy withDilation
Late and chronic cases are commonly associated with distal stenosis and the presence of a brous septum between the perigastric abscess and the intraluminal cavity.
The septotomy consists of the section of the septum with electrocoagulation or argon
plasma, followed by dilation with a 30mm achalasia balloon with the aid of Savary’s
metallic guidewire, under direct endoscopic view. The communication between the
abscess and the intragastric cavity and the reduction of intraluminal pressure allows
internal drainage of the abscess, leading to the closure of the stula [32].
54.2.3.2 Internal Drainage withPigtail Drain
Internal drainage with a double pigtail stent (DPS) is a relatively recent technique
for the treatment of stulas. The technique is based on the insertion of a DPS
through the stulous orice, so that one end is coupled in the cavity to be drained
and the other in the gastric lumen, to avoid migration and allow drainage to the
gastrointestinal lumen. The device creates an internal drainage system, and the foreign body reaction stimulates the tissue to re-epithelialize, being very useful for
abscesses with a long stulous path. In a period between 4 and 6weeks, the device
is changed, and, depending on the length of the stula, different gauges of the same
type of drain can be used. In some cases, a nasojejunal tube for enteral nutrition is
inserted. The technique has been showing results comparable to treatment with
SEMS with a lower rate of complications and early removal due to intolerance [32].
54.2.3.3 Vacuum Endoscopic Therapy
The good results of the treatment of stulas of the gastrointestinal tract, especially
for cases of esophageal stula, with endoscopic vacuum therapy (EVT), motivated
its application for the treatment of stula after bariatric surgery. The traditional
technique is based on the insertion of a polyurethane sponge in the abscess cavity,
which covers and reduces the stula orice, followed by the application of a negative pressure that promotes an active internal drainage system, removing the
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secretion from the wound and reducing the interstitial edema. Also, the sponge
induces a foreign body reaction, and the negative pressure stimulates the microcirculation, leading to a greater supply of growth factors and accelerating the formation of granulation tissue. The works reported in the literature demonstrate a high
success rate [33].
Despite the enthusiasm, some disadvantages are observed when the technique is
compared to other methods, such as the high amount of necessary endoscopic procedures, 11.3 per patient with sessions being performed every 3–5days, to change
the sponge, which can adhere to the granulation tissue and cause injury if the
removal is delayed as well as making it difcult to remove, with the risk of fragmentation of the device and the need for a surgical approach. Besides, the polyurethane
sponge system is related to difculty in crossing the cricopharyngeal space due to
the friction that is promoted.
54.2.3.4 Hemorrhage
Hemorrhage is most commonly seen with laparoscopic gastric bypass in open procedures [34]. Postoperative hemorrhage is treated at the surgeon’s discretion,
depending on the patient’s clinical condition [35]. In cases of bleeding in the stapling line or an ileum duodenal anastomosis, endoscopic treatment is possible with
the placement of clips, sclerotherapy, use of thermospray, or ablation with
argon plasma.
54.3 Final Considerations
Biliopancreatic diversion with a duodenal switch is a common weight loss procedure that is gaining popularity. The procedure is still not as common as vertical
gastrectomy and Roux-en-Y gastric bypass. Long-term studies have shown similar
results in patients with Roux-en-Y gastric bypass, vertical gastrectomy, and biliopancreatic bypass with duodenal switch. The main differences demonstrated are
that super obese patients with a BMI >50kg/m2 can lose more weight and maintain
weight loss better than other bariatric procedures. Biliopancreatic bypass with duodenal switch has also been shown to have a better effect on diabetes and on reducing
hyperlipidemia than other procedures [34]. The caveat is that this procedure requires
an adequate follow-up program, as there is a greater risk of nutritional deciencies
compared to other bariatric procedures [35].
The appearance of postoperative stula represents a great challenge, being difcult to diagnose, and its treatment is complex and multidisciplinary [36]. Therapeutic
options range from conservative clinical treatment to laparotomy with primary closure of the stula and, in cases of abdominal contamination, which are mostly radiological or laparoscopic drainage [37]. Endoscopic treatments are performed in cases
where there is stability and can be performed at all stages in cases of stulas.
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Chapter 55
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Global Analysis ofOur Experience
withHypoabsorptive Technique: >500
Cases DS vs. SADI-S
JordiPujolGebellí, ClaudioLazzara , andJavierOsorio
55.1 Introduction
Obesity is a worldwide epidemic, with rates that have tripled from the 1970s [1].
The duodenal switch (DS) procedure has proven to be the most effective bariatric
intervention for the treatment of morbid obesity and related metabolic diseases [2–
6]. However, it accounts for a small percentage of current bariatric procedures,
mainly because of complex technique, long surgical time, and risk of postoperative
complications and mid-/long-term diarrhea and malnutrition [7, 8]. In order to simplify the procedure, Sánchez-Pernaute and Torres introduced in 2007 the DS with
one anastomosis, named single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) [9]. Technically, DS and SADI-S have the same sleeve gastrectomy, having DS a Roux-en-Y and SADI-S a one loop Billroth II-like gastrointestinal
tract reconstruction; by avoiding the distal ileoileal anastomosis with a large total
alimentary limb, SADI-S was expected to decrease operating time and postoperative risks of leak, obstruction, internal hernia, and malnutrition while maintaining
the principles and efcacy of DS [10]. Both surgical procedures might be primary
or two-stage procedures for super-obesity patients or revisional techniques for
insufcient weight loss or weight regain after sleeve gastrectomy (SG). Although
there is little information on SADI-S safety and efcacy, the simplicity of the procedure, in comparison with DS, has caused an increasing interest among bariatric
surgeons. The aim of this chapter is to present and share the outcomes of DS and
SADI-S in terms of weight loss, postoperative complications, comorbidities
J. P. Gebellí · C. Lazzara (*) · J. Osorio
Bariatric and Metabolic Surgical Unit, Department of General and Digestive Surgery,
Bellvitge University Hospital, Barcelona, Spain
e-mail: jpujol@bellvitgehospital.cat; clazzara@bellvitgehospital.cat;
josorio@bellvitgehospital.cat
© 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_55
513
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