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Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
Andrés Sánchez-Pernaute, María Elia Pérez Aguirre and Aida
Pérez Jiménez
32
32.1 Introduction
Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) was introduced in Spain in May 2007 as
a modification and simplification of the traditional biliopancreatic diversion with duodenal switch (DS) [1]. SADI-S is
a one-loop duodenal switch in which the sleeve gastrectomy
is performed over a wide bougie (54 French), the antrum of
the stomach is partially preserved (section 5–6 cm from the
pylorus) and the duodenum is anastomosed to the proximal
ileum, with a variable length of the common alimentary
limb from 250 to 300 cm. Duodenal dissection is ideally
performed with preservation of the right gastric artery, to
improve vascularization and avoid anastomotic problems.
The duodeno-ileostomy can be hand sewn or mechanically
performed, with an usual width of 2–3 cm. Advantages of
the technique over Roux en Y gastric bypass are the preservation of the pylorus—which warrants a better antidiabetic response and avoids dumping syndrome—and a better
weight loss, usually 15% better than the standard gastric
bypass [2, 3]. The main advantage over the Roux en Y
duodenal switch is that reduction to one anastomosis saves
time in surgery, reduces anastomotic postoperative complications, and eliminates the probability of internal hernia in
the follow-up. The increase in the length of the common
channel decreases bowel movements and improves the
quality of life [4].
The key points of the operation are:
(1) To perform a wide sleeve gastrectomy with complete
resection of the gastric fundus. This is achieved through
the introduction of a wide bougie that minimizes the
probability of stricture at the incisura angularis; also,
the partial preservation of the antrum helps with the
gastric emptying and reduces gastroesophageal reflux.
(2) To dissect as much duodenum as possible. A complete
“under-vision” dissection is preferred, separating the
proximal duodenum from the head of the pancreas as
far as possible. A great help is to identify the gastroduodenal artery from the origin of the right gastroepiploic artery to the origin of the right gastric artery.
(3) To perform the duodeno-ileostomy at the proximal
ileum, leaving at least 250 cm of common channel but
not more than 300 cm.
(4) To avoid tension at the anastomosis.
For a successful result of SADI-S, a strict selection of
patients and a close follow-up with an adequate supplementation are mandatory.
32.2 Description of the Surgical Technique
(Video 32.1)
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_32) contains
supplementary material, which is available to authorized users.
A. Sánchez-Pernaute (*) · M. E. P. Aguirre
Department of Surgery, Hospital Clínico San Carlos,
Madrid, Spain
e-mail: pernaute@yahoo.com
A. P. Jiménez
Department of Surgery, Hospital Universitario Puerta del Sur,
Móstoles, Madrid, Spain
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_32
1. Patient, surgical team, and trocar position
The patient is placed in supine position with legs apart
and right arm in abduction. The surgeon stands between
patient’s legs.
Trocars are placed as follows (Fig. 32.1):
– A 10-mm trocar in the left upper quadrant for the camera
(30°).
– A 5-mm trocar in the epigastrium, near the xiphoid pro-
cess. It is used for the left hand of the surgeon and for
the liver retraction.
249
250 A. Sánchez-Pernaute et al.
3. Dissection of the posterior wall of the pylorus and
duodenum (Fig. 32.4).
The dissection of the duodenum starts at its posterior wall,
trying to find a retroduodenal window.
4. Suprapyloric duodenal dissection (Fig. 32.5).
After that, a suprapyloric dissection of the duodenum is
performed in order to find the communication with the posterior window.
5. Duodenal dissection (Fig. 32.6).
At this step, a complete dissection of the duodenum is performed and a vessel-loop is used to reference it.
6. Sleeve gastrectomy (Fig. 32.7).
The sleeve gastrectomy is now performed following a bougie
introduced into the stomach. The section starts 4 cm proximally from the pylorus and continues to the angle of His.
Fig. 32.1 Trocar placement
7. Duodenal section and reference stitch.
Section of the duodenum is performed with a stapler
– A 10-mm trocar in the right upper quadrant, for the liver
retraction and for the left hand of the surgeon to the
introduction of the stapler.
– A 10-mm trocar in the left upper quadrant, just above in
a subcostal position for the surgeon´s right hand.
(Fig. 32.8). After the section, a reference stitch is located in
the proximal portion of the sectioned duodenum (Fig. 32.9).
This stitch will be used to fix the ileum in the duodenoileal
anastomosis.
8. Measurement of the small bowel (Fig. 32.10).
2. Dissection of the greater gastric curvature
(Fig. 32.2)
This first step includes a complete dissection of the greater
curvature. It starts in the fundus and continues to the angle
of His cranially. Distally the dissection ends close to the
pylorus (Fig. 32.3). It is necessary to divide gastric short
vessels and has a correct view of the left crura.
The next step is to measure small bowel to select the area of
the anastomosis. At this point in the procedure, the surgeon
is positioned on the left side of the patient. Then 300 cm is
measured from the ileocecal valve.
9. Hand sewn end to side duodenoileal anastomosis
First of all to perform the duodenoileal anastomosis is to
complete a previous fixation stitch (Fig. 32.11) between
Fig. 32.2 Dissection of the greater gastric curvature. Close (a, b) and schematic view (c)
Fig. 32.3 Dissection of the greater gastric curvature and duodenum. Close (a, b) and schematic view (c)
duodenum and antimesenteric side of the ileum selected to
the anastomosis.
A posterior running suture is performed as the first step
of the duodenoileal anastomosis. After this, the duodenum
and the ileus are opened (Fig. 32.12). A running suture
is now performed to complete the posterior wall of the
anastomosis.
Then the anterior wall of the end to side duodenoileal
anastomosis is now performed with a running suture. Some
stitches are placed over this suture in order to reinforce the
anastomosis (Fig. 32.13).
25132 Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
Fig. 32.4 Dissection of the posterior wall of the pylorus duodenum
Fig. 32.5 Suprapyloric
duodenal dissection. Close
(a) and schematic view (b)
10. Final view (Fig. 32.14).
The procedure finishes with a total revision of the surgical
field.
252 A. Sánchez-Pernaute et al.
Fig. 32.6 Duodenal
dissection. Close (a, b, c) and
schematic view (d)
Fig. 32.7 Sleeve gastrectomy. Close (a, b) and schematic view (d)
Fig. 32.8 Duodenal section.
Close (a) and schematic view
(b)
Fig. 32.9 Reference stitch at
the duodenum. Close (a) and
schematic view (b)
25332 Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
254 A. Sánchez-Pernaute et al.
Fig. 32.10 Measurement of
the small bowel
Fig. 32.11 Fixation
stitch between duodenum
and ileum. Close (a) and
schematic view (b)
Fig. 32.12 Hand sewn
end to side duodenoileal
anastomosis (posterior wall).
Close (a, b, c) and schematic
view (d)
25532 Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
Fig. 32.13 Hand sewn duodenoileal anastomosis (anterior wall). Close (a, b) and schematic view (c)
256 A. Sánchez-Pernaute et al.
Fig. 32.14 Final view
References
1. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García
Pérez JC, Cabrerizo L, Díez Valladares L, Fernández C, Talavera P,
Torres A. Proximal duodenal-ileal end-to-side bypass with sleeve
gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8.
Epub 2007 Nov 27. PubMed PMID: 18040751.
2. Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, Talavera
P, Cabrerizo L, Matía P, Díez-Valladares L, Barabash A, MartínAntona E, García-Botella A, Garcia-Almenta EM, Torres A.
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg.
2010;20(12):1720–6. https://doi.org/10.1007/s11695-010-0247-3.
PubMed PMID: 20798995.
3. Sánchez-Pernaute A, Rubio MÁ, Pérez Aguirre E, Barabash A,
Cabrerizo L, Torres A. Single-anastomosis duodenoileal bypass
with sleeve gastrectomy: metabolic improvement and weight loss
in first 100 patients. Surg Obes Relat Dis. 2013;9(5):731–5. https://
doi.org/10.1016/j.soard.2012.07.018. Epub 2012 Aug 7. PubMed
PMID: 22963820.
4. Surve A, Cottam D, Sanchez-Pernaute A, Torres A, Roller J, Kwon
Y, Mourot J, Schniederjan B, Neichoy B, Enochs P, Tyner M,
Bruce J, Bovard S, Roslin M, Jawad M, Teixeira A, Srikanth M,
Free J, Zaveri H, Pilati D, Bull J, Belnap L, Richards C, Medlin
W, Moon R, Cottam A, Sabrudin S, Cottam S, Dhorepatil A. 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. https://doi.org/10.1016/j.soard.2018.01.020.
Epub 2018 Feb 2. PubMed PMID: 29530597.
Endoscopic and Minimally Invasive Surgical Treatment of Early Gastric Cancer
Noriyuki Inaki
33
33.1 Introduction
Early gastric cancer (EGC) is defined as invasive gastric cancer that invades no more deeply than the submucosa, irrespective of lymph node metastasis (T1, any
N). Treatment modalities for early gastric cancer (EGC)
according to stage include endoscopic resection, laparoscopic gastrectomy, antibiotic treatment for eradication of
Helicobacter pylori, and adjuvant therapies.
In this chapter, the two most important modalities of
treatment will be discussed, the laparoscopic distal gastrectomy (LDG) and the laparoscopy and endoscopy cooperative surgery for early gastric cancer with sentinel lymph
node biopsy (LECS).
33.1.1 Laparoscopic Distal Gastrectomy
Laparoscopic distal gastrectomy has become common,
and gastrectomy has gained consensus as a suitable treatment for early-stage gastric cancer [1]. The efficacy of
laparoscopic gastrectomy for advanced cancer and total laparoscopic gastrectomy and proximal gastrectomy for upper
gastric cancer is currently being studied [2]. This chapter
will illustrate and provide a summary of laparoscopic gastrectomy with D1+ dissection performed for early gastric
cancer.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_33) contains
supplementary material, which is available to authorized users.
N. Inaki (*)
Department of Digestive and General Surgery, Juntendo
University Urayasu Hospital, 2-1-1 Tomioka, Urayasu 279-0021,
Japan
e-mail: n.inaki@viola.ocn.ne.jp
33.1.2 Description of the Operative Technique (Videos 33.1 and 33.2)
The key steps to perform a laparoscopic distal gastrectomy
by an early gastric cancer are:
1. Indications, setup, and port settings
Laparoscopic distal gastrectomy with D1+ dissection is
generally prescribed for clinical stage I cancer that was
diagnosed prior to surgery.
Before surgery, the patient’s body was placed in the supine
position with the legs spread apart. The monitor is commonly
a single monitor and it was placed at the head of the patient
(Fig. 33.1). There were five ports for the trocar: a 12-mm
camera port at the navel, a 12-mm port below the left hypochondriac region, a 5-mm port on the left side of the abdomen, a 5-mm port on the right upper side of the abdomen, and
a 12-mm port on the right side of the abdomen (Fig. 33.2).
2. Lifting the left hepatic lobe
At the beginning of surgery, a Silicon Disc ™ (Hakko Co.
ltd., Nagano) was used and the left hepatic lobe was lifted
with a straight needle and 2–0 nylon thread (Fig. 33.3).
3. Distal gastrectomy and lymph node dissection D1+
(1) Dissection of the left greater omentum: The assistant
grasped the greater curvature of the stomach with the
right hand and the greater omentum with the left hand.
The greater omentum was separated while ensuring at
least 3 cm distance from the veins and arteries at the
margin (Fig. 33.4).
(2) Handling of the veins and arteries of the greater omen-
tum on the left side of the stomach (No. 4sb dissection): Clip separation was performed at the point where
the gastroepiploic branch branches off from the veins
and arteries of the greater omentum on the left side of
the stomach (Fig. 33.5).
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_33
257
258 N. Inaki
Fig. 33.3 Lifting the left hepatic lobe: left hepatic lobe is lifted up
using Silicon Disk™ with suturing
Fig. 33.1 Setup
Fig. 33.2 Port positions. Camera port, navel, 12 mm. Right abdo-
men, 5 mm, × 1 and 12 mm, × 1. Left abdomen, 5 mm, × 1 and
12 mm, × 1
Fig. 33.4 Dissection of left greater omentum: the greater omentum
was separated while ensuring a 4-cm distance from the veins and
arteries at the margin
Fig. 33.5 No.4sb LN dissection: left gastroepiploic artery was cut
preserving the vessel branch for the left side of the omentum