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xiv
Contents
9 Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Ainitze Ibarzabal Olano, Javier Osorio Aguilar,
and Amador Garcia Ruiz de Gordejuela
10 Psychological and Psychiatric Workup . . . . . . . . . . . . . . . . . . . . . . . . . 111
Hélio Tonelli and Andréia Tonelli
11 Nutritional, Behavioral, and Support for Duodenal Switch . . . . . . . . 129
Lillian Craggs-Dino
12 Preoperative Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Galileu Ferreira Ayala Farias and Lyz Bezerra Silva
13 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Léonie Bouvet
14 Preoperative Testing and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Virginia Tan and Abraham Fridman
15 Risk Assessment and Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
John Cole Cowling and Erik Wilson
16 Airway Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Joshua F. Chacon
17 Patient Positioning and Positioning for Bariatric Surgery . . . . . . . . . 179
Joshua F. Chacon
18 Intraoperative Monitoring of the Morbidly Obese Patient . . . . . . . . . 187
Joshua F. Chacon
19 Method of Anesthesia: Gas Selection and Adjunct Medications . . . . 193
Amir Samir
20 Regional Anesthesia in Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . 201
Andre Teixeira, Adam El Kommos,
and Marisabel Linares Bolsegui
21 Multimodal Analgesia in Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . 211
Andre Teixeira, Adam El Kommos, and Laura V. Medina Andara
22 Anatomical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Almino Cardoso Ramos and Eduardo Lemos De Souza Bastos
23 Robotic Duodenal Switch and SADI-S: Technical Aspects . . . . . . . . . 229
Aaron Bornstein and Andre Teixeira
24 Laparoscopic Biliopancreatic Diversion
with Duodenal Switch: Surgical Technique . . . . . . . . . . . . . . . . . . . . . 235
Laurent Biertho, Léonie Bouvet-Bouchard, and Phil Vourtzoumis
25 SADIS: Technical Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Adriana Ruano-Campos, Perez-Aguirre Elia,
Sánchez-Pernaute Andres, and Antonio Torres
Contents
xv
26 Technical Aspects of Single Anastomosis
Duodenal Switch: SIPS Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Michael Marchese, Lauren Rincon, Donna Bahroloomi,
and Mitchell Roslin
27 Duodenal Bipartition or Side-to-Side Duodeno-Ileostomy:
Rationale and Technical Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Michel Gagner and Maxime Lapointe-Gagner
28 Duodeno-Ileal Anastomosis with Hand- Sewn Technique . . . . . . . . . . 271
Amador Garcia Ruiz de Gordejuela, Marc Beisani Pellise,
and Oscar González López
29 Circular Anastomosis in Duodenal Switch . . . . . . . . . . . . . . . . . . . . . . 277
Ainitze Ibarzabal Olano, Javier Osorio Aguilar,
and Amador Garcia Ruiz de Gordejuela
30 Duodenoileal Anastomosis with Linear Stapler Technique . . . . . . . . . 283
Oscar Gonzalez Lopez, Amador Garcia Ruiz de Gordejuela,
and Marc Beisani Pellise
31 Staged Duodenal Switch for High-Risk Patients . . . . . . . . . . . . . . . . . 289
Andrew Collins, Gary Aghazarian, and Andre Teixeira
32 Duodenal Switch, SADI, and SIPS in Adolescent . . . . . . . . . . . . . . . . 299
Phil Vourtzoumis, Francois Julien, and Laurent Biertho
33 Duodenal Switch (DS), Single Anastomosis Duodeno-Ileal
Bypass (SADI) and Stomach Intestinal Pylorus-Sparing
Surgery (SIPS) in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Matyas Fehervari, Michael G. Fadel, and Haris Khwaja
34 Right Gastric Artery Ligation: The Brazilian Results . . . . . . . . . . . . 317
João Caetano Marchesini and João Batista Marchesini
35 Surgery Failure: What Are the Options? . . . . . . . . . . . . . . . . . . . . . . . 323
Julie L. Holihan and Erik Wilson
36 Causes of Weight Regain After Duodenal Switch
and Its Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Amin Andalib
37 Revisional Surgery for Weight Regain . . . . . . . . . . . . . . . . . . . . . . . . . 343
Sara Ardila, Nathan Zundel, and Muhammad Ghanem
38 Conversion of Sleeve Gastrectomy to Duodenal Switch
and SADI-S
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Almino Cardoso Ramos and Eduardo Lemos De Souza Bastos
39 Gastric Band Revision to Duodenal Switch . . . . . . . . . . . . . . . . . . . . . 369
Mohit Bhandari, Manoj Reddy, Shashank Trivedi, Susmit Kosta,
and Winni Mathur
xvi
Contents
40 Endoscopic Treatment of Weight Regain in Duodenal Switch . . . . . . 375
Eduardo Grecco, Thiago Ferreira de Souza, Manoel Galvao Neto,
Luiz Gustavo de Quadros, and Fernanda Oliveira Azor
41 Conversion of Gastric Bypass to Duodenal Switch . . . . . . . . . . . . . . . 381
Gary Aghazarian, Romulo Lind, and Andre Teixeira
42 Management of Duodenal Stump Blowout . . . . . . . . . . . . . . . . . . . . . . 389
Karthik Pittala, Nolan Reinhart, Desmond Zeng, Joseph A. Sujka,
and Christopher G. DuCoin
43 Duodenoileal Anastomosis Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Ramon Vilallonga, Sergi Sanchez-Cordero, and Marc Beisani
44 Closing the Mesenteric Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Phil Vourtzoumis, Francois Julien, and Laurent Biertho
45 Preventing Surgical Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Catherine Chung and Rana Pullatt
46 Malabsorptive Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Donna Bahroloomi, Sharon Zarabi, Amanda Becker,
and Mitchell Roslin
47 Postoperative Psychological Assistance . . . . . . . . . . . . . . . . . . . . . . . . . 431
Hélio Tonelli and Andréia Minski
48 Surgical Management of Leaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Ariel Shuchleib, Mario Shuchleib, and Elias Chousleb
49 Internal Hernias and Bowell Obstruction . . . . . . . . . . . . . . . . . . . . . . 453
Admar Concon Filho, Laisa Simakawa Jimenes,
Stephanie Kilaris Gallani,
and Marina Andrade Macedo Pacetti Miranda
50 Management of Portal Vein Thrombosis Following Bariatric
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Grant Jester, Jacob Barish Jacob, and Said Baidas
51 Gallstones and Choledocholithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Marcelo Falcão and Cláudio Vasconcelos
52 Hyperinsulinemic Postprandial Hypoglycemia After Duodenal
Switch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Anna Casajoana, Javier Osorio, and Jordi Pujol Gebellí
53 Diarrhea After Duodenal Switch: Medical and Surgical
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Barbara J. Allen and Patrick W. Domkowski
54 Endoscopic Treatment of Complications . . . . . . . . . . . . . . . . . . . . . . . 505
Luiz Gustavo de Quadros, Nathalia Guarnetti,
Thiago Ferreira de Souza, and Idiberto Jose Zotarelli Filho
Contents
xvii
55 Global Analysis of Our Experience with Hypoabsorptive
Technique: >500 Cases DS vs. SADI-S . . . . . . . . . . . . . . . . . . . . . . . . . 513
Jordi Pujol Gebellí, Claudio Lazzara, and Javier Osorio
56 Body Contouring After Duodenal Switch . . . . . . . . . . . . . . . . . . . . . . . 525
Omar E. Beidas
57 Bariatric Surgery Population in the ICU . . . . . . . . . . . . . . . . . . . . . . . 541
Tracy R. Bilski, Lucille Woodley, William S. Havron III,
and Anthony Gielow
58 Bariatric Emergencies for the General Surgeon . . . . . . . . . . . . . . . . . 553
Benjamin Castro, Anthony Gielow, and William S. Havron III
59 Robotic Bariatric Surgeon Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Fernando Kennedy Pereira Chaves, Lyz Bezerra Silva,
and Josemberg Campos
Part III Metabolic and Diabetes Type 2 Surgery
60 Mechanisms of Control of Diabetes 2 with Duodenal Switch . . . . . . . 569
Julie Holihan and Erik Wilson
61 The Evolution of Single-Anastomosis Duodenal Switch . . . . . . . . . . . 575
Daniel Cottam, Michelle Everly, and Amit Surve
62 Chapters on Metabolic Syndrome Control and the
Influence of Hormonal Changes Post-duodenal Switch (DS) . . . . . . . 583
David J. Tansey and Carel W. le Roux
63 Staged Duodenal Switch for High-Risk Patients . . . . . . . . . . . . . . . . . 607
Andrew Collins, Ibrahim M. Zeini, and Muhammad Ghanem
64 Duodenal Switch in Patients with Metabolic Syndrome . . . . . . . . . . . 619
Leslie J. Meredith, Muhammad Ghanem, and Andre Teixeira
65 Duodenal Switch (DS) for the Surgical Treatment
of Diabetes and Metabolic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
Lauren Rincon, Amanda Becker, Sharon Zarabi, and Mitchell Roslin
66 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Amador Garcia Ruiz de Gordejuela, Marc Beisani Pellise,
and Enric Caubet Busquet
67 Metabolic Syndrome and the Influence of Bile Acids . . . . . . . . . . . . . 645
Flavio Kreimer, Fernando Kennedy Pereira Chaves,
and Guilherme M. Campos
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
Part I
Introduction
Chapter 1
A Brief History oftheDuodenal Switch
JacquesM.Himpens
1.1 History
The history of duodenal switch dates back to the initial work of Tom DeMeester
who conceived a rerouting of bile and pancreatic secretions, to avoid duodenogastric reux, a condition that is resistant to pharmaceutical treatment [1].
The term duodenal switch refers to the separation of the distal duodenum from
the stomach and the proximal duodenum. The consequence is that bile and pancreatic secretions are indeed prevented from reuxing into the stomach, hence addressing pathologic duodenogastric reux [2] and biliary gastro-esophageal reux [3]
(Fig.1.1). Thus, in its initial embodiment, the DS was not a bariatric operation and
did not involve a gastrectomy. The purpose of the current chapter is to discuss the
advent and expansion of DS in metabolic-bariatric surgery (MBS), which typically
does include a gastrectomy.
When looking at the history of MBS, the rst attempts aimed at simply inducing
substantial weight loss, without much attention paid to what the actual physiologic
implications were. (The term “metabolic” in conjunction with “bariatric” (weight
loss) surgery was introduced by Buchwald [4]). Bariatric surgery initially did not
analyze the mechanisms through which surgical manipulations achieved weight
loss. The rst pioneers focused on bowel length and resected (Henriksen, 1952)
or—in an attempt to make the procedure less invasive—bypassed part of the small
bowel (Payne, 1963), leaving behind a long blind ending part of the jejunum and
ileum. Interestingly, when faced with the ill consequences of the iatrogenic short
bowel induced by his technique, Payne did not hesitate to reverse the anatomy when
sufcient weight loss had been achieved. Throughout the years, reversibility will
continue to be an important asset in bariatric surgery.
J. M. Himpens (*)
CHIREC Delta Hospital, Brussels, Belgium
© 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_1
3
4
Fig. 1.1 The (open)
duodenal switch procedure,
designed by DeMeester
(USA) in the 1980s. The
stomach is left untouched,
the duodenum is transected
some 3–4cm distal to the
pylorus, and the proximal
edge is anastomosed in
end-to-end fashion to a
Roux-en-Y limb going
through the transverse
mesocolon. The Roux limb
is fashioned by transecting
the jejunum some 25cm
distal to the Treitz angle.
The jejuno-jejunostomy
that completes the Roux
construction is located
approximately 55cm distal
to the duodeno-ileostomy
J. M. Himpens
Historically, after addressing (and subsequently abandoning) the aspect “bowel
length,” surgeons soon started focusing on the reservoir function of the stomach.
Taking into account the potential of reversibility, they looked into procedures that
transected the upper part of the stomach and reconstituted gastrointestinal continuity by connecting the proximal transected stomach to a loop of the small bowel.
Thus, Mason [5] transected the stomach horizontally, leaving a rather large pouch.
However, because he reconnected the stomach with a loop of jejunum, gastric reux
of bile and digestive juices often created a situation. This inconvenience was
approached by Griffen [6] who replaced the loop construction with a Roux-en-Y,
thereby completing what became known as the Roux-en-Y gastric bypass.
The principle of transecting the small bowel, anastomosing the distal part to a
viscus (often the stomach) and restoring continuity by reconnecting the proximal
part with the distal part of the transected bowel at some distance from the anastomosis with the viscus was rst described in the late nineteenth century by César Roux,
a Swiss surgeon [7] (Fig.1.2). Initially, the thus created “Roux” limb was a mere
12cm long. Of note, the Roux-en-Y technique was soon abandoned by its inventor,
1 A Brief History oftheDuodenal Switch
Fig. 1.2 The original
Roux-en-Y procedure,
invented by the Swiss
surgeon César Roux in the
1880s. After opening the
mesocolon, portion of the
greater curvature of the
stomach is pulled in an
infra-mesocolic position.
The proximal jejunum is
transected, and the distal
edge is anastomosed to the
thus prepared stomach.
The intestinal continuity is
restored by suturing the
proximal end of transected
jejunum to the mounted
jejunal loop, about 12cm
distal to the
gastroenterostomy
5
because of complications at the gastro-enterostomy. Nevertheless, the principle of
mounting a small bowel limb where no digestive juices ow was widely implemented in different domains, including MBS.
1.2 The Initiator: Scopinaro
As of 1977, Nicola Scopinaro netuned the intestinal bypass procedure—bypassing
duodenum and jejunum—and combined it with an antrectomy with Roux-en-Y
reconstruction including a Roux-limb of some 200cm [8] (Fig.1.3).
Scopinaro called his procedure the biliopancreatic diversion (BPD) because bile
and pancreatic juices were diverted away from the ow of nutrients and only allowed
to mix with the latter some 50cm proximal to the ileocecal valve, site of the jejunoileal anastomosis. The biliopancreatic “passive” limb length was not routinely measured in BPD, but the relatively short “active” limb (i.e., Roux limb + common
limb, together 250 cm long) implied that the passive limb was predominant in
length. As a consequence, in clinical practice, because of the large re-absorptive
surface of the biliopancreatic limb, pancreatic enzymes are almost undetectable at
6
Fig. 1.3 Scopinaro’s
(open) biliopancreatic
diversion (Italy, 1982).
When present, the gall
bladder is removed. The
stomach is reduced in
volume by a wide
antrectomy, leaving
200–300cc of fundus (the
“ad hoc stomach”),
depending on the patient’s
body mass index. A Roux
limb is created at the distal
jejunum, exactly 250cm
from the ileocecal valve,
and brought through the
transverse mesocolon for
anastomosis with the
lateral part of the distal
edge of the stomach. The
proximal cut edge of the
distal jejunum is sutured to
the distal ileum, 50cm
proximal to the ileocecal
valve
J. M. Himpens
50
the level of the jejunoileal anastomosis. The result is an imbalance between the
pancreatic secretions and the bile when they mix with nutrients. Therefore, while
weight loss is excellent, protein and micronutrient malnutrition constitute a true
hazard and malodorous diarrheic stools often impair quality of life. It is these undesirable side effects that prevented the widespread adoption of the procedure, and
actually caused its eventual disappearance [9].
1.3 The Pioneers: Hess andMarceau
Importantly, on top of the already mentioned downsides, the BPD construction
appeared to predispose to (gastro-enteral) anastomotic ulcer. Anticipating on these
side effects, and keeping the basic idea of separating the ingested food stuffs and the
1 A Brief History oftheDuodenal Switch
7
biliopancreatic secretions, a number of surgeons, including Hess (in the USA) [10]
and Marceau (in Canada) [11] came forward with a substantially altered version of
BPD that they called the biliopancreatic diversion with duodenal switch (BPD-DS).
Both Hess and Marceau honored Scopinaro’s principle of intestinal bypass but
they addressed the distal stomach and proximal duodenum in a specic way. Their
conguration was actually a hybrid of BPD and DeMeester’s duodenal switch procedure performed for duodenogastric reux as mentioned earlier.
A signicant difference with the BPD Roux construction is that Hess and
Marceau approached the problem of anastomotic ulcers by reducing the gastric
parietal cell mass, rather than the gastrin producing cells, as performed by Scopinaro.
They proceeded to resect the greater curvature of the stomach, that is, created a
longitudinal gastrectomy, commonly called a “sleeve gastrectomy (SG)”.
Importantly, this new approach allowed to preserve the pylorus while the duodenum
was transected some 3–4cm distal to it. Besides avoiding proximal anastomotic
ulceration, the new construction was meant to reduce the incidence of dumping [12]
by better regulating gastric emptying.
The sleeve gastrectomy (SG) itself plays a signicant functional role in the operation. As mentioned by Marceau, the sleeved stomach leaves a sufciently large
gastric remnant (in Picard Marceau’s initial description greater than 250cc [11]) so
as to initiate protein digestion. Conversely, Hess leaves a smaller stomach (some
150cc), which, however, is still substantially larger than in traditional RYGB.With
both Marceau’s and Hess’ technique, the reduction in stomach size benets early
satiety without inducing food intolerance. The preservation of the different compartments of the stomach in continuity with the proximal duodenum likely avoids
the ill consequences of a blind stomach as in classic BPD.
Unlike in Scopinaro’s procedure, Hess measured the entire bowel length (from
Treitz’ angle to the ileocecal valve) and, rather than arbitrarily using 250 cm of
distal small bowel as in classic BPD (see above), he used the distal 40% of small
bowel to create the alimentary and common limb. After separation from the proximal small bowel, he connected the 40% of the distal bowel to the proximal end of
transected duodenum, constituting the active limb that was in contact with nutrients.
The proximal bowel was then anastomosed to the active channel between 50 and
100cm proximal to the ileocecal valve, depending on the total bowel length and the
patient’s weight [13] (Fig.1.4).
In 1990, Picard Marceau brought his own personal touch to the Scopinaro
BPD.Quite as in Hess’s technique he included a sleeve gastrectomy, preserved the
proximal duodenum, and performed a duodeno-ileostomy, but he kept the bowel
lengths as described by Scopinaro, except for the common channel that he lengthened to some 100cm [11] (Fig.1.5).
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