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M. Gagner and M. Lapointe-Gagner
The results of patients operated on more than 10years ago show 18months of
linear weight loss and no weight regain. The weight loss from duodenal bipartition
is similar to SASI patients; however, they do not experience the bile reux that these
patients have with the biliopancreatic limb coming to the antrum. This is a major
advantage of the duodenal bipartition, as the bile getting to either the second duodenum (in an antecolic approach) will be dependent on the pylorus as a barrier, or the
third/fourth duodenum in an infra-colic approach, and adding more distance to
reux back into the stomach. The advantage of an antecolic approach leaves the
possibility of a revision to a full SADI or DS if needed, as a third-stage procedure,
in case of inadequate weight loss or type 2 diabetes recurrence.
Finally, these approaches will be the basis for lesser invasive procedures performed by magnetic surgery [16].
References
1. Chu C, Gagner M, Quinn T, Voellinger DC, Feng JJ, Inabnet WB, Herron D, Pomp A.Twostage laparoscopic BPD/DS. An alternative approach to super-super morbid obesity. Surg
Endosc. 2002:S187.
2. Lazzati A, Bechet S, Jouma S, Paolino L, Jung C.Revision surgery after sleeve gastrectomy:
a nationwide study with 10 years of follow-up. Surg Obes Relat Dis. 2020;16(10):1497–504.
3. Clapp B, Dodoo C, Harper B, Kim J, Castro C, Hamdan M, Grasso S, Davis B.Magnetic
sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP. Surg
Obes Relat Dis. 2021;17(3):555–61.
4. Dijkhorst PJ, Boerboom AB, Janssen IMC, Swank DJ, Wiezer RMJ, Hazebroek EJ, Berends
FJ, Aarts EO.Failed sleeve gastrectomy: single anastomosis Duodenoileal bypass or roux-en Y gastric bypass? A multicenter cohort study. Obes Surg. 2018;28(12):3834–42.
5. Sánchez-Pernaute A, Rubio MÁ, Conde M, Arrue E, Pérez-Aguirre E, Torres A. Singleanastomosis duodenoileal bypass as a second step after sleeve gastrectomy. Surg Obes Relat
Dis. 2015;11(2):351–7.
6. Del Genio G, Gagner M, Cuenca-Abente F, Nocca D, Biertho L, Del Genio F, Assalia A,
Del Genio A.Laparoscopic sleeve gastrectomy with duodeno-jejunal bypass: a new surgical
procedure for weight control. Feasibility and safety study in a porcine model. Obes Surg.
2008;18(10):1263–7.
7. Gagner M.Hypoabsorptive surgery is the best revisional strategy for metabolic and diabetes
outcomes. Surg Obes Relat Dis. 2020;16(10):1454–5.
8. Strain GW, Torghabeh MH, Gagner M, Ebel F, Dakin GF, Abelson JS, Connolly D, Pomp
A.The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years. Obes
Surg. 2017;27(3):787–94.
9. Santoro S, Castro LC, Velhote MC, Malzoni CE, Klajner S, Castro LP, Lacombe A, Santo
MA.Sleeve gastrectomy with transit bipartition: a potent intervention for metabolic syndrome
and obesity. Ann Surg. 2012;256(1):104–10.
10. Mahdy T, Gado W, Alwahidi A, Schou C, Emile SH.Sleeve gastrectomy, one-anastomosis gastric bypass (OAGB), and single anastomosis sleeve ileal (SASI) bypass in treatment of morbid
obesity: a retrospective cohort study. Obes Surg. 2021;31(4):1579–89.
11. Gagner M.Safety and efcacy of a side-to-side duodeno-ileal anastomosis for weight loss and
type-2 diabetes: duodenal bipartition, a novel metabolic surgery procedure. Ann Surg Innov
Res. 2015;9:6.
27 Duodenal Bipartition or Side-to-Side Duodeno-Ileostomy: Rationale and Technical…
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12. 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.
13. Gagner M.Side-to-side duodeno-colic anastomosis provides dramatic weight loss. A potentially strong anti-diabetic operation for type-2 diabetes. Minerva Chir. 2017;72(3):169–77.
14. Gagner M. Emerging Techniques in Bariatric Surgery - Laparoscopic Duodeno- Ileostomy.
ACS-2771 Online video Library of the American College of Surgeons. 2009.
15. Gagner M.Chapter 10: Bipartición duodenoileal con anastomosis laterolateral. In: Palermo M,
González AR, editors. In Atlas de Cirugia Bariatrica y Metabolica. Abordaje Laparoscópico,
Endoscópico y Técnicas Miniinvasivas + Acceso a Contenidos Online. Palo Alto California,
Amolca Publisher; 2018.
16. Gagner M.Laparoendoscopic magnetic gastrointestinal anastomosis. Chapter 14. In: Gagner
M, editor. Magnetic surgery. NewYork, NY: Springer; 2021.
Chapter 28
Duodeno-Ileal Anastomosis
withHand- Sewn Technique
AmadorGarciaRuizde Gordejuela, MarcBeisaniPellise,
andOscarGonzálezLópez
28.1 Introduction
Duodeno-ileal anastomosis is one of the trickiest steps during a duodenal switch
procedure. Although it may seem a simple end-to-side or end-to-end small bowel
anastomosis, the anatomical issues of both ends and the anthropometric characteristics of the patients may complicate the procedure itself. Hand-sewn anastomosis
also requires a skilled surgeon with good experience in laparoscopic suturing [1].
On the other hand, it may provide a safe and reliable anastomosis.
28.2 Surgical Technique
Patients are placed in a supine position with opened legs, in a modied LloydDavies position, and ve to six trocars are placed as shown in Fig.28.1. For the
duodeno-ileal anastomosis, the surgeon will work between the legs of the patient,
with the assistants at both sides.
We usually perform it in a simplied fashion [2], rst constructing the duodenoileal anastomosis and, after that, the Roux anastomosis next to it, as in the simplied
Roux-en-Y gastric bypass described by Lonroth [3]. During the counting of the
alimentary limb, it is important to move the small bowel to the right side of the
A. G. R. de Gordejuela (*) · O. G. López
Endocrine, Metabolic and Bariatric Surgery Unit, Vall d’Hebron University Hospital,
Autonomous University of Barcelona, Barcelona, Spain
M. B. Pellise
Bariatric Surgery Unit, General and Digestive Surgery Department, Moises Broggi Hospital,
CSI, Sant Joan Despi, Barcelona, Spain
© 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_28
271
272
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Fig. 28.1 Trocar
positioning for duodenal
switch
A. G. R. de Gordejuela et al.
Screen
10
5
Assisrant Assisrant
12
Surgeon
12
10
5
patient. This way, once the anastomosis is being constructed, the alimentary limb
will be kept on the right side of the patient and the biliopancreatic limb on the left
side. This practice avoids torsion of the mesenterium and enables an easy ascending
of the intestinal loop to the duodenum.
Our group usually ligates and sections the right gastric artery on its root, as it was
presented by Marchesini etal. [4, 5]. This technical gesture offers a greater mobilization of the duodenal ending, reducing tension to the anastomosis, without compromising the blood supply.
For the hand-sewn anastomosis, we usually prefer monolament absorbable
sutures. Our general practice consists in performing a double layer with 2–0 and
3–0 running sutures.
The rst layer is a sero-serosal end-to-side 2–0 running suture of the posterior
wall. This rst layer will approach and x the ileum to the duodenal ending. In this
layer, it is important to take big bites of the duodenal ending (even including the
staple line) and going almost through the mesenteric side of the small bowel
(Fig.28.2).
We usually keep both endings of that rst running suture quite long, in order to
allow the assistant to grab them from the epigastric and left side trocars. This gesture, combined with the previous ligation of the right gastric artery, enables the
assistant to take control of the whole anastomosis. It then can be easily mobilized
and oriented as desired, in a maneuver that resembles the ying of a kite (Fig.28.3).
28 Duodeno-Ileal Anastomosis withHand-Sewn Technique
Fig. 28.2 First layer of the
duodeno-ileal anastomosis
Fig. 28.3 Kitesurng of
the anastomosis from the
assistant
273
The assistant’s kite piloting of the anastomosis is of much help when performing a
hand-sewn duodeno-ileal anastomosis, for it facilitates enormously the surgeons’
suturing effort by rotating and tilting the anastomosis as suited for each stitch.
After nishing the rst posterior layer, the surgeon will open both sides of the
anastomosis. The length of the opening will be determined by the width of the duodenal ending. It is important to be careful not to harm the posterior wall during the
opening. It should be also taken into consideration that the ileal ending may dilate
during the suturing due to tractions, so it may be recommended to open it a little less
than the duodenum.
Next layer is the inner layer of the posterior wall. We usually use a 3–0 monolament running suture. This layer should include the whole posterior wall. For the
274
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A. G. R. de Gordejuela et al.
angles, the creation of “V”-shaped stitches (Connell stitches) facilitates a good closure of these weak points.
The rst layer of the anterior wall will also be a 3–0 monolament running
suture. This suture will close the anastomosis. Unlike the previous layer, here it is
recommended to be careful and keep the mucosa out of the stitch. It may be argued
to be only an aesthetic preference, but we rmly believe it favors a better consolidation of the anastomosis.
Finally, a second anterior layer of 2–0 running monolament suture is performed.
This will be a sero-serosal suture to reduce tension and keep the anastomosis secured
and closed.
All the layers are constructed from the right side to the left side of the patient
(from the lesser to the greater curvature). As said before, the kite piloting of the
anastomosis is the key to obtain the right orientation needed for each stitch.
28.3 Potential Points ofDiscussion
Here we summarize potential variations of the technique we have described:
• Suturing. We highly recommend running sutures to single stitches. Single stitch-
ing is time-consuming, and in cases where the duodenum is still attached down
to the liver, they can be really tricky to complete.
• Sutures. For running sutures, the absorbable monolament is our choice. We do
not consider non-absorbable sutures due to the risk of ulcer formation.
• Single vs. double layer. A single layer is feasible and may be easier to perform.
It may also reduce the risk of stenosis. But in patients operated for duodenal
switch, their anthropometrics are usually associated with heavy and short mesen-
teries that may create tension in the anastomosis. Some surgeons usually do not
perform the anterior sero-serosal layer.
• Barbed sutures. They may be helpful when creating the anastomosis, but they are
usually more expensive, and, importantly, they do not have a way back, which
can be a major drawback in some situations.
References
1. Jiang H, Lin L, Jiang X, Qiao H.Meta-analysis of hand-sewn versus mechanical gastrojeju-
nal anastomosis during laparoscopic roux-en-Y gastric bypass for morbid obesity. Int J Surg.
2016;32:150–7.
2. Finno P, Osorio J, García-Ruiz-de-Gordejuela A, Casajoana A, Sorribas M, Admella V,
Serrano M, Marchesini JB, Ramos AC, Pujol-Gebellí J. Single versus double-anastomosis
duodenal switch: single-site comparative cohort study in 440 consecutive patients. Obes Surg.
2020;30:3309–16.
3. Ramos AC, Galvao Neto M, Santana Galvao M, Carlo A, Canseco E, Lima M, Falcão M,
Murakami A.Simplied laparoscopic duodenal switch. Surg Obes Relat Dis. 2007;3:565–8.
28 Duodeno-Ileal Anastomosis withHand-Sewn Technique
4. Batista Marchesini J. A safer and simpler technique for the duodenal switch : to the editor.
Obesity Surg. 2007;17:1136.
5. Gebelli JP, de Gordejuela AGR, Ramos AC, Nora M, Pereira AM, Campos JM, Ramos MGG,
de Souza Bastos EL, Marchesini JBJBJB.Sadi-S with right gastric artery ligation: technical
systematization and early results. Arq Bras Cir Dig. 2016;29(Suppl 1):85–90.
275
Chapter 29
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Circular Anastomosis inDuodenal Switch
AinitzeIbarzabalOlano, JavierOsorioAguilar,
andAmadorGarciaRuizde Gordejuela
29.1 Introduction
The duodenal switch is a bariatric surgical procedure that was conceived as a modication of the Scopinaro technique. This technique, which can be considered one of
the most complex procedures in obesity surgery, was described by Hess and Marceau
in 1988, and unlike the Scopinaro technique, it preserved the pylorus and avoided
biliary reux. In September 1999, Rabkin performed the rst laparoscopically
assisted duodenal switch, and in the same year, Michel Gagner performed it totally
laparoscopically. From then until the implementation of single anastomosis malabsorptive techniques, it has been the malabsorptive technique of choice.
Technically, it involves two main steps: restriction and malabsorption. There are
several technical variations described in literature from both steps.
One of the most challenging steps of the procedure is duodeno-ileal anastomosis.
It can be performed in three different ways: linear mechanic, hand-sewn, and circular mechanic. A multicenter study with 457 patients showed that both sutures (linear
and circular) are safe with a low rate of postoperative complications, although the
circular sutures showed a greater tendency to hemorrhage and surgical wound
A. I. Olano (*)
Gastrointestinal Surgery Department, Hospital Clinic, University of Barcelona,
Barcelona, Spain
e-mail: aibarza@clinic.cat
J. O. Aguilar
Bariatric Surgery Unit, General Surgery Department, Bellvitge University Hospital,
L’Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
A. G. R. de Gordejuela
Endocrine, Metabolic and Bariatric Surgery Unit, Vall d’Hebron University Hospital,
Autonomous University of Barcelona, Barcelona, Spain
© 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_29
277
278
A. I. Olano et al.
infection but required less surgical time [1, 2]. There is no evidence on the suitability of one type of anastomosis or another in duodenal switch.
Our group usually performs the circular mechanic anastomosis.
29.2 Circular Mechanic Duodeno-Ileal Anastomosis
Once the vertical gastrectomy has been performed, the duodenum is dissected
3–6cm from the pylorus and sectioned. The preservation or not of the right gastric
artery varies according to the surgical groups. The section may offer an advantage
of an enhanced mobility of the duodenal ending, favoring a less tension anastomosis.
After performing the duodenal dissection, and without sectioning the right gastric artery, we introduce the circular suture device from the mouth guided by a
nasogastric tube. The tip of the device can be taken out in the middle zone of the
staples in the duodenum.
In cases of a high duodenum, or even very stacked below the liver, the tip of the
nasogastric tube can be taken out also from the inferior margin if the duodenum is
not very mobile. This technical trick will allow more margin of mobility and a few
centimeters to perform the anastomosis easier.
Occasionally, it may be difcult to introduce the OrVil from the mouth. In those
cases, the trocar orice where we will place the circular suture device can be
enlarged, and after having made a running suture with a monolament suture in the
duodenum, we introduce the OrVil through the patient’s abdominal wall.
After this step, we identify the alimentary loop 250cm from the ileocecal valve
and section it. We then perform an enterotomy at the sectioned distal ending and
introduce the circular suture device through this hole. Usually and if the duodenal
stump is mobile, this device can be introduced from the left side of the patient
(enlarging the hole of the 12mm trocar in our right hand), but if this is not the case,
the device can be introduced from the right side.
From the right, it is more difcult to introduce the device into the ileal loop, but
it is easier to perform the anastomosis if the duodenal stump is not very mobile, and
from the left, it is easy to introduce the device into the loop, but it is difcult to
perform the anastomosis if the duodenal stump is xed.
The diameter of the circular device is always 25mm. Even though the 21mm
suture may be much easier to introduce and handle, it is related to stenosis.
Next, we section the ileal loop with a linear suture device and reinforce the anastomosis at the corner end with a loose stitch of an absorbable suture. We removed
the intestinal fragment through the trocar orice that we enlarged to introduce the
suture device protected in an Endo bag.
Once the duodeno-ileal anastomosis has been performed, we proceed to perform
the common channel at 100cm from the ileocecal valve and close the mesenteric
defects with non-absorbable sutures.
29 Circular Anastomosis inDuodenal Switch
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279
29.3 Technical Issues
This circular mechanical anastomosis allows to perform a standardized anastomosis
from patient to patient with less risk of stricture, as some studies have shown, but
with potential higher risk for bleeding.
The main technical difculties we may face from this anastomosis are:
Introduction of the OrVil from the mouth. Duodenal switch is mainly reserved
for higher BMI patients, so sometimes it can be challenging to direct the orogastric
tube until the distal stomach and pass the pylorus with the tip.
Introducing the circular suturing device. As it has been previously described,
introducing it from the right side of the patients allows a better approach to the
duodenal ending but a more difcult introduction of the ileum. From the left side
of the patient, the ileum is easily approached, but the anastomosis can be challenging, especially in those cases with higher or stacked duodenal endings.
When the OrVil cannot be introduced from the mouth, it is necessary to open the
duodenal ending and perform a purse-string suture. This technical gesture may
reduce the length of the duodenal ending and may compromise the pylorus in some
patients.
29.4 Technical Variations oftheCircular Anastomosis
Even though the circular mechanic anastomosis seems to be the most stable and
with less technical variations, we may nd several:
• The diameter of the stapler is not discussed, as the 21mm is highly related to
stenosis.
• Introduction of the OrVil: from the mouth or from the abdominal wall with a
purse-string suture at the duodenal ending.
• Introduction of the stapler. It can be done from the right or the left side of the
patient. Both have pros and cons that have been previously discussed.
• Opening of the duodenal ending. When the OrVil is introduced from the
mouth, the tip of the tube is usually extracted from the middle of the posterior
wall, trying to use the whole ending and allowing to create some kind of alien-
ation from the duodenum to the ileum. Some difcult cases will require per-
forming the opening at the inferior corner of the duodenal section, allowing
the anastomosis to move down the anastomosis a few centimeters and reduc-
ing tension.
• The single stitches of reinforcement of the staple line are not performed by all
groups. This technical gesture reduces the tension and may assure some kind of
better hemostasis.
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