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33 Duodenal Switch (DS), Single Anastomosis Duodeno-Ileal Bypass (SADI…
313
improvement in glucose homeostasis should be anticipated following DS,
SADI and SIPS in diabetic patients, and their medication should be modified
accordingly. Geriatric patients are more prone to dehydration and hypotension
which must be taken into account when adjusting antihypertensive medication
postoperatively [39]. Dumping syndrome is frequent following bariatric surgery and is determined by the size of gastric pouch and the speed of gastric
emptying. Elderly patients are more vulnerable to reactive hypoglycaemia following these operations in the short and long term, and therefore they must be
monitored carefully [40]. Long-term nutritional deficiencies are common in the
elderly following DS; hence, vitamin and micronutrient replacement are mandatory for all patients. Finally, rapid weight loss can lead to symptomatic cholelithiasis with difficult endoscopic approaches related to these surgeries, and
therefore ursodeoxycholic acid should be considered to mitigate gallstonerelated complications [39].
As discussed above, there has been a rapid change in the last 10years in the
reports of the outcome of bariatric surgeries in the elderly. Surgical technique,
however, has not changed signicantly over the last 10 years in this eld.
Laparoscopic bariatric procedures have been performed for more than 30years,
and there have been no major advancements in the steps of these operations either.
So why has there been a sudden change in age-related outcome? The reason for
this improvement is most likely related to the development of perioperative
enhanced recovery programmes for bariatric patients [41, 42]. These pathways
seem to improve not just the perioperative surgical outcomes but the weight loss,
co-morbidity status and quality of life [42]. Elderly patients are more likely to
develop severe postoperative complications due to their reduced reserve capacity.
Enhanced recovery pathways are standardising the perioperative care leading to a
decrease in morbidity and early recognition of complications. For bariatric surgery in the elderly, an established local enhanced recovery programme is
recommended.
33.8 Long-Term Results
Bariatric surgery in the elderly has been associated with good long-term weight loss
and reduction of co-morbidities [18]. At the same time, DS has been associated with
favourable long-term results in the geriatric population. Although weight loss outcomes appear to be inferior to younger population, remission of co-morbidities is
equivalent between these groups [3]. This simultaneously corresponds with previous ndings of slow metabolism and impaired weight loss and gives reassurance to
bariatric surgeons that DS, SADI and SIPS have equivalent long-term outcomes in
both the young and elderly patients.
314
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M. Fehervari et al.
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age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic
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7. Gallagher R, Armari E, White H, Hollams D.Multi-component weight-loss interventions for
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9. Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, etal. Clinical
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of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American
Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity
Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association,
and American Society of Anesthesiologists. Obesity (Silver Spring). 2020;28(4):O1–O58.
10. Etzioni DA, Liu JH, Maggard MA, Ko CY.The aging population and its impact on the surgery
workforce. Ann Surg. 2003;238(2):170–7.
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age. Surg Gynecol Obstet. 1977;144(2):192–4.
12. Nelson LG, Lopez PP, Haines K, Stefan B, Martin T, Gonzalez R, etal. Outcomes of bariatric
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13. NIH Conference. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Intern Med. 1991;115(12):956–61.
14. Bhandari M, Mathur W, Fobi M, Kosta S.Outcomes of bariatric surgery in geriatric patients
>/= 65 years: single institution study. Obes Surg. 2019;29(5):1470–6.
15. Chow A, Switzer NJ, Gill RS, Dang J, Ko YM, Shi X, etal. Roux-en-Y gastric bypass in the
elderly: a systematic review. Obes Surg. 2016;26(3):626–30.
16. Contreras JE, Santander C, Court I, Bravo J.Correlation between age and weight loss after
bariatric surgery. Obes Surg. 2013;23(8):1286–9.
17. Vallois A, Menahem B, Alves A. Is laparoscopic bariatric surgery safe and effective in
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18. Haiat Factor R, Leibovitz E, Shimonov M.Bariatrics in geriatrics- is age an obstacle for bariatric surgery? Harefuah. 2018;157(8):498–502.
19. Marczuk P, Kubisa MJ, Swiech M, Waledziak M, Kowalewski P, Major P, etal. Effectiveness
and safety of Roux-en-Y gastric bypass in elderly patients-systematic review and metaanalysis. Obes Surg. 2019;29(2):361–8.
20. Giordano S, Salminen P.Laparoscopic sleeve gastrectomy is safe for patients over 60 years of
age: a meta-analysis of comparative studies. J Laparoendosc Adv Surg Tech A. 2020;30(1):12–9.
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33 Duodenal Switch (DS), Single Anastomosis Duodeno-Ileal Bypass (SADI…
22. Vinolas H, Barnetche T, Ferrandi G, Monsaingeon-Henry M, Pupier E, Collet D, etal. Oral
hydration, food intake, and nutritional status before and after bariatric surgery. Obes Surg.
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23. Surve A, Rao R, Cottam D, Rao A, Ide L, Cottam S, etal. Early outcomes of primary SADI-S:
an Australian experience. Obes Surg. 2020;30(4):1429–36.
24. 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.
25. Surve A, Zaveri H, Cottam D, Belnap L, Cottam A, Cottam S.A retrospective comparison
of biliopancreatic diversion with duodenal switch with single anastomosis duodenal switch
(SIPS-stomach intestinal pylorus sparing surgery) at a single institution with two year follow up. Surg Obes Relat Dis. 2017;13(3):415–22.
26. Cottam A, Cottam D, Portenier D, Zaveri H, Surve A, Cottam S, etal. A matched cohort analysis of stomach intestinal pylorus saving (SIPS) surgery versus biliopancreatic diversion with
duodenal switch with two-year follow-up. Obes Surg. 2017;27(2):454–61.
27. 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(9):2098–104.
28. Sanchez-Pernaute A, Rubio MA, Perez N, Marcuello C, Torres A, Perez-Aguirre E.Singleanastomosis duodenoileal bypass as a revisional or second-step operation after sleeve gastrectomy. Surg Obes Relat Dis. 2020;16(10):1491–6.
29. Cottam A, Cottam D, Roslin M, Cottam S, Medlin W, Richards C, etal. A matched cohort
analysis of sleeve gastrectomy with and without 300cm loop duodenal switch with 18-month
follow-up. Obes Surg. 2016;26(10):2363–9.
30. Cottam A, Cottam D, Medlin W, Richards C, Cottam S, Zaveri H, etal. A matched cohort
analysis of single anastomosis loop duodenal switch versus Roux-en-Y gastric bypass with
18-month follow-up. Surg Endosc. 2016;30(9):3958–64.
31. Prachand VN, Ward M, Alverdy JC.Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI > or = 50 kg/m2)
compared with gastric bypass. J Gastrointest Surg. 2010;14(2):211–20.
32. Prachand VN, Davee RT, Alverdy JC. Duodenal switch provides superior weight loss
in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass. Ann Surg.
2006;244(4):611–9.
33. Biertho L, Biron S, Hould FS, Lebel S, Marceau S, Marceau P. Is biliopancreatic diversion
with duodenal switch indicated for patients with body mass index <50 kg/m2? Surg Obes Relat
Dis. 2010;6(5):508–14.
34. Partridge JS, Harari D, Martin FC, Dhesi JK.The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a
systematic review. Anaesthesia. 2014;69(Suppl 1):8–16.
35. Chan SP, Ip KY, Irwin MG.Peri-operative optimisation of elderly and frail patients: a narrative
review. Anaesthesia. 2019;74(Suppl 1):80–9.
36. Mohapatra S, Gangadharan K, Pitchumoni CS.Malnutrition in obesity before and after bariatric surgery. Dis Mon. 2020;66(2):100866.
37. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length
of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr.
2003;22(3):235–9.
38. Frasson M, Braga M, Vignali A, Zuliani W, Di Carlo V. Benets of laparoscopic colorectal
resection are more pronounced in elderly patients. Dis Colon Rectum. 2008;51(3):296–300.
39. Kim TY, Kim S, Schafer AL. Medical management of the postoperative bariatric surgery
patient. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K,
etal., editors. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2000.
40. Berg P, McCallum R.Dumping syndrome: a review of the current concepts of pathophysiology, diagnosis, and treatment. Dig Dis Sci. 2016;61(1):11–8.
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M. Fehervari et al.
41. Meunier H, Le Roux Y, Fiant AL, Marion Y, Bion AL, Gautier T, etal. Does the implementation of enhanced recovery after surgery (ERAS) guidelines improve outcomes of bariatric
surgery? A propensity score analysis in 464 patients. Obes Surg. 2019;29(9):2843–53.
42. Mantziari S, Dayer A, Duvoisin C, Demartines N, Allemann P, Calmes JM, etal. Long-term
weight loss, metabolic outcomes, and quality of life at 10 years after Roux-en-Y gastric bypass
are independent of Patients’ age at baseline. Obes Surg. 2020;30(4):1181–8.
Chapter 34
Right Gastric Artery Ligation:
TheBrazilian Results
JoãoCaetanoMarchesini andJoãoBatistaMarchesini
Bariatric surgery is considered the most effective management for weight loss in
patients with morbid obesity. It is also the most effective approach for improvement
or remission of related comorbidities. Among the several factors that inuence the
surgeon’s choice of technique are gender, BMI, meal preferences, age, presence of
GERD, comorbidities, the local anatomy, and surgeon’s skills [1].
Since 1994 when Wittgrove and Clark started the laparoscopic RYGB, it has
been the most performed bariatric procedure until 2013 and was considered as the
gold standard in this eld. For the last years, sleeve gastrectomy has emerged and
gained surgeon’s preference exponentially up to reach the position of the most performed surgery in some countries, including the USA [2, 3].
Despite their success, both procedures achieve moderate results in terms of
weight loss and have a relative high rate (20–25%) of insufcient weight loss or
weight regain [3, 4].
J. C. Marchesini (*)
Brazilian Society of Bariatric and Metabolic Surgery, Brazilian College of Surgeons,
Sao Paulo, Brazil
International Federation for the Surgery of Obesity and Metabolic Disorders, Curitiba, Brazil
American Society of Metabolic and Bariatric Surgery, Newberry, FL, USA
J. B. Marchesini
Brazilian Society of Bariatric and Metabolic Surgery, Brazilian College of Surgeons,
Sao Paulo, Brazil
American Society of Metabolic and Bariatric Surgery, Newberry, FL, USA
American College of Surgeons, Chicago, IL, USA
American Board of Surgery, Philadelphia, PA, USA
Federal University of Parana, Curitiba, 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_34
317
318
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J. C. Marchesini and J. B. Marchesini
The second pathway for development of bariatric surgery was based on the
improvement attempts of the original jejunoileal bypass with different lengths of the
excluded biliopancreatic limb in association with a moderate gastric restriction
resulting in a second generation of malabsorptive operations. At the end of the
1980s, Marceau and Hess added some technical changes in the biliopancreatic
diversion proposed by Nicola Scopinaro in 1979 [5], resulting in another type of
biliopancreatic diversion: the sleeve gastrectomy with duodenal switch (DS) [6, 7] .
It was based after DeMeester’s proposal of a duodenal switch for the treatment of
reux alkaline gastritis [8]. It is considered a modern version of the original biliopancreatic diversion and has been published with better results in terms of weight
loss and control of related diseases. Unfortunately, this technique shows the worse
side effects regarding nutritional problems.
This procedure has more than 35years of history and has demonstrated the best
results ever in terms of durable weight loss and comorbidity resolution. Despite this,
in the last International Federation for the Surgery of Obesity and Metabolic
Disorders (IFSO) bariatric surgery survey, it only represented less than 0.5% of the
worldwide series [2].
The main reason for such conservative numbers is that biliopancreatic diversion
with duodenal switch is usually associated with high morbidity and mortality rates,
high technical complexity, and elevated long-term nutritional sequelae [1]. Recent
literature about BPDDS with large follow-up points out good results and few complications but even though this literature is unanimous. Undoubtedly, this is the
most technically demanding and complex bariatric procedure, and the skills and
training of the surgeon certainly will inuence in the decision in doing it [9, 10].
The hardest part of the procedure is related to the duodenal approach and the
duodeno-ileal anastomosis.
On the standard BPDDS technique, gastric blood supply is provided by the left
and right gastric arteries after the vertical sleeve gastrectomy. The divided duodenal
bulb remains in place, over the head of the pancreas and under the liver, leading to
a generally difcult duodeno-ileal anastomosis. The three major causes of anastomotic leakage are tension, poor technique, and poor blood supply. In order to have
good blood supply, many duodeno-ileal anastomoses remain tense and technically
imperfect [11]. Previous studies performed by us to evaluate gastric blood supply
found that the left gastric artery alone was sufcient to perfuse the entire organ due
to the rich submucosal arterial network (Figs.34.1a and b) [12, 13]. On our proposal, the right gastric and the right and left gastroepiploic arteries are divided, and
the sleeve gastrectomy portion, pylorus, and duodenal bulb are maintained through
the left gastric artery blood supply. Technically, the surgeon lifts and supports the
duodenum on his left hand grasper, and the assistant lifts the gastric antrum creating
space for the artery dissection with the ultrasonic scissors (Fig.34.1c). The duodeno-
ileal anastomosis is always performed manually (Figs.34.1d and e).
The pylorus-preserving Longmire technique for reconstruction of the GI tract
after duodeno-pancreatectomy [14], modied by Sugiyama etal. [15], involves an
anastomosis of the remnant proximal duodenal bulb to the small bowel, transecting
the right gastric and right gastroepiploic arteries. The ligation at its root guarantees
cd
34 Right Gastric Artery Ligation: TheBrazilian Results
ab
319
e
Fig. 34.1 (a) Contrast material injected into a single artery (left gastric artery) shows the rich gastric
submucosal network (cadaver study). (b) Vinyl skeleton of the gastric blood supply showing the rich
submucosal vascular structure (cadaver specimen). (c) Anatomical position of the right gastric artery. (d)
Opening the duodenum for the duodeno-ileal anastomosis showing normal vascular aspect of the
mucosa after the ligation of the right gastric artery. (e) Finishing the duodeno- ileal anastomosis
320
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J. C. Marchesini and J. B. Marchesini
that the blood supply from the lesser curvature of the stomach keeps unaltered supplying good vascularization for the new anastomosis.
From September 1995 to January 2019, we performed a total of 1356 BBPDS in
morbidly obese patients, freeing the duodenal bulb and pyloric portion of the stomach by ligating the right gastric artery. The main indication was for patients with
BMI over 45kg/m2 with severe comorbidities or any patient with BMI over 50kg/
m2 that had a clear understanding of the procedure and the necessity of a closer
follow-up.
Important to notice is that the remnant stomach and the duodenal bulb are easily
mobilized inside the abdomen in laparoscopic procedures and out of the abdomen
in open procedures, leading to a simpler and easier anastomosis [11].
Leakages occurred in 16 patients (1.17%) at the uppermost part of the sleeve
gastrectomy, in 2 cases at the duodeno-ileal anastomosis (0.14%), and in one case at
the enteroanastomosis (0.07%). Overall morbidity rate was 5.8% (78 patients) and
mortality rate was 0.22% (3 patients). Reoperation occurred in 4.2% (58 patients).
The rich submucosal blood supply ensures that the divided duodenal bulb during
a duodenal switch procedure remains viable, and the anastomosis performed in this
manner is not compromised by ischemic phenomena. In our two cases of leakages,
both were identied as technical failure and treated with drainage and had a good
outcome with no sequelae.
Based on our long-term clinical experience from this large number of patients,
the low risk offered, and the facilitation promoted by this technical variation, the
authors highly recommend its current use.
References
1. Gebelli JP, Gordejuela AGR, Ramos AC, Nora M, etal. SADI-S with right gastric artery ligation: technical systematization and early results. Arq Bras Cir Dig. 2019;29(Suppl 1):85–90.
2. Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro
N.IFSO worldwide survey 2016: primary, endoluminal and revisional procedures. Obes Surg.
2018;28:3783–94.
3. Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, Brengman M, Kurian M, Hutter
M, Stegemann L, Kallies K, Nguyen NT, Ponce J, Morton JM.Systematic review on reoperative bariatric surgery. American Society for Metabolic and Bariatric Surgery Revision Task
Force. Surg Obes Relat Dis. 2014;10:952–72.
4. Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW.Weight recidivism post-bariatric
surgery: a systematic review. Obes Surg. 2013;23:1922–33.
5. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V.Biliopancreatic bypass for obesity: initial experiences in man. Br J Surg. 1979;66:618–20.
6. Hess DW, Hess DS. Biliopancreatic diversion with a duodenal switch. Obes Surg.
1998;8:267–82.
7. Legacé M, Marceau P, Marceau S, etal. Biliopancreatic diversion with proximal with a new
type of gastrectomy : some previous conclusions revisited. Obes Surg. 1995;5:411–8.
8. DeMeester TR, Fuchs KH, Ball CS, etal. Experimental and clinical results with proximal endto- end duodenojejunostomy for pathologic duodenogastric reux. Ann Surg. 1987;206:414–26.
34 Right Gastric Artery Ligation: TheBrazilian Results
9. Roslin MS, Gagner M, Goriparthi R, Mitzman B.The rationale for a duodenal switch as the
primary surgical treatment of advanced type 2 diabetes mellitus and metabolic disease. Surg
Obes Relat Dis. 2015;11:704–10.
10. Prachand VN, Ward M, Alverdy JC.Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI ≥50 kg/m2) compared
with gastric bypass. J Gastrointest Surg. 2010;14:211–20.
11. Marchesini JB. A safer and simpler technique for the duodenal switch. Obes Surg.
2007;17:1136.
12. Marchesini JB, Costa e Silva IT, LAG B, etal. Circulação da pequena curvatura após vagotomia superseletiva. Rev Col Bras de Cirurgiões. 1980;7:9–12.
13. Marchesini JB, Bueno LAG, Costa e Silva IT, et al. Estudo em molde vinílico da vascularização da pequena curvatura do estômago após vagotomia superseletiva. Rev Col Bras de
Cirurgiões. 1981;8:209–301.
14. Traverso LW, Longmire WP. Preservation of the pylorus in pancreaticoduodenectomy. Surg
Gynecol Obstet. 1978;146:959–62.
15. Sugiyama M, Abe N, Ueki H, etal. A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. Am J Surg. 2004;187:743–6.
321
Chapter 35
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Surgery Failure: What Are theOptions?
JulieL.Holihan andErikWilson
35.1 Introduction
Bariatric surgery is currently the best-known strategy for long-term weight loss.
However, even patients who undergo bariatric surgery can fail to lose adequate
weight or have weight regain (weight recidivism). Successful weight loss following
bariatric surgery is commonly dened as at least 50% of excess weight loss [1].
Other denitions include weight loss of at least 25% of preoperative weight or
achieving BMI <40 [2]. Denitions for weight recidivism can be variable, but it is
often dened as 25% weight regain from lowest weight [1]. Weight recidivism
occurs in 20–50% of patients who have had bariatric surgery [1, 3, 4]. However,
failure following duodenal switch is uncommon. In fact, duodenal switch is often
used as a revisional procedure following a failed Roux-en-Y gastric bypass or sleeve
gastrectomy. Despite this, there are still a number of options for weight loss after
failure of a duodenal switch.
35.2 Prevalence ofFailure
Failure to achieve weight loss and weight recidivism varies by type of bariatric surgery, with duodenal switch-biliopancreatic diversion being one of the least likely to
fail. A review of prospective and randomized trials of duodenal switch demonstrated
a 0–14% rate of failure following surgery (Table35.1). Variations in this rate are
likely due to differences in surgical technique and follow-up duration.
J. L. Holihan (*) · E. Wilson
The University of Texas Health Science Center at Houston, Houston, TX, USA
e-mail: Julie.L.Holihan@uth.tmc.edu; erik.b.wilson@uth.tmc.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_35
323
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