Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1002_Библиотеки_им_академика_М_И_Перельмана
.pdf
324
Table 35.1 Summary of evidence of failure following duodenal switch
Author (year) N Study type Follow-up Failure denition Failure rate
Strain (2017) [5] 275 Prospective 1–9years Underwent additional
surgery for insufcient
weight loss
Risstad (2015) [6] 29 RCT 61months
(54–73)
Cloutier (2017) [7] 20 RCT 12months EWL<50% 0 (0%)
Skroubis (2014) [8] 130 Prospective 96months EWL<50% 5%
Hedberg (2012) [9] 47 RCT 4±1year EWL<50% 4.8%
Sovik (2011) [10] 61 RCT 2years BMI>40 0/27 (0%)
BMI>40 4 (14%)
J. L. Holihan and E. Wilson
30 (11%)
35.3 Reasons forFailure
To understand failure options, we need to understand reasons for failure. There are
several reasons why a patient may be unsuccessful.
35.3.1 Patient Comorbidities
Unrecognized patient comorbidities have the potential to lead to surgical failure.
Conditions such as alcoholism or other addictions can be missed preoperatively.
Consumption of excessive alcoholic beverages can lead to excess weight gain
through increased caloric intake from the beverages themselves and by leading to
poor judgment when making dietary decisions. Furthermore, calories from alcohol
are completely absorbed even after a duodenal switch, making the malabsorptive
component of the surgery ineffective. Careful preoperative screening can help to
avoid this problem.
35.3.2 Psychological Conditions
Psychological conditions can contribute to failure to achieve adequate weight
loss. Though most patients undergo psychological screening prior to surgery,
certain psychological conditions can be missed. A study of long-term outcomes
following duodenal switch demonstrated that of nine patients with weight loss
“failure,” six of them had an undiagnosed psychological condition [2]. Examples
of these conditions include bulimia, neuroses, and phobias. Thorough preoperative psychological evaluation is necessary to prevent missing these.
35 Surgery Failure: What Are theOptions?
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
325
35.3.3 Physiologic/Anatomic Reasons
There are anatomic reasons that can lead to poor weight loss following duodenal
switch. First, a gastric sleeve that is too large can negatively affect weight loss. Most
surgeons aim for a gastric volume of less than 200mL following surgery. Next,
inadequate limb length can be responsible for poor weight loss following duodenal
switch due to a lack of malabsorption. Malabsorption is a key component of weight
loss following a duodenal switch [11]. Most surgeons aim for a common channel
between 50 and 150cm and a biliopancreatic limb of 100–550cm to achieve this.
35.3.4 Lack ofSupport
In patients who have regained weight following bariatric surgery, many report feeling a lack of support from friends, family, and healthcare providers [12]. One study
showed that patients who are unmarried or unemployed were more likely to experience weight loss failure compared to others, suggesting that a lack of social support
may contribute to weight loss failure [2]. In addition, patients who skip follow-up
appointments have been shown in some studies to have more weight regain than
those who attend them [1]. Ensuring that a patient has access to adequate support
via healthcare providers and/or peer support groups may help to mitigate this.
35.3.5 Noncompliance withLifestyle Changes
Bariatric surgery is most effective when combined with lifestyle changes, including
improved nutrition and exercise habits. However, many patients are unable to maintain
this and adopt poor habits following surgery. This can lead to weight gain or failure to
lose weight. Such habits may include frequent snacking/grazing, high carbohydrate or
sweet intake, and high intake of liquid calories among other things. In addition, inactivity
and a sedentary lifestyle can contribute to surgical failure. Preoperative education and
setting long-term expectations are imperative to ensuring postoperative success.
Oftentimes, there is no one simple cause for surgical failure. Rather, the etiology
is multifactorial. Physicians should consider all of these options when evaluating a
post-duodenal switch patient for failure.
35.4 Patient Assessment
When a patient presents after duodenal switch with inadequate weight loss or weight
recidivism, a thorough history should be obtained. The history should focus on
behaviors such as alcohol intake and eating habits, which may help to uncover any
326
J. L. Holihan and E. Wilson
previously undiagnosed comorbidities and psychological conditions. A careful
dietary history should be taken including:
• Calorie consumption.
• Quality of diet, sweets.
• Portion size.
• Binge eating.
• Protein/carbohydrate intake.
• Snacking/grazing.
This will help uncover any unhealthy habits a patient may have. Food diaries can
be a useful adjunct in determining dietary behaviors. Patients should also be questioned about physical activity and dedicated exercise time. Pedometers or other
activity trackers may be utilized.
Next, the patient should be assessed for possible anatomic causes for the failure.
Patients with higher gastric volumes have been shown to have more weight gain
than those with lower gastric volume [1]. Sleeve size can be evaluated via upper GI
or EGD, with ideal size of less than 200mL.
Next, limb length should be assessed. In general, the common channel should be
100cm. The alimentary limb is 150cm. The biliopancreatic limb is 100–550cm
[13]. There is no easy way to determine limb length. Reviewing old operative reports
may provide this information; however, even operative reports can be inaccurate if
measuring was not meticulously performed. The most denitive method for measuring limb length is laparoscopy, but this is often unnecessary.
Since limb length is important to ensuring that the patient has adequate malabsorption, it can also be determined indirectly. Malabsorption can be measured by
measuring fecal fat, fat-soluble vitamin levels, and frequency of bowel movements.
Increased fecal fat levels are expected after duodenal switch, and normal levels may
indicate inadequate limb length [13]. In addition, bowel movements are generally
more frequent following duodenal switch, with patients experiencing around 20 per
week [14]. If a patient has no change in frequency of bowel movements following
surgery, this may also indicate a lack of malabsorption.
Finally, once it has been determined that there is no medical or psychological
history or anatomic reason for surgery failure, a patient’s resources and social support can be evaluated. Many patients will benet from closer follow-up and accountability, which may have been lacking. Evaluation of partner and household habits
may be prudent.
35.5 Options Following Failure
Treatment strategy will depend on ndings from the patient assessment; however,
treatments can be classied as medical or surgical.
35 Surgery Failure: What Are theOptions?
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
327
35.5.1 Medical Options
Some patients have no correctable anatomic abnormality with their duodenal switch.
These patients may benet from an intensive medical weight loss program. Such a
program is aimed at improving their dietary habits, improving food choices, and
increasing physical activity/exercise. Measuring basal metabolic rate can be a useful adjunct to give patients a better idea of their individual caloric needs. In addition,
such a program can provide support and accountability for patients that may help
them to adhere to a healthier new lifestyle.
In some cases, anti-obesity medications can be used in conjunction with nutrition
and exercise to improve weight loss. There are many weight loss medications available (Table35.2) [15]. There is a lack of high-quality evidence supporting these,
particularly after duodenal switch. However, small case series and observational
studies suggest possible benets following bariatric surgery. Referral to an obesity
medicine specialist who can prescribe and monitor an appropriate anti-obesity medication should be considered.
Another option for additional weight loss following duodenal switch is the use
of an oral superabsorbent hydrogel. Unlike anti-obesity medications, which can
have frequent adverse effects, oral superabsorbent hydrogels are pharmacologically inert and are actually marked as a medical device rather than as a medication. These superabsorbent hydrogels are comprised of a polymer matrix that can
absorb approximately 100 times their weight in water [16]. The particles function
by occupying space in the stomach and small intestine, with the goal of promoting fullness [16]. This has not been studied in post-bariatric surgery patients.
However, in non- bariatric surgery patients, patients treated with oral superabsorbent hydrogels had a higher percentage of weight loss compared to those treated
with placebo [17]. The most frequent side effects were mild gastrointestinal
effects. While further studies are needed, particularly in patients following bariatric surgery, oral superabsorbent hydrogels are a promising option for additional
weight loss.
Table 35.2 Anti-obesity
medications approved for
long-term use by the FDA
Anti-obesity medication Class
Phentermine-topiramate Sympathomimetic/
Orlistat Lipase inhibitor
Naltrexone-bupropion Amine reuptake inhibitor
Liraglutide GLP-1 receptor agonist
anti-epileptic
328
J. L. Holihan and E. Wilson
35.5.2 Surgical Options
Surgical options exist for patients found to have an anatomic abnormality on assessment. For those found to have a dilated sleeve, it is sometimes possible to perform
a re-sleeve gastrectomy. The technique for this is as follows: laparoscopic lysis of
adhesions is carefully performed to reveal the full sleeve. A 36–40 Fr bougie is
inserted. An area approximately 5cm proximal to the pylorus up to the esophageal
hiatus is completely cleared. A linear stapler is used to divide any redundancy in the
gastric sleeve along the bougie.
Another option for a dilated sleeve is an endoscopic sleeve gastroplasty. This is
an endoscopic technique that reduces stomach volume through plication. Plication
is not permanent and generally lasts 1–2years. This is often long enough to allow
patients to achieve additional weight loss. In this technique, 6–12 sutures are placed
in a running fashion starting at the antrum and moving proximally [18]. Patients are
put on a post-bariatric surgery liquid diet, just as if they had had a primary bariatric
surgery, following this procedure.
If a lack of malabsorption is thought to be the problem, the common channel can
be shortened. The channel should measure 100cm. The distal end of the biliopancreatic limb can be divided, and a new, distal anastomosis can be performed. An
alternative to this is increasing the length of the biliopancreatic limb, the bypassed
portion of the small bowel. The normal length of the biliopancreatic limb is variable, ranging from 100 to 550cm. The length of the patient’s current biliopancreatic
limb will determine how much it can be shortened.
35.6 Conclusions
Failure following duodenal switch is uncommon, with 0–14% of patients experiencing inadequate weight loss or weight recidivism. A careful and thorough patient
assessment can reveal the underlying etiology for failure, allowing for successful
treatment and improvement in weight loss.
References
1. Athanasiadis DI, Martin A, Kapsampelis P, Monfared S, Stefanidis D.Factors associated with
weight regain post-bariatric surgery: a systematic review. Surg Endosc. 2021;35(8):4069–84.
2. Sánchez-Cabezudo Diaz-Guerra C, Larrad JA.Analysis of weight loss with the biliopancreatic
diversion of Larrad: absolute failures or relative successes? Obes Surg. 2002;12(2):249–52.
3. Christou NV, Look D, Maclean LD.Weight gain after short- and long-limb gastric bypass in
patients followed for longer than 10 years. Ann Surg. 2006;244(5):734–40.
4. Andalib A, Alamri H, Almuhanna Y, Bouchard P, Demyttenaere S, Court O.Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve,
35 Surgery Failure: What Are theOptions?
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
329
Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis). Surg Endosc.
2021;35(8):4644–52.
5. Strain GW, Torghabeh MH, Gagner M, Ebel F, Dakin GF, Abelson JS, etal. The impact
of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years. Obes Surg.
2017;27(3):787–94.
6. Risstad H, Søvik TT, Engström M, Aasheim ET, Fagerland MW, Olsén MF, etal. Five-year
outcomes after laparoscopic gastric bypass and laparoscopic duodenal switch in patients with
body mass index of 50 to 60: a randomized clinical trial. JAMA Surg. 2015;150(4):352–61.
7. Cloutier A, Lebel S, Hould F, Julien F, Marceau S, Bouvet L, etal. Long alimentary limb
duodenal switch (LADS): a short-term prospective randomized trial. Surg Obes Relat Dis.
2018;14(1):30–7.
8. Skroubis G, Kouri N, Mead N, Kalfarentzos F.Long-term results of a prospective comparison
of Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese
population (BMI 35–50kg/m(2)). Obes Surg. 2014;24(2):197–204.
9. Hedberg J, Sundbom M.Superior weight loss and lower HbA1c 3 years after duodenal switch
compared with Roux-en-Y gastric bypass—A randomized controlled trial. Surg Obes Relat
Dis. 2012;8(3):338–43.
10. Søvik TT, Aasheim ET, Taha O, Engström M, Fagerland MW, Björkman S, etal. Weight loss,
cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial. Ann Intern Med. 2011;155(5):281–91.
11. Slater G, Duncombe J, Fielding GA.Poor weight loss despite biliopancreatic diversion and
subsequent revision to a 30-cm common channel after initial laparoscopic adjustable gastric
banding: an analysis of 8 cases. Surg Obes Relat Dis. 2005;1(6):573–9.
12. Tolvanen L, Svensson Å, Hemmingsson E, Christenson A, Lagerros YT.Perceived and preferred social support in patients experiencing weight regain after bariatric surgery-a qualitative
study. Obes Surg. 2021;31(3):1256–64.
13. Kumar R, Lieske JC, Collazo-Clavell ML, Sarr MG, Olson ER, Vrtiska TJ, et al. Fat malabsorption and increased intestinal oxalate absorption are common after Roux-en-Y gastric
bypass surgery. Surgery. 2011;149(5):654–61.
14. Elias K, Bekhali Z, Hedberg J, Graf W, Sundbom M.Changes in bowel habits and patientscored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal
switch. Surg Obes Relat Dis. 2018;14(2):144–9.
15. Gutt S, Schraier S, González Bagnes MF, Yu M, González CD, Di Girolamo G. Long-term
pharmacotherapy of obesity in patients that have undergone bariatric surgery: pharmacological prevention and management of body weight regain. Expert Opin Pharmacother.
2019;20(8):939–47.
16. Pass A, Bialonczyk D, Chiquette E, Goldman JD.Oral superabsorbent hydrogel (plenity) for
weight management. Ann Pharmacother. 2020;1060028020983046
17. Greenway FL, Aronne LJ, Raben A, Astrup A, Apovian CM, Hill JO, et al. A randomized,
double-blind, placebo-controlled study of Gelesis100: a novel nonsystemic oral hydrogel for
weight loss. Obesity (Silver Spring). 2019;27(2):205–16.
18. Winder JS, Rodriguez JH.Emerging endoscopic interventions in bariatric surgery. Surg Clin
North Am. 2021;101(2):373–9.
Chapter 36
Causes ofWeight Regain After Duodenal
Switch andIts Derivatives
AminAndalib
36.1 Introduction
Classic duodenal switch (DS) and its derivative procedures are shown to be more
effective than other common malabsorptive procedures such as Roux-en-Y gastric
bypass (RYGB) both in achieving durable weight loss and resolving comorbidities
[1–3]. However, certain reservations against classic DS like technical complexities
and potential side effects such as frequent bowel movements and fat, micronutrient,
and protein-calorie malnutrition render it unpopular and its practice to be scattered
into only a handful of high-volume centers worldwide. As a result, classic DS comprises less than 5% of the annual bariatric procedures performed globally [4, 5].
Over the past decade, certain modications have been introduced to the classic
DS procedure via the single anastomosis DS (SADS) derivatives, which have shown
promising results while addressing some of the apprehensions toward classic DS
procedure. The most established of these derivatives are the single anastomosis
duodeno-ileal bypass (SADI) and stomach intestinal pylorus-preserving surgery
(SIPS) [6, 7]. The modications implemented in SADS operations have the potential to change the procedure trends in the coming years especially in the current era
of predominance of sleeve gastrectomy (SG) and the potential need for effective
second-stage procedures for those with severe obesity with body mass index
(BMI)≥50kg/m2 and salvage surgeries for others with weight recidivism or refractory obesity-related comorbidities [8, 9].
Since its introduction in the late 1990s and despite the unpopularity and reluctance toward classic DS procedure [10, 11], there are several studies that report on
A. Andalib (*)
Department of Surgery, McGill University, Montreal, QC, Canada
Montreal General Hospital, Montreal, QC, Canada
e-mail: amin.andalib@mcgill.ca
© 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_36
331
332
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. Andalib
its long-term outcomes [12–14]. However, the literature on long-term outcomes of
the SADS derivatives is still lacking [15]. Moreover, information on weight loss
failure and regain after classic DS and its derivative procedures are even more
scarce. Nevertheless, this chapter aims to report on the incidence and the various
causes of weight regain after these hypo-absorptive bariatric procedures based on
the available body of literature.
36.2 Long-Term Outcomes ofDuodenal Switch
andDerivatives
36.2.1 Classic DS
Among established bariatric procedures, classic DS has been shown to offer patients
the most profound and sustained weight loss [16]. When compared to RYGB as the
most common malabsorptive procedure performed worldwide, classic DS is shown
to lead to a superior and sustained weight loss with a difference of an extra 7–9 BMI
points up to 5years after surgery especially in patients suffering from severe obesity
(BMI≥50kg/m2) [17, 18]. According to reports from high-volume centers with
large cohorts and long follow-up time >10years after surgery with excellent retention rates (72–92%), classic DS procedure leads to a sustained weight loss equivalent to 71–75% excess weight loss (EWL), 55kg in absolute weight loss, and a
20-point drop in the BMI [12–14, 19]. These drastic and decade-long weight loss
estimates are virtually identical among all these long-term case series from four
high-volume centers that include two of the original pioneering institutions where
classic DS was rst proposed and performed in.
As one of the pioneering centers, Hess et al. have provide a comprehensive
account of 1404 consecutive DS procedures performed at their institution over a
16-year period [19]. They obtained a complete follow-up on 92% of the 182 eligible
patients who had their surgery more than 10years prior and reported a mean of 75%
EWL after classic DS.Moreover, 94% of these patients had achieved and maintained a satisfactory weight loss of ≥50% EWL up to 12years after surgery [19].
Similarly, in their 20-year comprehensive account of consecutive DS procedures in
2615 patients, Marceau etal. also report a mean weight loss of 55.3kg equivalent to
a 71% EWL or a 20-unit drop in BMI that was maintained for 5 to 20years after
surgery with a mean follow-up time of 9.8years [12]. They had an overall 92%
complete follow-up for the entire cohort and 82% retention rate among the 383
patients that were at least 15years out from their DS procedures [12].
In another long-term study, Blockmans etal. report on the 10+ year outcomes of
153 patients that had undergone laparoscopic classic DS at their center (79% 10-year
follow-up rate) [13]. At a mean follow-up time of 10.8years, they observed a mean
absolute weight loss of 54kg and again a 20-point decrease in BMI [13]. Moreover,
when they grouped patients in those with morbid obesity vs. severe obesity (≥50kg/
36 Causes ofWeight Regain After Duodenal Switch andIts Derivatives
333
m2), they observed that the amount of weight loss was even more profound in the
heavier subgroup by a mean of 4units in their respective BMI drop [13]. These ndings demonstrate the long-term efcacy of the classic DS procedure in achieving a
profound and durable weight loss especially in patients suffering from severe
obesity.
In terms of long-term improvements in associated comorbidities, hypo- absorptive
procedures like the biliopancreatic diversion along with classic DS are also shown
to lead to profound and sustained improvements especially in metabolic syndrome
[1, 2, 12, 13]. In their 20-year comprehensive report with a mean follow-up of
9.8years after DS (92% follow-up rate; N=2615), Marceau etal. observed a 93.4%
sustained remission rate of diabetes (blood glucose<6mmol/L; glycated hemoglobin A1C<6.5%), where nearly 40% of the patients were diabetic at baseline; only
4% of those diabetics who obtained remission suffered a relapse but only after a
mean of 9.6years after surgery, and they observed no new incident cases of diabetes
in the patients that were not diabetic at baseline [12]. At a mean follow-up time of
nearly 11years after classic DS, Blockmans etal. also observed signicant rates of
long-term resolution of metabolic syndrome with 86% complete remission of diabetes and 81% and 95% resolution of hypertension and dyslipidemia, respectively
[13]. However, they observed an alarming 43% rate of de novo gastroesophageal
reux disease (GERD) in their cohort of 115 patients with at least 10years of follow- up after classic DS (gastroscopy was not performed systematically) [13]. This
statistic could be alarming given that SG as the restrictive component of classic DS
is a reux-generating procedure and GERD can potentially lead to Barrett’s esophagus, which in turn can progress from metaplasia to dysplastic disease and adenocarcinoma. Nevertheless, a recent population-level data comparing the reux-protective
procedure (RYGB) to the reux-prone procedures including SG and classic DS
(1860 classic DS procedures) did not show a signicant difference in the incidence
of esophageal cancer at a mean follow-up time of 7.6years and up to 12years after
bariatric surgery [20].
36.2.2 Single Anastomosis DS Derivatives
As mentioned earlier, the DS derivatives all aim to address some of the technical
and long-term nutritional concerns with the classic DS procedure. The two most
established and studied of these derivative operations are SADI (introduced in 2007)
and SIPS (introduced in 2016), which are essentially the same procedure with a
small difference in the length of their proposed common channel and are essentially
grouped together as SADS [6, 7].
As per the updated statement by the International Federation for the Surgery of
Obesity and Metabolic Disorders (IFSO) on SADS, as of March 2020, there were
only 42 case series and 8 case reports on SADS most of which were reported after
2018 [15]. Furthermore, studies with long-term data (≥5 years) are even more
scarce with only three studies from two centers all of which with small cohorts and
334
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. Andalib
low reported follow-up rates (<60%) [15]. There has only been one prospective
study comparing SADS with the classic DS but with only short-term outcomes
reported so far at 1year [21]. Hence, contrary to classic DS, there is a lack of data
on long-term outcomes of SADS, and the majority of reported information is
medium-term at best.
Two recent systematic reviews have demonstrated a sustained EWL of 85%
equivalent to a 19-point decrease in BMI units up to 2years after SADS [22, 23].
Between both systematic reviews, 13–42% of the included studies comprised of
SADS surgeries as salvage or second-stage procedures after a previous SG.As for
improvements in comorbidities, SADS derivatives are also shown to be associated
with 74% resolution of diabetes, 60–95% for hypertension, and 68–77% for dyslipidemia [22, 23]. Given the promising short- to mid-term outcomes especially in the
era of SG predominance and the need for salvage procedures especially for patients
suffering from severe obesity, SADS procedures have been endorsed by prominent
international bariatric societies including IFSO and the American Society for
Metabolic and Bariatric Surgery (ASMBS), who evidently call for more prospective
studies to assess outcomes [15, 24, 25].
36.3 Weight Regain After Duodenal Switch andDerivatives
36.3.1 Classic DS
The convincing long-term (≥10 years) efcacy of the classic DS procedure in
achieving profound and durable weight loss especially in patients suffering from
severe obesity has turned it into a superior procedure especially as a second-stage
surgery for super-super obese patients with BMI ≥ 60 kg/m2 [12, 13, 19, 26].
Conversions to classic DS have also been shown to have superior results or used as
ultimate revisional attempts to address signicant weight recidivism after other
common procedures including SG and RYGB [9, 27–29].
Various dichotomous denitions exist to describe success of weight loss after
bariatric surgery such as percent EWL, percent total weight loss, percent excess
BMI loss, or change in BMI [30]. Perhaps the most commonly used cutoff to dene
success after bariatric surgery is achieving ≥50% EWL, which is also not ideal
given the lack of correlation with specic factors such as improvements in comorbidities and other patient reported outcomes like quality of life and satisfaction [31].
Another limitation of using 50% EWL cutoff is that percent EWL may signicantly
overestimate primary weight loss failure in patients with severe obesity at baseline
(BMI>50kg/m2) compared to their lower weight counterparts due to distortion
from the initial BMI [32]. Furthermore, weight regain/recidivism is not dened in a
standard fashion and very poorly reported in various studies [32, 33]. Moreover,
given that weight regain always increases with time since both surgery and the nadir
weight, the timing of assessment should always be reported and considered when
interpreting the data, and weight regain should be reported a minimum of 3years
and ideally long-term (≥5years) after bariatric surgery [34]. Return to BMIs>35
Соседние файлы в папке Библиотека им академика М.И. Перельмана