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40 Endoscopic Treatment ofWeight Regain inDuodenal Switch
379
References
1. Anderson B, Gill RS, de Gara CJ, Karmali S, Gagner M.Biliopancreatic diversion: the effectiveness of duodenal switch and its limitations. Gastroenterol Res Pract. 2013;2013:1–8.
2. El Ansari W, Elhag W.Weight regain and insufcient weight loss after bariatric surgery: denitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps—a scoping review. Obes Surg. 2021;31(4):1755–66.
3. Pereira SS, Guimarães M, Almeida R, Pereira AM, Lobato CB, Hartmann B, et al.
Biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) result in distinct post-prandial hormone proles. Int J Obes. 2019;43(12):2518–27.
4. Marceau P, Biron S, Marceau S, Hould F-S, Lebel S, Lescelleur O, et al. Biliopancreatic
diversion- duodenal switch: independent contributions of sleeve resection and duodenal exclusion. Obes Surg. 2014;24(11):1843–9.
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. Nett PC, Kröll D, Borbély Y. Re-sleeve gastrectomy as revisional bariatric procedure after
biliopancreatic diversion with duodenal switch. Surg Endosc. 2016;30(8):3511–5.
7. Gagner M, Rogula T.Laparoscopic reoperative sleeve gastrectomy for poor weight loss after
biliopancreatic diversion with duodenal switch. Obes Surg. 2003;13(4):649–54.
8. Marrache MK, Al-Sabban A, Itani MI, Sartoretto A, Kumbhari V.Endoscopic sleeve gastroplasty by use of a novel suturing pattern, which allays concerns for revisional bariatric surgery.
VideoGIE. 2020;5(4):133–4.
9. Topart PA, Becouarn G.Revision and reversal after biliopancreatic diversion for excessive side
effects or ineffective weight loss: a review of the current literature on indications and procedures. Surg Obes Relat Dis. 2015;11(4):965–72.
10. Nedelcu M, Noel P, Iannelli A, Gagner M.Revised sleeve gastrectomy (re-sleeve). Surg Obes
Relat Dis. 2015;11(6):1282–8.
11. Li S, Jiao S, Zhang S, Zhou J. Revisional surgeries of laparoscopic sleeve gastrectomy.
Diabetes Metab Syndr Obes. 2021;14:575–88.
12. Maselli DB, Alqahtani AR, Abu Dayyeh BK, Elahmedi M, Storm AC, Matar R, etal. Revisional
endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study. Gastrointest Endosc. 2021;93(1):122–30.
13. Neto MG, Moon RC, de Quadros LG, Grecco E, Filho AC, de Souza TF, et al. Safety and
short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report
from a multicenter study. Surg Endosc. 2020;34(10):4388–94.
Chapter 41
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Conversion ofGastric Bypass toDuodenal
Switch
GaryAghazarian, RomuloLind, andAndreTeixeira
41.1 Introduction
The most common bariatric procedure in 2013 was the Roux-en-Y gastric bypass
(RYGB); however, there is a trend in reducing its proportion worldwide, while
sleeve gastrectomy is rising [1]. Due to its wide use and rates of weight regain or
insufcient weight loss, RYGB patients with failure of treatment can become even
more common over the next several years. For this reason, bariatric surgeons should
know how to correctly evaluate and treat these patients.
41.2 Gastric Bypass Failure
The most commonly used criterion for failure is an excess weight loss lower than
50%, although there is no uniform or internationally recognized denition for what
constitutes failure of bariatric surgery. Some authors described failure of the procedure based on weight regain or an inadequate excess weight loss. The recurrence of
comorbidities can indicate a failure of surgery [1]. This theory can hold true even in
patients who present an adequate excess weight loss (EWL). Several studies have
shown rates of up to 54% failure to lose weight or weight recidivism. RYGB patients
can have 23% of weight regain from nadir weight [2]. Therefore, the necessity of
reoperation is based upon inadequate excess weight loss, weight regain, and/or lack
of comorbidity improvement.
G. Aghazarian (*) · R. Lind · A. Teixeira
Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health,
Orlando, FL, USA
e-mail: romulo.lind@orlandohealth.com
© 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_41
381
382
G. Aghazarian et al.
41.3 Surgical Options
There are many surgical options described including banding, gastric pouch revision, gastrojejunal anastomosis revision, conversion to distal gastric bypass, and
endoscopic revision. Conversion to biliopancreatic diversion with duodenal switch
(BPD-DS) is an alternative to get the best long-term weight loss and control of
comorbidities [1]. This procedure is complex and technically challenging due to
the several steps required to accomplish the surgery. As described in detail below,
the surgeon must take down the gastrojejunostomy, reestablish the gastrogastric
continuity, perform the sleeve gastrectomy, reverse the jejunojejunostomy, and
complete the duodenal switch. The procedure can be done in a single- or two-step
manner [3].
41.4 Surgical Treatment
Using the da Vinci Xi robotic platform, this procedure is performed using the following trocars placed along the same transverse axis: 8mm at the right midaxillary
line, 12mm at the right midclavicular line, 8mm superior to the umbilicus, 12mm
at the left midclavicular line, and 8mm at the left midaxillary line. A 5mm trocar is
entered at the subxiphoid area for placement of a liver retractor.
With the patient in the Trendelenburg position, running the small intestine
approximately 250 cm from the ileocecal valve, the surgeon will mark this
point of the ileum with a Vicryl stitch. The small intestine just proximal to this
suture is then marked with a skin marker. Prior to docking the robot, the patient
is placed in reverse Trendelenburg position. The robot is then docked at the
patient’s side.
41.4.1 Part 1: Gastrogastrostomy Creation
First attention is directed at the gastrojejunostomy. Adhesions are taken down to
clearly identify the gastric pouch, gastric remnant, and alimentary (Roux) limb of
the gastric bypass. Using a linear stapler, the Roux limb is transected at the gastrojejunostomy. A side-to-side anastomosis is made between the gastric pouch and
gastric remnant using a linear stapler in order to restore the normal anatomy of the
stomach. If the tissue is too thick for the stapler, a hand-sewn anastomosis in a twolayer fashion will be warranted. After creation of the stapled anastomosis, the common gastrostomy is closed with a running absorbable suture in a one- or two-layer
fashion. A 40 French (F) ViSiGi tube is passed through the anastomosis to ensure it
is not too tight.
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41.4.2 Part 2: Sleeve Gastrectomy
Using the bipolar vessel sealer energy device, the greater curvature of the stomach
is devascularized and mobilized approximately 4–6cm from the pylorus superiorly
to the left crus of the diaphragm. After mobilization, the 40F ViSiGi tube is passed
into the antrum in order to guide gastric division. If a hiatal hernia is noted during
the procedure, repair is indicated to reduce postoperative gastroesophageal reux
and retained elements of the stomach leading to impaired weight loss. Creation of
the gastric sleeve utilizes a thick tissue cartridge with a linear stapler. Stapling must
be conducted in the same horizontal plane to avoid functional obstruction caused by
a spiral-sleeve contour. Stapling along the bougie should not be overly tight, as
improper staple ring may occur. The stapling will begin 4–6cm above the pylorus
to spare much of the antrum. The stapling should be performed approximately 1cm
away from the bougie to create a sleeve that is not as tight as a traditional sleeve
gastrectomy. The duodenal switch patient will endure both restriction from the
sleeve and malabsorption from the switch component. A “looser” sleeve will help to
ensure that these patients do not become malnourished from providing too much
restriction.
41.4.3 Part 3: Reversal ofJejunojejunostomy
The previous jejunojejunostomy is divided using the linear stapler. The distal end of
the biliopancreatic limb is reconnected to the proximal end of the gastric bypass
Roux limb. This anastomosis is performed in a side-to-side fashion [3]. The common enterotomy is closed via stapler or with an absorbable suture.
41.4.4 Part 4: Duodenoileostomy Creation
Duodenal Transection: Excessive visceral fat may complicate the dissection, and
bleeding can blur the tissue planes. Due to this, the duodenal transection can be
technically demanding; however, it is critical to minimize excessive duodenal
devascularization and injury to the duodenum and pancreas. With lateral retraction
of the antrum to linearize the rst portion of the duodenum, free the peritoneum on
the inferior and superior portions of the duodenum, until the duodenum fuses posteriorly with the pancreas. A curved instrument such as the tip-up fenestrated grasper
can be used to create this retroduodenal tunnel. After the tunnel is created, a Penrose
drain can be placed around the duodenum to help aid with exposure. Posteriorly
through this window, a stapler cartridge can be applied while avoiding the gastroduodenal artery. The duodenal stump staple line is inspected for bleeding and/or
384
G. Aghazarian et al.
poor perfusion. Reinforcement of the staple line usually is not necessary unless
there is any concern for healing.
Duodenoileostomy Creation: The ileum marked at 250cm from the terminal
ileum is brought superiorly to the rst portion of the transected duodenum. If there
appears to be too much tension in reaching this point, the greater omentum can be
opened toward the patient’s right, allowing the ileum to be connected with the duodenum. If signicant tension still remains on the alimentary limb, it can be brought
through a mesocolic window opposed to the omental window. Using an absorbable
suture, the ileum is lined up to the duodenum by creating the posterior outer row of
the anastomosis.
The duodenoileostomy anastomosis may be implemented with many techniques; understanding each technique allows for surgical flexibility depending
on differing anatomy. The techniques include hand-sewn technique and linear
stapler technique. If the procedure were to be done via the laparoscopic
approach, a third technique is available utilizing the circular stapler, which is
detailed in Chap. 28.
The hand-sewn technique constructs more consistent sizing of anastomosis than
either technique involving stapler use. Enterotomies are made along the entire
length of the duodenum and ileum using the robotic scissors with monopolar energy.
The inner layer of the anastomosis is created with an absorbable suture starting with
the inner posterior row. The inner layer is completed with anterior closure. The
suture from the posterior outer layer may be run along the anterior aspect of the
connection to complete the two-layer anastomosis. The ViSiGi tube is passed into
the antrum of the stomach with administration of methylene blue dye and air to test
the anastomosis for leak or stricture.
In the linear staple technique, an enterotomy is made in the ileum and duodenum.
A stapler is inserted, but due to difcult alignment of the stapler to form the anastomosis, two rings are often necessary. Lastly, the common enterotomy is hand-sewn
closed. Due to these angulation challenges, there is inconsistency in the size and
shape of anastomosis with this method.
Alimentary Limb Creation: Using the linear stapler, the ileum just proximal to
the anastomosis is transected along with a portion of its mesentery to prevent undue
tension on the duodenoileostomy. The alimentary limb is then counted for 125cm
starting proximally at the duodenoileostomy toward the terminal ileum. At the
125cm mark, a suture is used to approximate the alimentary limb to the distal biliopancreatic limb for creation of the ileoileostomy.
41.4.5 Part 5: Ileoileostomy Creation
A second suture may be placed between the alimentary and biliopancreatic limb to
aid with insertion of the linear stapler. Using the robotic scissors with monopolar
energy, small enterotomies are made in each limb. A linear stapler is inserted to
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create a side-to-side functional end-to-side anastomosis. The common enterotomy
is closed using a single-layer stitch to avoid narrowing of the anastomosis. Lastly,
the mesenteric defect is closed.
41.4.6 Part 6: Surgery Completion
The robotic instruments are removed, and the robot is undocked from the
patient’s side. The abdomen is irrigated and suctioned dry. A drain is placed
near the duodenal dissection and duodenal stump. The sleeve gastrectomy
specimen is delivered from the abdomen; the fascia at the 12mm ports and skin
incisions are closed.
41.5 Postoperative Care
Telemetry and the use of continuous pulse oximetry can aid in the detection of early
postoperative complications. Patients are NPO with IV uid administration until the
following morning. Patients should be placed on chemoprophylaxis for venothromboembolism and should ambulate within 4h of the surgery. Patients with obstructive sleep apnea should utilize their at-home airway device to maintain patency.
Spirometry and other respiratory therapy may be utilized to decrease incidence of
pneumonia and atelectasis following surgery [4].
An upper gastrointestinal study is performed on postoperative day 1. A drain
amylase level is sent to assess for pancreatic injury. If both these studies are within
normal limits, the patient may be started on a phase one bariatric diet.
Many patients may be discharged on the second to third postoperative day.
Others, especially those with longer, more extensive procedures, may require an
extended stay. The patients may have less predictable comorbidities. For 2weeks
following the operation, patients will stay on a puree diet and transition to solid
foods over the course of one month.
For 2weeks after surgery, patients are instructed to take Eliquis 2.5mg twice
daily for prophylaxis against portal vein and lower extremity deep vein
thrombosis.
For one month after surgery, patients are instructed to take:
• Proton pump inhibitor
• Multivitamin with iron
• Vitamin D
• Calcium citrate
• B complex vitamin
• 80–90g of protein daily (as a liquid)
• Vitamin A (indenitely)
386
These patients are followed regularly in the ofce with laboratory blood work at
the 3-month, 6-month, and 1-year postoperative mark. Depending on the patient
condition and any vitamin/nutritional deciencies, the follow-up period can be
extended to every 6months to 1year thereafter.
G. Aghazarian et al.
41.6 One Stage Vs. Two Stage
As with any extensive procedure, the patient must be able to withstand the stress of
the operation from a physiological standpoint. There are several factors that should
persuade a surgeon to perform the conversion in a one-stage versus two-stage operation. Preoperatively, if the patient has any signs of physiologic compromise (coronary artery disease, pulmonary disease, chronic renal failure, etc.), they may be
better suited to undergo the conversion in two stages.
Intraoperatively, there are many factors that can weigh into this decision. If the
gastric pouch is less than 4cm in size, these patients are at an increased risk of gastrogastric anastomotic leak. For this reason, the surgeon should complete up to part
2 (sleeve gastrectomy) or part 3 (reversal of jejunojejunostomy) and complete the
second stage at a later date, usually 3–6months postoperatively. Other intraoperative factors that may persuade toward a two-stage operation are listed below:
• Physiological compromise in the patient
• Patients unlikely to tolerate prolonged general anesthesia
• Presence of adhesions
• Hepatomegaly
• Liver cirrhosis
• Torque on instruments [5]
41.7 Traditional Vs. Single Anastomosis
Revision to BPD-DS (traditional duodenal switch) can be done in one or two stages
and involves four anastomoses: gastrogastrostomy, duodenoileostomy, ileoileostomy, and jejunojejunostomy (to reconnect the old Roux limb) [6]. The single-
anastomosis duodenal-ileal bypass (SADI-S) was introduced by Sanchez-Pernaute
etal. in 2007 [7]. The reason for this modication was to eliminate the distal ileoileal
anastomosis. The rationale for removing this portion of the procedure was to
decrease the operative time as well as the added risk for leak, obstruction, or internal
hernia through the newly created mesenteric defect. Several reports with up to
5years of follow-up have demonstrated the safety and efcacy of this procedure [8].
However, the SADI-S has not been universally embraced. As of March 2020, the
American Society for Metabolic and Bariatric Surgery (ASMBS) updated its stance
on the single-anastomosis duodenal switch stating “…the ASMBS has reached the
conclusion that SADI-S provides similar outcomes to those reported after classic
41 Conversion ofGastric Bypass toDuodenal Switch
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387
DS and should therefore be endorsed….” Upon this review, the committee found
that the currently available peer-reviewed literature did not suggest outcomes that
will differ substantially from those seen with the classic DS [9].
Moon etal. (2019) found evidence to suggest that conversion to BPD-DS may
result in faster weight loss than conversion to a SADI-S, but both procedures provided signicant additional weight loss after conversion from RYGB [10]. For this
reason, it is imperative for the bariatric surgeon to consider the SADI-S as a legitimate procedure for conversion from gastric bypass. This especially holds true when
operative times are prolonged. As stated above, there may be an overall benet to
only performing three anastomoses (gastrogastrostomy, duodenoileostomy, and
jejunojejunostomy) as opposed to four for which further research is warranted.
41.8 Results
Due to the complexity of the conversion of the RYGB to SADI-S and BPD-DS, the
procedure is not commonly performed. For this reason, the research is limited in the
safety and efcaciousness of the conversion. Parikh etal. (2007) demonstrated dramatic weight loss after revision, with EWL of 62.7%, overall mean weight loss of
35.5kg, and mean BMI decrease of 10.5kg/m2. The comorbidities resolved completely in all patients, and no mortality or reoperation for leakage or malnutrition
was reported [7]. The sample size for this study included 12 patients for analysis.
Halawani et al. (2017) demonstrated a mean EWL of 64.1% and mean BMI
decrease of 9.8kg/m2. Their results indicated that conversion of failed RYGB to
BPD-DS is laparoscopically or robotically safe and effective [11]. This retrospective chart review included nine patients.
41.9 Conclusions
The conversion from RYGB to duodenal switch is a feasible surgery. With careful
patient and procedure selection, great excess weight loss and improvement of comorbidities can be obtained. However, it has not gained wide acceptance due to the complexity of the procedure and the concern for long-term severe malnutrition. Further
research is warranted to better understand the long-term effects of this conversion.
References
1. Ettinger J, Azaro E, Weiner R, Higa KD, Galvao Neto M, Fernandes Teixeira A, etal., editors. Gastric bypass: bariatric and metabolic surgery perspectives. 1st ed. Springer Nature:
Cham; 2020.
2. Homan J, Betzel B, Aarts EO, van Laarhoven KJHM, Janssen IMC, Berends FJ.Secondary
surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with
duodenal switch. Surg Obes Relat Dis. 2015;11(4):771–7.
388
3. Maleckas A, Gudaitytė R, Petereit R, Venclauskas L, Veličkienė D.Weight regain after gastric
bypass: etiology and treatment options. Gland Surg. 2016;5(6):617–24.
4. Mechanick JI, Apovian C, Brethauer S, etal. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures.
Endocr Pract. 2019;25(12):1346–59. https://doi.org/10.4158/GL- 2019- 0406.
5. Still C, Sarwer DB, Blankenship J, American Society for Metabolic and Bariatric Surgery. The
ASMBS textbook of bariatric surgery, vol. 2. Springer eBooks. 2014.
6. Parikh M, Pomp A, Gagner M.Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis.
2007;3(6):611–8.
7. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García Pérez JC, Cabrerizo L, Díez
Valladares L, etal. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8.
8. Moon RC, Kirkpatrick V, Gaskins L, Teixeira AF, Jawad MA. Safety and effectiveness of
single- versus double-anastomosis duodenal switch at a single institution. Surg Obes Relat
Dis. 2019;15(2):245–52.
9. Kallies K, Rogers AM, American Society for Metabolic and Bariatric Surgery Clinical Issues
Committee. American Society for Metabolic and Bariatric Surgery updated statement on
single- anastomosis duodenal switch. Surg Obes Relat Dis. 2020;16(7):825–30.
10. Moon RC, Alkhairi L, Wier AJ, Teixeira AF, Jawad MA. Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI-S and BPD-DS) for weight regain. Surg Endosc.
2020;34(10):4422–8.
11. Halawani HM, Bonanni F, Betancourt A, Antanavicius G.Conversion of failed Roux-en-Y
gastric bypass to biliopancreatic diversion with duodenal switch: outcomes of 9 case series.
Surg Obes Relat Dis. 2017;13(8):1272–7.
G. Aghazarian et al.
Chapter 42
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Management ofDuodenal Stump Blowout
KarthikPittala, NolanReinhart, DesmondZeng, JosephA.Sujka,
andChristopherG.DuCoin
42.1 Introduction
Duodenal switch has been shown to provide the highest excess body weight loss of
all bariatric surgeries, but along with these benets comes increased risk of perioperative complications including duodenal stump blowout (DSB) [1]. DSB is an
infrequent but potentially disastrous complication after duodenal switch which
involves loss of integrity of the closure of the duodenal stump. It can lead to severe
diffuse inammation in the peritoneal cavity and global sepsis if not treated
promptly. There are multiple treatment options for stump blowout depending on the
severity of the leakage and inammation present. These include a conservative management strategy with antibiotics and parenteral nutrition or invasive management
including percutaneous drain placement and surgical reoperation.
42.2 Presentation ofStump Blowout
DSB can occur in any operation involving creation of a duodenal stump, such as
gastrectomy or duodenal switch. Patients typically present with vague symptoms
such as tachycardia, nausea, vomiting, fatigue, and abdominal pain. The abdominal
pain can vary inlocation and severity with no pathopneumonic pattern. On physical
exam, the patient’s abdomen may be distended, tympanic, and tender. There may be
signs of peritonitis such as rebound tenderness, rigidity, and guarding. The patient
may also show signs of dehydration or anemia if there has been recurrent emesis or
associated hemoperitoneum [2, 3]. If the patient has a surgical drain, there may be
K. Pittala · N. Reinhart · D. Zeng · J. A. Sujka (*) · C. G. DuCoin
Department of Surgery, University of South Florida Morsani College of Medicine,
Tampa, FL, USA
© 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_42
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