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Bo abdominal w

Fig. 3.2 Ileum is marked at 100 and 250cm from the ileocecal valve and secured to the anterior abdominal wall at the 250cm mark before docking the robot

Duodenum

wel anchored to anterior

all

250 cm

100 cm

Y.-Y. Juo and R. Sudan

Pylorus

With the shaft of robotic arm 4, the liver is retracted. The gallbladder infundibulum is retracted laterally and inferiorly toward the right lower quadrant with arm 3, while the harmonic scalpel in arm 1 is used to dissect out the critical view. Once this is done, the cystic duct and artery are divided in the standard fashion and the gallbladder is dissected off the cystohepatic place using the harmonic scalpel from arm

1. We use indocyanine green and the rey mode to help identify the biliary structures to prevent injury to common bile duct or hepatic ducts.

3.5.4 Sleeve Gastrectomy

The sleeve gastrectomy portion of BPD-DS is performed in a similar fashion to standalone sleeve gastrectomy except the stomach is typically sized to be larger in capacity. First, the greater omentum is mobilized off the greater curvature of the distal stomach to the angle of His. Second, the sleeve gastrectomy is fashioned with a 40 French bougie inside the stomach, positioned to follow along the curvature of the lesser curvature. The stomach was divided from approximately 5cm proximal to the pylorus all the way to the angle of His. In our practice, we utilize multiple loads of 45mm linear cutter stapler (black load, Medtronic or equivalent) for dividing the thicker portion of the stomach near the antrum, and transition to a purple load at the more proximal, thinner, portion of the stomach. Staple line reinforcement of the surgeon’s preference is recommended. We routinely use Seamguards® (Gore, USA).

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3.5.5 Duodenal Dissection andDuodeno-Ileostomy

The duodenal dissection is the technical portion of the BPD-DS that is least familiar to bariatric surgeons not familiar with the procedure. While several different techniques exist, we mobilize the greater curvature of the stomach to about 4cm distal to the pylorus. In stand-alone sleeve gastrectomy, this dissection typically stops at 4–5cm proximal to the pylorus. At this point, the pylorus is retracted superiorly and the proximal duodenum is mobilized off the pancreas/retroperitoneal with the ultrasonic dissector. This dissection is carried distally and inferiorly until the gastroduodenal artery is visualized. This is approximately 4cm distal to the pylorus. A tunnel is created between the gastroduodenal artery and the posterior wall of the proximal duodenum until reaching a window at the superior edge of the duodenum. The duodenum is then divided with a 60mm linear staple load (tan load, Medtronic or equivalent). We minimize dissection at the superior border of the proximal duodenal stump in order to maintain perfusion of the anastomosis. Some authors have described dividing the right gastric for further mobilization of the stomach but we have typically not found the need to perform this maneuver.

We then retrieve the intestine that was anchored to the abdominal wall at the beginning of the case, which represents the ileum at 250cm from the ileocecal valve. An antecolic duodeno-ileal anastomosis is then fashioned between the ileum and the proximal duodenal stump. We rst secure the duodenal stump to the side of the ileal segment in an end-to-side fashion with a backrow of barbed absorbable suture. We then create enterotomies on each side before creating a full thickness handsewn anastomosis by circumferentially sewing the duodenal and ileal wall to each other (see Fig.3.3).

Fig. 3.3 Illustration of duodeno-ileal anastomosis and sleeve gastrectomy. This marks the completion of a SADI procedure

Proximal anastomosis

100 cm

Sleeve

Pylorus

100 cm common channel

Y.-Y. Juo and R. Sudan

At this point, we usually infuse indocyanine green through an orogastric tube to evaluate for dye extravasation to ensure water-tightness of the anastomosis. Alternatively, an esophagogastroduodenoscopy could be used to ensure patency of the anastomosis, absence of intraluminal bleeding, as well as allow an air leak test of the anastomosis.

3.5.6 Ileo-Ileal Anastomosis

The main difference between formal BPD-DS and SADI is whether the surgeon chooses to proceed with the creation of the ileo-ileostomy. Traditional Roux-en-Y conguration of BPD-DS requires transection of the BP-limb and creation of the ileo-ileostomy while the surgery is considered complete after creation of the duodeno- ileostomy in a SADI.

The proximal end of the ileal loop is then transected with a 60mm cutting stapler (tan load, Medtronic or equivalent), thus separating the biliopancreatic limb on the proximal end from the Roux limb on the distal end. We run the Roux limb in an antegrade fashion until identifying the previously placed marking suture at 100cm. A stapled side-to-side anastomosis is then performed between the ileum at the 100cm mark and the distal end of the biliopancreatic limb using a single load of 60mm linear stapler (tan load, Medtronic or equivalent). The common enterotomy is closed in a handsewn manner using a barbed absorbable suture (see Fig.3.4).

Fig. 3.4 The ileo-ileal anastomosis is performed to create a 100cm common channel, before the biliary limb is divided from the duodeno-ileal anastomosis

250 cm alimentary limb

Biliary limb

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3.5.7 Mesentery Defect Closures

At the end of the procedure, mesentery defects at the newly created ileo-ileal anastomosis and the duodeno-ileostomy are both closed with a running barbed nonabsorbable suture in order to reduce internal hernia risk in the future.

3.6 Post-operative Care

Guiding principles of postoperative care after DS are similar to other bariatric surgeries. Routine intensive care unit admission is not necessary, but we recommend telemetry and continuous pulse oximetry given high prevalence of sleep apnea in this patient population.

We generally allow patients to have sips for comfort with maintenance IV uid support as early as the evening of surgery. Pain is managed with a multi-modality regimen consisting of acetaminophen, ketorolac, and gabapentin. Oxycodone is only administered on an as needed basis if the pain is not controlled with the medications mentioned previously. Patients are required to ambulate on the evening of surgery and have pneumatic compression sleeves while in bed. Deep venous thrombosis chemoprophylaxis is typically started by the next morning after surgery. Incentive spirometry is also routinely used to prevent atelectasis and pneumonia.

By postoperative day 1, patients are started on their bariatric liquid diet regimen, consisting of 1–2Oz sips of clear liquid diet every 15min while awake. They are discharged home when pain and nausea are under control and they can demonstrate sufcient oral intake to maintain hydration.

Patients stay on the clear liquid diet until their 2–3week follow-up appointment, at which time nutritional supplementation with two multivitamins, Vitamin B12, Vitamin D, and calcium citrate are started in accordance with published guidelines [22]. They are routinely followed up at 3, 6, and 12months post-operatively, and then annually afterward. Follow-up frequency may be increased as needed for concerns related to failure to thrive.

3.7 Complications

DS is generally considered the most complex and technically challenging of bariatric procedures. Traditionally, higher morbidity and mortality rates were reported than gastric bypass [23]. However, it is important to keep in mind that these early gures also represent early learning curves in patients with higher BMI and procedures with longer operative times.

Y.-Y. Juo and R. Sudan

Certain complications from DS are common to other anastomotic bariatric procedures, and their incidence is proportional to the baseline risk prole of the patients. These include bleeding, pulmonary complications, bowel obstructions, anastomotic strictures, or leaks.

One of the most commonly feared long-term complications of DS is its potential for inducing nutritional deciencies from protein, vitamin, and mineral malabsorption. Many erroneously compared the DS to the historic jejunoileal bypass, citing its short common limb as a concern for malabsorption, whereas jejunoileal bypass actually derived its major poor outcomes as a consequence of its long blind loop resulting in bacterial overgrowth. In our experience, the long-term nutritional deciency risk can often be overcome by careful patient selection and follow-up. In a large case series [24], protein deciency occurs in up to 25% of patients in the rst 6months, but then gradually tapered off to only 5% during follow-up at 2years after surgery. Only 0.6% of patients ultimately required limb lengthening revisional procedures. Other micronutrient deciencies can be as prevalent as 30–60% despite compliant supplementation intake. However, micronutrient deciency is frequently present in morbidly obese patients even before surgery, sometimes up to 70% in several series [25].

All these concerns argue for a selective patient criteria and higher vigilance for both pre- and postoperative nutritional deciencies. Daily vitamin supplementation is a lifelong commitment that must be strongly emphasized during preoperative counseling.

3.8 Outcomes

Meta-analyses of available literature has repeatedly shown that BPD-DS is superior to all other bariatric procedures with regard to weight loss efcacy, resulting in

70.1% excess weight loss, in contrast to 61.2% for gastric bypass [26] and 49% for sleeve gastrectomy [27]. Furthermore, this difference is especially pronounced with patients with BMI over 50kg/m2. In a large case series of patients with super morbid obesity, Prachand et al. found BPD-DS patients to have higher percent excess weight loss, percent absolute weight loss, and percent change in BMI than patients undergoing gastric bypass during 3years of follow-up [18]. In another landmark multi-institutional randomized controlled trial, BPD-DS again demonstrated a higher excess BMI loss than gastric bypass (75 vs. 54%, p<0.001). Despite longer operative time and length of stay for the BPD-DS group, no signicant difference in morbidity or mortality was found in this trial [28].

Perhaps more important than the body weight loss, BPD-DS patients experienced more comprehensive resolution of obesity-related comorbidities including diabetes, hypertension, and sleep apnea. Prior literature has shown a 98% resolution of diabetes among BPD-DS patients, which is higher than 84% after gastric bypass [26] and 47% after sleeve gastrectomy [29]. Again, this effect is more pronounced

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in patients with super morbid obesity, with case series reporting 100% patients being free of all diabetic medications after BPD-DS, in comparison with 60% of patients after gastric bypass [18].

3.9 BPD-DS asRevisional Surgery forWeight Regain

With the accumulating prevalence of post-bariatric patients in the population, there is also an increasing concern for weight regain, usually resulting in recurrence of obesity-related comorbidities and decrease in quality of life [30]. In fact, up to

36.9% of gastric bypass patients have been reported to experience weight recidivism, dened as >25% weight gain from nadir, during a 6.9-year follow-up in a study by Cooper etal. [31] As the most effective and long-lasting bariatric procedure available, BPD-DS is now receiving increasing interest as a destination revisional procedure after weight regain following other bariatric procedures.

Laparoscopic sleeve gastrectomy has only begun to be performed as a standalone procedure since 2008 and by 2014 has become the most popular bariatric procedure both in the USA and worldwide [32]. Recently, data began to emerge that weight recidivism during follow-up beyond 12months could be substantial [33]. Weight regain in the order of 0.5–1.5kg/m2 in a slow upward trend fashion has been reported, with weight recidivism ranging from 5.7% at 2years to 75.6% at 6years [34]. When faced with recidivism, conversion from sleeve gastrectomy to BPD-DS has been shown to be more effective than other options such as “re-sleeve” or conversion to RYGB [35]. A large case series showed that 1-year conversion to BPD-DS resulted in larger BMI decrease, total weight loss, than either Roux-en-Y gastric bypass, SADI, or re-sleeve. Major 90-day and long-term complications were similar among all comparison groups [36].

Conversion of Roux-en-Y gastric bypass to a BPD/DS is a technically challenging undertaking, involving four anastomoses. Most existing literature consists of small sample-size case series [37]. In one study, average operative time was about

402.6min and mean EWL% after surgery was 64.1% [38]. A systematic review of revisional surgeries after RYGB for weight regain also showed that excess body mass index loss was the highest at 1- and 3-year follow-up for BPD-DS (47.6% and 47.3%, respectively), in comparison with alternative options such as distal bypass (54% and

52.2%, respectively) and gastric pouch/anastomosis revision (43.4% and 14%).

3.10 Summary

DS, or its recent derivative, SADI, remains the most effective bariatric procedure available. With a more stringent patient selection criteria and vigilant postoperative follow-up, DS can achieve excellent outcomes in weight loss and metabolic

Y.-Y. Juo and R. Sudan

syndrome resolution. Our comprehensive clinical guide describes our roboticassisted technique in performing DS in such a way as to maximize efciency in operating in different quadrants of the abdomen.

Key Learning Points

1. Duodenal switch (DS) remains the most effective bariatric operation currently

being practiced, both with regard to weight loss and resolution of obesity-related comorbidities.

2. Due to its higher risk for long-term nutritional deciencies, patient selection

criteria must be even more stringent for DS than other bariatric procedures. Currently it is frequently reserved for patients with BMI>50kg/m2 or severe, uncontrolled metabolic syndrome.

3. Single-anastomosis duodeno-ileal bypass (SADI) is recently receiving much

attention due to it being perceived as a less malabsorptive nature than a formal DS with Roux-en-Y duodeno-ileostomy conguration. The long-term efcacy of SADI in comparison with DS has yet to be proven.

4. DS is enjoying a recent surge in interest due to its role as an option for revisional

surgery for weight regain after sleeve gastrectomy. Its efcacy for weight loss has been shown to be higher than alternatives such as “re-sleeve” or conversion to Roux-en-Y gastric bypass.

References

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2. Sudan R, Jain-Spangler K. tailoring bariatric surgery: sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. J Laparoendosc Adv Surg Tech A. 2018;28(8):956–61. https://pubmed.ncbi.nlm.nih.gov/30059264/.

3. Estimate of Bariatric Surgery Numbers, 2011–2019 | American Society for Metabolic and Bariatric Surgery. 2021. https://asmbs.org/resources/estimate- of- bariatric- surgery- numbers.

4. 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;2013:974762.

https://pubmed.ncbi.nlm.nih.gov/24639868/.

5. Peterson K, Anderson J, Boundy E, Ferguson L, Erickson K.Rapid evidence review of bariatric surgery in super obesity (BMI ≥ 50 kg/m2). J Gen Intern Med. 2017;32(Suppl 1):56–64.

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6. Clapp B, Wynn M, Martyn C, Foster C, O’Dell M, Tyroch A.Long term (7 or more years) outcomes of the sleeve gastrectomy: a meta-analysis. Surg Obes Relat Dis. 2018;14(6):741–7.

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7. Scorpinaro N, Gianetta E, Civalleri D, Bonalumi U, Lombezzi R, Friedman D, et al. The bilio-pancreatic bypass for functional surgical treatment of obesity. Minerva Med. 1979;70(52):3537–47.

8. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8(3):267–82. https://pubmed.ncbi.nlm.nih.gov/9678194/.

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9. Ren CJ, Patterson E, Gagner M.Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg. 2000;10(6):514–23.

https://pubmed.ncbi.nlm.nih.gov/11175958/.

10. Sudan R, Puri V, Sudan D.Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique. Surg Endosc Other Interv Tech. 2007;21(5):729–33. https://pubmed.

ncbi.nlm.nih.gov/17308948/.

11. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García Pérez JC, Cabrerizo L, Díez Valladares L, et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8. https://pubmed.ncbi.nlm.nih.

gov/18040751/.

12. DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrk TC, Marcus TN.Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reux. Ann Surg. 1987;206(4):414–26. https://pubmed.ncbi.nlm.nih.gov/3662657/.

13. Roslin M, Tugertimur B, Zarabi S, Cottam D.Is there a better design for a bariatric procedure? The case for a single anastomosis duodenal switch. Obes Surg. 28:4077–86. https://pubmed.

ncbi.nlm.nih.gov/30288670/.

14. Kallies K, Rogers AM.American Society for Metabolic and Bariatric Surgery updated statement on single-anastomosis duodenal switch. Surg Obes Relat Dis. 2020;16:825–30. https://

pubmed.ncbi.nlm.nih.gov/32371036/.

15. Yashkov Y, Bordan N, Torres A, Malykhina A, Bekuzarov D. SADI-S 250 vs Roux-en-Y Duodenal Switch (RY-DS): results of 5-year observational study. Obes Surg. 2021;31(2):570–9.

https://pubmed.ncbi.nlm.nih.gov/33047290/.

16. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S–19S. https://

pubmed.ncbi.nlm.nih.gov/1733140/.

17. Gagner M, Matteotti R.Laparoscopic biliopancreatic diversion with duodenal switch. Surg Clin N Am. 2005;85:141–9. https://pubmed.ncbi.nlm.nih.gov/15619535/.

18. 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(2):211–20. https://pubmed.ncbi.nlm.

nih.gov/19937190/.

19. The ASMBS Textbook of Bariatric Surgery. The ASMBS textbook of bariatric surgery. NewYork: Springer; 2015.

20. Daher HB, Sharara AI. Gastroesophageal reux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions. World J Gastroenterol. 2019;25(33):4805–13. https://

pubmed.ncbi.nlm.nih.gov/31543675/.

21. Leyva-Alvizo A, Arredondo-Saldaña G, Leal-Isla-Flores V, Romanelli J, Sudan R, Gibbs KE, etal. Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery. Surg Obes Relat Dis. 2020;16(1):158–64. https://pubmed.

ncbi.nlm.nih.gov/31839526/.

22. Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L.American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727–41.

https://pubmed.ncbi.nlm.nih.gov/28392254/.

23. Hedberg J, Sundström J, Sundbom M.Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons. Obes Rev. 2014;15(7):555–63. https://

pubmed.ncbi.nlm.nih.gov/24666623/.

24. Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, etal. Duodenal switch: longterm results. Obes Surg. 2007;17(11):1421–30. https://pubmed.ncbi.nlm.nih.gov/18219767/.

25. Mohapatra S, Gangadharan K, Pitchumoni CS.Malnutrition in obesity before and after bariatric surgery. Dis Mon. 2020;66(2):100866. https://pubmed.ncbi.nlm.nih.gov/31301800/.

26. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, etal. Bariatric surgery: a systematic review and meta-analysis. J Am Med Assoc. 2004;292:1724–37. https://

pubmed.ncbi.nlm.nih.gov/15479938/.

27. Salminen P, Helmio M, Ovaska J, Juuti A, Leivonen M, Peromaa-Haavisto P, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity the SLEEVEPASS randomized clinical trial. JAMA. 2018;319(3):241–54. https://pubmed.ncbi.nlm.nih.gov/29340676/.

28. Søvik TT, Taha O, Aasheim ET, Engström M, Kristinsson J, Björkman S, etal. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg. 2010;97(2):160–6. https://pubmed.ncbi.nlm.nih.gov/20035530/.

29. Borgeraas H, Hofsø D, Hertel JK, Hjelmesæth J.Comparison of the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Obes Rev. 2020;21:e13011. https://pubmed.

ncbi.nlm.nih.gov/32162437/.

30. 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. https://pubmed.ncbi.nlm.nih.

gov/23996349/.

31. Cooper TC, Simmons EB, Webb K, Burns JL, Kushner RF.Trends in weight regain following Roux-en-Y gastric bypass (RYGB) bariatric surgery. Obes Surg. 2015;25(8):1474–81. https://

pubmed.ncbi.nlm.nih.gov/25595383/.

32. Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, etal. IFSO worldwide survey 2016: primary, endoluminal, and revisional procedures. Obes Surg. 2018;28(12):3783–94.

https://pubmed.ncbi.nlm.nih.gov/30121858/.

33. Mann JP, Jakes AD, Hayden JD, Barth JH. Systematic review of denitions of failure in revisional bariatric surgery. Obes Surg. 2015;25(3):571–4. https://pubmed.ncbi.nlm.nih.

gov/25515500/.

34. Himpens J, Dobbeleir J, Peeters G.Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg. 2010;252(2):319–24. https://pubmed.ncbi.nlm.nih.gov/20622654/.

35. Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A.Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis. 2015;11(1):79–85. https://

pubmed.ncbi.nlm.nih.gov/25304833/.

36. 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, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis). Surg Endosc. 2020;35(8):4644–52. https://pubmed.ncbi.nlm.nih.gov/32780238/.

37. Tran DD, Nwokeabia ID, Purnell S, Zafar SN, Ortega G, Hughes K, etal. Revision of RouxEn- Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg. 2016;26:1627–34. https://pubmed.ncbi.nlm.nih.gov/27138603/.

38. 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. https://pubmed.ncbi.nlm.nih.gov/28600114/.

Y.-Y. Juo and R. Sudan

Chapter 4

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Primary Single Anastomosis Duodenal Switch: Perspective fromaLengthy Experience

MitchellRoslin, MichaelMarchese, DaniyalAbbs, andDonnaBahroloomi

4.1 Historical Perspective ofWeight Loss Procedures

There is no consensus regarding the ideal bariatric procedure. Although different surgeries have gained popularity at points in bariatric history, all procedures have side effects and complications. It can be argued that side effects are an inherent issue with weight loss surgery. In comparison to the majority of surgical procedures that remove or repair damaged tissue, bariatric surgery creates a controlled abnormality. Thus, by design normal anatomy is distorted. The goal of bariatric surgery is nding the appropriate balance between lasting weight loss and unpleasant side effects or nutritional complications. To achieve this goal, either the stomach alone, or the stomach and intestine are altered.

Procedures that only manipulate the intestine, such as the jejunoileal intestinal bypass (JIB), were fraught with complications, often required reversal, and have been abandoned. However, both weight loss and lasting resolution of diabetes was achieved in numerous patients. Realizing the dangers of short bowel syndrome, Mason described the vertical banded gastroplasty (VBG) in 1982 [1]. He hypothesized that targeting the stomach was safer and with decreased risk for anemia, bone loss, and other issues that result from intestinal manipulation. Although true, other issues became apparent with this procedure. The xed outlet and vertical staple line creates a high-pressure system resulting in staple line dehiscence, gastroesophageal reux disease (GERD), and maladaptive eating of calorically dense foods which pass with less effort [2]. A study published by the Mayo Clinic in 2000 demonstrated that fewer than 25% of patients who underwent VBG were content with their long-term results [3].

M. Roslin (*) · M. Marchese · D. Abbs · D. Bahroloomi Lenox Hill Hospital, New York City, NY, USA e-mail: MRoslin@northwell.edu; Dbahroloomi@northwell.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_4

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31.08.202626 Мб0Книга_1004_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_1005_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_1006_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_1007_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_1008_Библиотеки_им_академика_М_И_Перельмана.pdf