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The Swedish laparoscopic duodenal switch—from omega-loop to Roux-en-Y

2015; Elsevier BV; Volume: 12; Issue: 2 Linguagem: Inglês

10.1016/j.soard.2015.10.063

1878-7533

Stephan Axer, Leif Hoffmann,

Gastroesophageal reflux and treatments

The biliopancreatic diversion with duodenal switch (BPD-DS) is considered to be the most effective bariatric procedure for introduction and maintenance of weight loss and resolution of obesity-related co-morbidities [[1]Buchwald H. Avidor Y. Braunwald E. et al.Bariatric surgery: systematic review and meta-analysis.JAMA. 2004; 292: 1724-1737Crossref PubMed Scopus (5477) Google Scholar]. Scopinaro described the biliopancreatic diversion (BPD) in 1979 with a partial distal gastrectomy, closure of the duodenal stump, a Roux-en-Y gastroenterostomy, and an anastomosis between the biliary and the alimentary limb 50 cm proximal to ileocecal valve [[2]Scopinaro N. Gianetta E. Civalleri D. Bonalumi U. Bachi V. Biliopancreatic by-pass for obesity. II. Initial experience in man.Br J Surg. 1979; 66: 618-620Crossref PubMed Scopus (438) Google Scholar]. To gain control of complications related to Scopinaro's procedure, the common channel was lengthened and the duodenal switch (DS) was added. The latter comprises a vertical sleeve gastrectomy with preservation of the pylorus and a duodenoileostomy [[3]Van Hee R.H. Biliopancreatic diversion in the surgical treatment of morbid obesity.World J Surg. 2004; 28: 435-444Crossref PubMed Scopus (46) Google Scholar]. In 1999 a laparoscopic approach for the DS procedure was introduced [[4]Ren C.J. Patterson E. Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients.Obes Surg. 2000; 10: 514-523Crossref PubMed Scopus (455) Google Scholar]. Study results concerning postoperative complication rates comparing open and laparoscopic DS are inconsistent [5Buchwald H. Estok R. Fahrbach K. Banel D. Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis.Surgery. 2007; 142: 621-635Abstract Full Text Full Text PDF PubMed Scopus (547) Google Scholar, 6Biertho L. Lebel S. Marceau S. et al.Perioperative complications in a consecutive series of 1000 duodenal switches.Surg Obes Relat Dis. 2013; 9: 63-68Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. This might be a result of the complexity of the surgery and the relatively small number of procedures performed worldwide. Internal herniation (IH) is a common complication after bariatric surgery. It has been shown that the closure of the mesenteric defects reduces the risk of IH and ileus. Closure of the mesenteric defects is technically challenging during standard laparoscopic DS with the entero-entero-anastomosis (EA) in the lower part of the abdomen. For successful advancement of the laparoscopic DS, the following 3 aims were defined that the novel procedure had to fulfill: (1) enhancement of the surgical workflow, (2) better overview of the correct positioning of the different limbs, and (3) facilitation of the closure of the mesenteric defects. The presented procedure accomplishes these targets. The main issue of the modified laparoscopic DS technique, also called SOFY-DS, is the chronology of performing the anastomoses and the positioning of the different limbs. SOFY refers to the sequential construction: started as an omega-loop, finished as Roux-en-Y. The SOFY-DS is a surgical option for patients with a BMI>50 kg/m2. In the preoperative course, a low calorie diet or very low calorie diet regimen for 3 to 4 weeks is mandatory. Patients receive a preoperative single-shot antibiotic with cefotaxime and standard antithrombosis prophylaxis. A 6-trocar technique is used with the patient in a supine American position. The surgeon is standing on the patient's right side almost throughout the surgery. Solely for the measurement and marking of the intestine, the surgeon must shift to the patient's left side. The vertical sleeve gastrectomy is performed over a 35-Fr bougie without reinforcement of the staple line. The duodenum is divided with a 60-mm linear stapler 3 cm distally of the pylorus. Starting at the ileocecal valve, the common channel is measured in 10-cm steps for 100 cm. The location of the ileoileostomy is marked with 2 sutures of different lengths. The shorter suture marks the common channel. The alimentary limb is measured for 150 cm, where the location for the duodeno-ileal anastomosis (DIA) is marked with a single suture. The bowel is brought into an antecolic position and placed in contact with the postpyloric duodenum as an omega-loop (Fig. 1, A-B). This maneuver ensures that the alimentary limb is placed in the right side of the abdomen, whereas the biliary limb is located on the left. The DIA is created as an end-to-side anastomosis, completely hand-sutured with a posterior anchor suture using a 3-0 resorbable suture. The ileum with the marked location for the EA is positioned in contact with the biliary limb 6 cm proximal to the DIA (Fig. 1, C-D). A side-to-side antiperistaltic anastomosis is performed with a 45-mm linear stapler. By dividing the bowel between the 2 anastomoses with a 60-mm linear stapler, the omega-loop-construction is transformed into a Roux-Y construction (Fig. 1, E-F). The mesenteric defects are closed with nonresorbable staples. In Sweden the laparoscopic gastric bypass with an antecolic omega-loop transferred into a Roux-en-Y construction is a broadly standardized and widespread procedure [[7]Olbers T. Lönroth H. Fagevik-Olsén M. Lundell L. Laparoscopic gastric bypass: development of technique, respiratory function, and long-term outcome.Obes Surg. 2003; 13: 364-370Crossref PubMed Scopus (161) Google Scholar]. Inspired by this technique, the SOFY-DS has been developed based on procedural details that are familiar among the majority of bariatric surgeons. Bariatric procedures with an intestinal omega-loop in an antecolic position have been described previously for the mini-gastric bypass [[8]Rutledge R. The mini-gastric bypass: experience with the first 1274 cases.Obes Surg. 2001; 11: 276-280Crossref PubMed Scopus (414) Google Scholar], the Roux-en-Y gastric bypass [[8]Rutledge R. The mini-gastric bypass: experience with the first 1274 cases.Obes Surg. 2001; 11: 276-280Crossref PubMed Scopus (414) Google Scholar], and the single anastomosis duodenoileostomy [[9]Sánchez-Pernaute A. Rubio Herrera M.A. Pérez-Aguirre E. et al.Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique.Obes Surg. 2007; 17: 1614-1618Crossref PubMed Scopus (144) Google Scholar]. With the SOFY-DS procedure the DIA is performed as an end-to-side anastomosis previously described by Weiner et al. in a publication comparing 3 different duodeno-ileal anastomotic techniques [[10]Weiner R.A. Blanco-Engert R. Weiner S. Pomhoff I. Schramm M. Laparoscopic biliopancreatic diversion with duodenal switch: three different duodeno-ileal anastomotic techniques and initial experience.Obes Surg. 2004; 14: 334-340Crossref PubMed Scopus (32) Google Scholar]. This has to be regarded as a variation of Baltasar's technique with a hand-sutured end-to-end duodeno-ileostomy [[11]Baltasar A. Bou R. Bengochea M. et al.Duodenal switch: an effective therapy for morbid obesity - intermediate results.Obes Surg. 2001; 11: 54-58Crossref PubMed Scopus (92) Google Scholar]. To perform the distal anastomosis after the proximal anastomosis and to transfer the initial omega-loop into a Roux-en-Y construction by division of the intestine between the 2 anastomoses is an essential feature of the laparoscopic gastric bypass technique described by Olbers and Lönroth [[7]Olbers T. Lönroth H. Fagevik-Olsén M. Lundell L. Laparoscopic gastric bypass: development of technique, respiratory function, and long-term outcome.Obes Surg. 2003; 13: 364-370Crossref PubMed Scopus (161) Google Scholar]. IH complicating laparoscopic DS has been reported by several authors [6Biertho L. Lebel S. Marceau S. et al.Perioperative complications in a consecutive series of 1000 duodenal switches.Surg Obes Relat Dis. 2013; 9: 63-68Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 12Khwaja H.A. Stewart D.J. Magee C.J. Javed S.M. Kerrigan D.D. Petersen hernia complicating laparoscopic duodenal switch.Surg Obes Relat Dis. 2012; 8: 236-238Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 13Mitchell M.T. Carabetta J.M. Shah R.N. O'Riordan M.A. Gasparaitis A.E. Alverdy J.C. Duodenal switch gastric bypass for morbid obesity: imaging of postsurgical anatomy and postoperative gastrointestinal complications.AJR Am J Roentgenol. 2009; 193: 1576-1580Crossref PubMed Scopus (16) Google Scholar]. Comeau et al. found an IH in 2.4% of patients who underwent laparoscopic DS and concluded that a primary closure of the mesenteric defects is crucial [[14]Comeau E. Gagner M. Inabnet W.B. et al.Symptomatic internal hernias after laparoscopic bariatric surgery.Surg Endosc. 2005; 9: 34-39Crossref Scopus (120) Google Scholar]. The SOFY-DS procedure facilitates the entire closure of the mesenteric defects, which is a basic requirement to minimize the risk of IH. Petersen's space may be closed from both sides if desired. The EA is located to the left of Petersen's space. Access to the peritoneal edge defining the defect behind the EA is more expedient than in a standard laparoscopic DS in which the anastomosis is located in the lower part of the abdomen. Exact exposure of the mesenteric defects and overview of the different limbs contribute to the prevention of kinking or bowel rotation. Scientific studies and surgical practice contribute to the acceptance of novel surgeries or advancements of established procedures. Improvement of surgical workflow and facilitation of certain steps are subjective parameters that can hardly be quantified when procedures are still new. In the authors' institution the median time of surgery has decreased with approximately by 5% to 134 minutes after implementation of the SOFY-DS procedure. The frequency of IH and time measurement of the substeps will be a matter of subsequent analysis and critical assessment.