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Exploring the Role of Single Anastomosis Bariatric Surgery

| September 1, 2016

by Eric J. DeMaria, MD, and Antonio J. Torres MD, PhD, FACS, FASMBS

Dr. DeMaria is Director of Bariatric Surgery, Bon Secours Maryview Medical Center, Portsmouth, Virginia; Bon Secours Surgical Specialists, Surgical Weight Loss Center, Suffolk, Virginia. Antonio J. Torres MD, PhD, FACS, FASMBS

Dr. Torres is Chief General Surgery Service Department of Surgery, Complutense University of Madrid, Hospital Clinico “San Carlos” Madrid, Spain. He is also the Past President of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO [2011–2012), Chairman Board of Trustees for IFSO (2015-present), and Governor Capítulo Español del American College of Surgeons (ACS)

Bariatric Times. 2016;13(9):10–12.


Single anastomosis bariatric surgery has flourished in many places around the world over the past decade. Although the “loop” anatomy was rejected many years ago by pioneering bariatric surgeons, the advent of the procedure commonly called “the mini gastric bypass” re-introduced the concept and has convinced many surgeons around the world of its value.

Critics claim concerns about bile reflux and even GI malignancy. Surgeons from the United States have been particularly slow to adopt the single anastomosis gastric bypass procedure. Proponents argue that the Roux anatomy is not an essential component for a successful bariatric procedure and actually introduces more risk than the loop configuration.
Recently, a number of investigators have begun performing a modified duodenal switch procedure using a similar loop configuration, arguing that the distal small bowel anastomosis is particularly difficult from a technical standpoint and that there is no reason to believe that a Roux configuration is beneficial as a component of the duodenal switch procedure.

Here, we review the origin and available data of single anastomosis DS. We also highlight a full-day course on single anastomosis bariatric procedures taking place during the XXI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)

Single-anastomosis Duodenal Switch
The single anastomosis DS is also known by the following names:
•    Stomach Intestinal Pylorus Sparing Surgery (SIPS)
•    Single Loop DS
•    Single-Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy (SADI-S)

Origin. First described in 2007 by Sánchez-Pernaute et al[1] as “proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy,” this technique is based on the biliopancreatic diversion with duodenal switch (BPD-DS). After the sleeve gastrectomy is performed, the duodenum is anastomosed to the ileum in a Billroth-II fashion. A 200-cm common channel-alimentary limb is devised (Figure
1
and Figure
2
).

Sánchez-Pernaute et al anticipated an appropriate weight loss, at least similar to that obtained after gastric bypass, and noted the following theoretical benefits for operated patients: a shorter operative time, the performance of only one anastomosis, and no mesentery opening.

Data. Currently, four published studies with 222 total patients (including second-stage patients) with follow-up from 18 months to 5 years are available in the literature. The American Society for Metabolic and Bariatric Surgery (ASMBS) referenced these studies in a recent statement on single-anastomosis duodenal switch.[2] Presently, the ASMBS considers single-anastomosis duodenal switch procedures investigational and encourge publication of short- and long-term safety and efficacy outcomes.
1.) 2013: Sánchez-Pernaute A, Rubio MA, Pérez-Aguirre E, et al. Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients.
Sánchez-Pernaute et al[3] studied the single-anastomosis duodenoileal bypass with sleeve gastrectomy in a series of 100 patients who were consecutively operated on at a tertiary center university hospital. They analyzed patients’ weight loss and metabolic results and found the following:
•    Mortality/complications
-No mortality and no severe complications developed.
•    Weight loss
-Mean excess weight loss of more than 95 percent maintained during the follow-up period.
•    Comorbidities
-More than 90 percent of the patients experienced complete remission of type 2 diabetes mellitus (T2DM).
-Hypertension was controlled in 98 percent of the patients and remission rate was 58 percent.

2.) 2015: Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy by Sánchez-Pernaute A, Rubio MA, Conde M, et al.
Sánchez-Pernaute et al[4]published results of a second study on single-anastomosis duodenoileal bypass with sleeve gastrectomy in 2015. The study included 16 patients who underwent sleeve gastrectomy and then submitted to a single-anastomosis duodenoileal bypass with a 250-cm common channel.The authors analyzed weight loss and co-morbidities resolution.
•    Mortality/complications
-No postoperative complications
•    Weight loss
-Mean excess weight loss of 72 percent two years after the second-step surgery.
•    Comorbidities
-88 percent of patients experienced complete remission of T2DM
-60 perecent of patients experienced complete remission of hypertension,
-40 percent of patients experienced complete remission of dyslipidemia.

3.) 2015: Cottam A, Cottam D, Medlin W, et al. A matched cohort analysis of single anastomosis loop duodenal switch versus Roux-en-Y gastric bypass with 18-month follow-up. Cottam A et al[5] published results of a retrospective matched cohort study of 108 patients: 54 patients had gastric bypass; 54 patients underwent loop duodenal switch (LDS). The authors sought to compare the 18-month follow-up data on weight loss outcomes and complications of these procedures performed in a single United States center.

•    Mortality/complications
-No postoperative complications
•    Weight loss
-Gastric bypass and LDS had statistically similar weight loss at 18 months, 39.6 and 41 percent, respectively.
•    Complications/complaints
-Reported complaints of nausea was lower in the group that underwent LDS (5%) compared to those who underwent gastric bypass (26%)
-Diagnostic endoscopies and ulcer occurrence were also higher in the gastric bypass group: 21 versus 3 and 6 versus 0, respectively.

4.) 2015: Sánchez-Pernaute A, Rubio MA, Cabrerizo L, et al. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Sánchez-Pernaute et al[6] analyzed the results the SADI-S on 97 patients with obesity and T2DM (mean body mass index (BMI): 44.3kg/m2). They were able to follow up with patients from 6 months to 5 years postoperative. The follow-up rate decreased as time from surgery increased; 95.5% the first year and 92.5%, 91.6%, 86.7%, and 78% for the second to fifth years, respectively. They reported the following:

•    Mortality/complications
-No mortality
-1 anastomotic leak
-1 reoperation for hemoperitoneum
-1 reoperation for an incarcerated umbilical hernia
•    Weight loss
-6 months postoperative: 73% EWL
-1 year postoperative: 91% EWL     -2 year postoperative: 92% EWL
-3 year postoperative: 85% EWL
-4 year postoperative: 88% EWL
-5 year postoperative: 98% EWL

The authors concluded that SADI-S is an effective therapeutic option for patients with obesity and T2DM.

Single Anastomosis Bariatric Procedures Course During XXI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)  
Single Anastomosis Gastric Bypass or One Anastomosis Gastric Bypass—The Former Mini-gastric Bypass. Exploring the role of the single anastomosis bariatric surgery. Is the roux limb a critical component of bariatric procedures? A balanced view
Objectives:
• To understand the concepts and physiology of the procedures
• Learn how to perform procedures using different techniques
• How to treat early and late complications, and excess or inadequate weight loss
• To promote familiarity with variations of techniques
• To discuss the diet, supplements, and follow-up of the bariatric patient
IFSO has organized a full day course at it’s 2016 annual meeting, which will be held September 28 to October 1, 2016, in Rio de Janeiro, Brazil, to critically examine the advantages and disadvantages that may be associated with single anastomosis bariatric procedures. Invited speakers from around the world were chosen to present both favorable and critical perspectives on this relatively new anatomic variant for bariatric procedures. While past courses on this topic could be critiqued as including only speakers who were enthusiasts for the single anastomosis procedures, the course directors for this course have made a concerted effort to provide balance between pro- and con- lectures in order to allow those attending to gain a comprehensive understanding of the issues and ultimately make up their own minds regarding the benefits and risks of single anastomosis bariatric procedures, including both gastric bypass and duodenal switch.

References
1.    Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–1618. Epub 2007 Nov 27.
2.    Kim J; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. American Society for Metabolic and Bariatric Surgery statement on single-anastomosis duodenal switch. Surg Obes Relat Dis. 2016;12(5):944-5. Epub 2016 May 7.
3.    Sánchez-Pernaute A, Rubio MA, Pérez-Aguirre E, et al. Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients. Surg Obes Relat Dis. 2013;9:731–735.
4.    Sánchez-Pernaute A, Rubio MA, Conde M, et al. Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy. Surg Obes Relat Dis. 2015;11: 351–355.
5.    Cottam A, Cottam D, Medlin W. et al. A matched cohort analysis of single anastomosis loop duodenal switch versus Roux-en-Y gastric bypass with 18-month follow-up. Surg Endosc. Epub. 2015 Dec 22.
6.    Sánchez-Pernaute A., Rubio, M.A., Cabrerizo, L. et al. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015; 11: 1092–1098.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

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