How to Fashion a Duodeno-jejunostomy During a Laparoscopic Biliopancreatic Diversion with Duodenal Switch

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This month’s technique: How to Fashion a Duodeno-jejunostomy During a Laparoscopic Biliopancreatic Diversion with Duodenal Switch.

This Month’s Featured Expert:

Michel Gagner, MD, FRCSC, FACS, FASMBS, FICS, AFC (Hon.) Clinical Professor of Surgery; Chief, Bariatric and  Metabolic Surgery, Montreal, Quebec, Canada

Bariatric Times. 2012;9(7):10–11

Introduction
Laparoscopic duodenal switch (DS) is likely to increase in popularity, as patients undergoing sleeve gastrectomy (SG [the first stage of a DS]) may experience weight regain and could benefit from an added malabsorptive component. Certainly in patients with super-obesity (BMI>50kg/m2), SG is the procedure of choice, as demonstrated in recent randomized trials and other comparative studies, in which greater weight loss and resolution of comorbidities have been demonstrated.[1] Hence, in my opinion, SG should be performed more frequently in America, but several obstacles have impaired its progression (e.g., insurance coverage, general misconception [much like the jejuno-ileal bypass or classic biliopancreatic diversion], scientific ignorance or biases, and technical difficulties.) This short article will address technical aspects of the procedure.

Types of duodeno-ileostomy
Just like a gastrojejunostomy can be constructed with a circular stapler, linear stapler, or hand sewn, so too can this anastomosis. The circular stapler was used early on in my experience to decrease operative time, and mostly a CEEA™ 21 (Covidien, Mansfield, Massachusetts) was used, as a 25 was generally too big and caused ileal tearing.[2,3] Circular stapling is a fast and reliable technique to do this anastomosis. The Quebec City team of Picard Marceau performed the procedure openly using the Valtrac™ 21 (Covidien).[4] The major drawback, however, is that there is a larger abdominal opening on the right side with potential for wound infections and/or incisional hernias. Nowadays, I prefer the one-layer handsewn technique. The short linear stapler can also be used with a running suture to close the gap, but in general, it is inferior to hand sewn technique because of the gap between two parallel staple lines created by the second linear stapling.[5,6] An ischemia with leak could follow, and the time to do a long running is essentially the same as doing the whole anastomosis with a hand-sewn technique. It can also be performed for a duodeno-jejunal bypass (after sleeve gastrectomy for type 2 diabetes in leaner subjects).

The hand-sewn duodeno-ileostomy
Step 1. Mobilization of the inferior pylorus and first duodenum. I generally use a Harmonic Ace® scalpel of 5mm to mobilize the lower distal antrum vessels, pyloric, and those from the first duodenum (Figure 1). The distance from the pylorus is on average 3cm, and varies among patients. Adhesions behind the antrum and pylorus are also taken down with sharp scissors. The lower mobilization permits a wide and full view of the posterior superior border, and avoids damage to the pancreas or injury to the gastro-duodenal artery. This artery is the limit of distal duodenal dissection. Care is taken not to burn the duodenal wall, which is generally very thin in this area.

Step 2. Superior duodenal window. In general, I open the peritoneum only and very close to the superior duodenum (at a distance 1 to 2cm from the pylorus [Figure 2]). Small vessels are usual present and may need to be taken with the scalpel. The tunnel is generally done from behind the duodenum by swinging the stomach superior and anterior. Bluntly the tunnel is about 1cm to permit the introduction of the linear anvil of the linear stapler.

Step 3. Duodenal transection. A laparoscopic stapler with articulation using a blue cartridge with absorbable Seamguard® (W.L. Gore and Associates, Inc., Flagstaff, Arizona) is generally used to transect the duodenum in one sweep (Figures 3 and 4). Alternatively if buttress is not used, the distal staple line is oversewn with a running 3-0 absorbable monofilament.

Step 4. Ileal measurements. I generally go on the left side of the patient with a camera assistant and have the patient in Trendelenburg position with the right side up. This brings the caecum and ileo-cecal valve in full view. Some adhesions from previous appendectomy or pelvis surgery may need to be divided before measurements, as the ileum can be adherent to side walls. I prefer to use 50cm umbilical tape to measure segments of 50cm, and I put a metal clip on the mesentery next to the common channel of 100cm (from the ileo-ceacal valve) and divide the bowel at 250cm from the valve (or 150cm proximal from the common channel mark).

Step 5. Duodeno-ileostomy posterior running suture. The ileum segment is positioned antecolic, and greater omentum can be split on the right side (a mirror of the omental splitting in Roux-en-Y gastric bypass) to permit the ileum mesentery to easily come upward over the transverse colon. About one 25cm absorbable 3-0 monofilament with a half circle SH-2 needle are used to connect the superior staple proximal duodenal line with the ileal serosa on the antimesenteric border. A good square knot is tied, and pulling in the suture usually brings the tow loops together easily. A running suture is continued and tied at the inferior end of the duodenal staple line (Figure 5).

Step 6. Opening of both lumen. The Harmonic can be used to open a 1cm opening on the ileum inferiorly, approximately 5mm inferior to the suture line (avoiding it). A 5mm metal hook is often used to make a similar opening on the duodenum side, which is thicker. Most often, the ileal opening tends to enlarge as one sews and, therefore, the duodenum opening at the beginning is usually wider at 1.5 to 2cm, depending on what you have after the post pyloric duodenum tissue contraction. The back wall should never be caught (for fear of burns and late leakage from ischemia). Both lumens are aspirated for their contents to make room for suturing and mucosal identification.

Step 7. Anterior running suture. Again, a 25cm, absorbable 3-0 monofilament suture is started superior and to the right. Sew the anterior corner of the duodenum with the anterior ileum and running toward the inferior and left (Figure 6). Both sutures can be tied at the end without closing the lumen (Figure 7).

Step 8. Division of ileum. A linear stapler, 60mm long with a white cartridge and bioabsorbable Seamguard (W.L. Gore and Associates, Inc.) is generally used, and division of the mesentery is short, 1 to 2cm at the most, to preserve blood supply at its maximum.

Step 9. Methylene blue test. A nasogastric tube #18 is inserted by the anesthesiologist and positioned through the pylorus or close by, and a 60mL syringe (mix of saline and one ampoule of methylene blue) is connected. I clamp the ileum about 10cm distal to the anastomosis and get a full distension to test the anastomosis for possible leak points, but also to assess if passage of dye is freely occurring. Extra stitches of absorbable 3-0 monofilament are done if leak is encountered (a rare occurrence).

Step 10. Closure of Petersen’s defect. After lifting the transverse colon superiorly and anteriorly, this opens up the Petersen’s defect on the left side between the mesentery of the ileum above and the mesentery of the transverse colon inferiorly, as they unite at the bottom inferiorly. A running suture of silk 2-0 with a semicircular SH needle is used to unite both mesenteries. Strategically, it is easier on some patients to start at the bottom and go up. On several occasions, a purse string is best because the peritoneal is flimsy, and tearing may occur with an attempted running suture.

Discussion/Conclusion
Although this anastomosis can be performed with various techniques, including the circular stapler (end-to-side), and linear stapler, I now prefer the hand-sewn technique (end-to-side), single layer, as it provides the strongest bond, is less prone to leak, and can accommodate various diameters of ileum. The total number of DS interventions is slowly increasing and is used more frequently after failures of adjustable gastric banding, where the anastomosis is performed on fresh, non-scarred tissue, and also “short DS” procedures are performed to treat type 2 diabetes mellitus in patients without severe obesity.[7–9] Hence, bariatric surgeons should become increasingly familiar with laparoscopic dueodeno-ileostomy and duodeno-jejunostomy.

References
1.    Søvik TT, Aasheim ET, Taha O, et al. Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenalswitch: a randomized trial. Ann Intern Med. 2011;155(5):281–291.
2.    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):514–523
3.    Consten EC, Gagner M, Pomp A, Inabnet WB. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg. 2004;14(10):1360–1366.
4.    Biertho L, Lebel S, Marceau S, et al. Perioperative complications in a consecutive series of 1000 duodenal switches. Surg Obes Relat Dis. 2011 Nov 15. [Epub ahead of print]
5.    Weiner RA, 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(3):334–340.
6.    Baltasar A. Hand-sewn laparoscopic duodenal switch. Surg Obes Relat Dis. 2007;3(1):94–96.
7.    Gagner M, Matteotti R. Laparoscopic biliopancreatic diversion with duodenal switch. Surg Clin North Am. 2005;85(1):141–149.
8.    Gagner M, Boza C. Laparoscopic duodenal switch for morbid obesity. Expert Rev Med Devices. 2006;3(1):105–112.
9.    Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc. 2007;21(11):1931–1935.

Funding: There was no funding for the preparation of this manuscript.

Disclosures: Dr. Gagner is a speaker for and has received honoraria from the following companies: W.L. Gore and Associates, Inc., Covidien, and Ethicon Endo-Surgery.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery