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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY V: Conversions immediately following primary DS. Perhaps more importantly, the period following initial LSG provides the surgeon and patient the opportunity to assess the patient's ability to maintain adherence to follow up and incorporate behavioral changes critical to the success and avoidance of nutritional complications after DS. AUTHOR'S TECHNIQUE Revision of LSG to DS is facilitated by several useful technical maneuvers. I routinely place a nonabsorbable seromuscular anterior marking stitch at the level of the pylorus at the time of initial LSG, both to provide a ready visual landmark for measuring the extent of antral resection at the time of LSG as well as at the time of revision to DS should it be necessary, as scarring between the distal antrum and the liver may make external visualization of the pylorus difficult. A full Kocher maneuver is not generally required to perform duodenal transection. Instead, generous incision of the peritoneum cephalad and caudal to the first portion of the duodenum allows adequate mobilization, with transection taking place at the level of fusion with the pancreatic head. The retroduodenal window is limited to a width that will accommodate the stapler cartridge, avoiding excessive devascularization of the duodenum. I transect the duodenum utilizing a single firing of a medium tissue thickness roticulating stapler cartridge, with bioabsorbable buttressing applied solely to the anvil and the cartridge passing behind the duodenum. A single firing obviates issues with crossing staple lines, the buttress material improves hemostasis and facilitates the creation of the subsequent duodenoileostomy by linearizing the duodenal cuff, and omission of buttress on the cartridge reduces resistance to its passage through the relatively small retroduodenal window. A sagittal slit is made in the greater omentum in alignment with the duodenal cuff to facilitate tension-free antecolic passage of the Roux limb. The ileum is measured retrograde from the cecum a distance of 100cm (the length of the common channel), where two marking stitches of different lengths are placed to delineate proximal-distal orientation. From here, the alimentary limb is measured an additional 150cm proximally and transected with a thin tissue thickness roticulating stapler cartridge with bioabsorbable buttressing applied to both jaws. The biliopancreatic limb is marked immediately with a stitch or clip to eliminate confusion with the Roux limb, which is now brought up in an antecolic fashion to the level of the duodenal cuff. I perform both anastomoses from the patient's left side, and I prefer a two-layered hand-sewn approach using running 3-0 absorbable suture for the proximal anastomosis, approximating the entire duodenal cuff staple line to the antimesenteric aspect of the proximal Roux limb as the posterior outer row. Generous enterotomies are made on both sides using monopolar energy, since the anastomotic diameter should not be limited as is the case with RYGB. The inner layer is performed in a running over-and-over fashion posteriorly with two separate sutures. Rather than starting at the midpoint of the posterior row, I begin approximately three-quarters of the way toward the caudal corner and, following myself, suture toward the cephalad corner where I transition to a running Connell stitch to a point midway down the anterior inner row. The second inner layer suture is started immediately caudal to the start of the first stitch and similarly transitioned to a Connell stitch at the caudal corner where, after reaching the prior suture, the needles are cut and the sutures tied to one another. The anterior outer layer is then performed in a running seromuscular manner. The distal anastomosis is fashioned in a manner that is mirror-image to the jejunojejunostomy of a RYGB, and mesenteric defects closed using running nonabsorbable suture. We perform intraoperative endoscopy and insufflation to assess the integrity of the proximal anastomosis prior to the completion of the procedure. A linear stapler is used by some surgeons to perform the proximal anastomosis, but I find that it can result in a narrower or angulated anastomosis, and hemostasis may not be as reliable as with a sutured anastomosis. The role of circular stapled anastomosis in LSG to DS revision is limited, as a portion of the duodenal cuff staple line must be excised to allow anvil placement, a purse string stitch must be added, the relatively small diameter of the ileum rarely accommodates a device larger than a 21EEA, and use of the EEA device results in a larger fascial defect that requires formal closure and may be associated with greater incisional discomfort and risk for wound infection. Ostensibly due to the minimal amount of gastric manipulation that occurs during LSG to DS revision, most patients tolerate low carbohydrate liquids the evening of surgery, and generally can be discharged in the afternoon the day after revision, generally 1 to 2 days earlier than those undergoing primary DS, revision of LSG to SG, or re-sleeve. Daily protein intake goal is 75 to 100g. In addition to the multivitamin, B-complex, and calcium citrate supplements that we recommend to our RYGB patients, we routinely add water miscible forms of vitamin A and D to the patient's regimen. CONCLUSION In summary, in the setting of inadequate weight loss following LSG, revision to DS offers several distinct May 2013 • Supplement A • Bariatric Times A23