Bariatric Times

Sleeve Gastrectomy 2015

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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A18 Bariatric Times • April 2015 • Supplement A 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY C urrently, there is no consensus for the ideal operation for bariatric patients with weight regain after their primary surgery. Recently, we treated a 61-year-old African American female patient with past medical history significant for diabetes, hypertension, atrial fibrillation (managed with warfarin), obstructive sleep apnea, hyperlipidemia, and super obesity. Her past surgical history included cholecystectomy and sleeve gastrectomy in 2007. At that time, she weighed 387 pounds with a body mass index (BMI) of 69kg/m 2 . A sleeve gastrectomy was performed due to her increased perioperative risk and severe adhesions from her prior operations. Postoperatively, she initially lost about 70 pounds, but then regained much of it over the years. After failing to make many of her clinic visits, the patient presented back to us with a weight of 365 pounds and a BMI of 67kg/m 2 . Given her super obesity and increased surgical risk, we offered to perform a laparoscopic loop duodenal switch as her second bariatric procedure. Consideration of a duodenal switch felt like the natural choice, since it typically is the second step of the two-staged procedure. Loop duodenal switch, or the single anastomosis duodeno-ileal bypass (SADI), offers the theoretical advantage of less surgical risk with a shorter operating time, one less anastomosis, no mesentery defects, and, therefore, less complications. The loop duodenal switch offers the potential benefits of the traditional biliopancreatic diversion with duodenal switch (BPD-DS), while minimizing its surgical and nutritional risks. After discussions with the patient and completion of our pre- operative bariatric surgery evaluation, a loop duodenal switch was performed. We chose to make our antecolic isoperistaltic end-to- side anastomosis at around 300cm proximal to the ileal-cecal junction (Figure 1). The duodenal transection was performed about 3 to 4cm distal to the pylorus or at the junction of D1 and D2 with the Endo GIA ™ stapling system, (Covidien, New Haven, Connecticut, United States). The staple line at the distal duodenal stump was reinforced with a running permanent suture. A running hand-sewn anastomosis was then performed in two layers posteriorly, and a single layer anteriorly. The anastomosis was approximately 2cm in length. The subsequent air leak test with the endoscope was negative and no drain was placed. The total procedure time was three hours. This was mainly due the significant amount of time spent on adhesiolysis from the patient's prior cholecystectomy and sleeve gastrectomy. Excluding the lysis of adhesions, the approximate time spent on the loop duodenal switch was roughly two hours. The patient tolerated the procedure well. She was started on a low-caloric, • Duodenal switch is a good revisional option for weight regain in the super morbidly obese. • High-risk individuals may benefit from the lowest options, which now include the loop duodenal switch. • Further study will be necessary to elucidate the risk/benefit of this new surgical option. KEY POINTS Weight Regain Options after Sleeve Gastrectomy in High-Risk Super Morbidly Obese Patients JEGAN GOPAL, MD, and DANA PORTENIER, MD D uke University Medical Center, Durham, North Carolina, United States Bariatric Times. 2015;12(4 Suppl A):A18–19. DISCLOSURE: Dr. Gopal is a consultant for Teleflex (Research Triangle Park, North Carolina, United States). Dr. Portenier reports the following conflicts of interest relevant to the content of this article: consultant (Covidien, New Haven, Connecticut, United States), grant support (W. L. Gore & Associates, Inc., Flagstaff, Arizona, United States), consultant (Teleflex), and proctor (Intuitive Surgical, Inc., Sunnyvale, California, United States). ADDRESS CORRESPONDENCE TO: Dr. Dana Portenier, 407 Crutchfield St., Durham, NC 27713; (919) 470-7041; Fax: (919) 470-7028; E-mail: dana.portenier@duke.edu

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