Bariatric Times

ICCDS-1 2016

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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B14 Bariatric Times • November 2016 • Supplement B FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH D espite robust evidence supporting the superiority of duodenal switch (DS) for weight loss and impact on metabolic comorbidities in patients with super- obesity as compared to other bariatric procedures, DS accounts for 2.2 percent of bariatric procedures performed worldwide. 1 Although concern for long-term nutritional consequences and alterations in bowel function are commonly stated reasons that surgeons are hesitant to meaningfully incorporate DS into their clinical practice, the relative unfamiliarity with the laparoscopic anatomy and techniques for duodenoileostomy (DI) remains a barrier as well. As with any gastrointestinal procedure requiring resection or anastomosis, leak of enteric contents (especially from the duodenoileostomy) is a feared and potentially devastating complication following DS procedures. Indeed, a recent meta-analysis suggests a higher risk of leak following DS as compared to Roux-en-Y gastric bypass (RYGB). 2 Review of the studies included in this analysis as well as subsequent series demonstrates significant heterogeneity in duodenal mobilization and anastomotic techniques (open vs. laparoscopic, linear stapled vs. hand- sewn, etc.) with a leak rate at the duodenoileostomy and duodenal stump ranging from 0 to 2.6 percent and 0.9 to 6.8 percent, respectively. 3,4 Although most DS surgeons have adopted a hand-sewn technique, there are insufficient comparative data to advocate for a specific technical approach to be used to minimize their risk. In the absence of such data, however, it is important to consider how variations in technique specific to DS might affect the various factors that contribute to anastomotic healing. Given that the quality of tissue perfusion at transection and anastomotic sites is hypothesized to contribute to leak, the impact of technique on both blood flow and tension must be critically considered. Cadaveric gastric perfusion studies have demonstrated that the left gastric artery is sufficient to perfuse the entire stomach due to rich submucosal arterial network, an observation applied in the Marchesini technique whereby the right gastric and the right and left gastroepiploic arteries are routinely divided, which allows the duodenal cuff to extend inferiorly, reducing tension. 5 In his series of 500 patients, Marchesini describes no leaks at the DI using this technique. 5 Although it is difficult to improve on this outstanding result, transection of the vessels as described does reduce tissue perfusion, at least until microvascular collateralization is complete. Similarly, another approach to duodenal mobilization used by several authors involves extension of the greater curvature mobilization distal to the pylorus to the level of planned duodenal transection. While this technique may provide some advantage with regards to reduction of technical difficulty and enhancing surgical efficiency, it does necessitate the transection of at least some post- pyloric perforating vessels supplying the proximal duodenum, incrementally reducing perfusion. As such, the approach that we have taken since 2002 in our laparoscopic DS cases has been to create a limited retroduodenal window at the level of duodenal transection just large enough to accommodate the endoscopic stapler. Additional measures taken to reduce the risk of technical complications include transection of • Unfamiliarity with the laparoscopic anatomy and techniques for duodenoileostomy (DI) remains a barrier to incorporating duodenal switch into bariatric practice • Since the quality of tissue perfusion at transection and anastomotic sites is hypothesized to contribute to leak, the impact of technique on both blood flow and tension must be critically considered • There are three key differences between standard and loop DI anatomy that may likely contribute to clinical course and management (if not frequency) of a DI leak: 1) presence of biliopancreatic secretions at the level of the anastomosis, 2) volume of secretions at the anastomosis, and 3) the presence of an afferent loop (in loop DI) KEY POINTS Management of Duodenal Leaks Vivek N. Prachand, MD FACS B ariatric Times. 2016;13(11 Suppl B):B14–B15. AUTHOR AFFILIATIONS: Dr. Vivek N. Prachand is Associate Professor of Surgery, Director of Minimally Invasive Surgery, Chief Quality Officer, Department of Surgery, Surgeon Champion, ACS-NSQIP, Executive Medical Director for Procedural Quality and Safety, Committee on Molecular Metabolism and Nutrition, The University of Chicago Medicine & Biological Sciences, Chicago Illinois. ADDRESS FOR CORRESPONDENCE: Dr. Vivek N. Prachand, 5841 S. Maryland Ave., MC 5036, Chicago, IL 60637; Phone: 773-702-0190; Fax: 773-834-3204; E-mail: vprachan@surgery.bsd.uchicago.edu FUNDING AND DISCLOSURES: No funding was provided. Dr. Prachand reports no conflicts of interest relevant to the content of this article.

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