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November 2016 • Supplement B • Bariatric Times B15 FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH the duodenum with a single firing of a 60 mm cartridge so as to avoid o verlapping staple lines on the duodenum and unilateral use of absorbable buttressing material on the anterior jaw of the stapler for hemostasis, even pressure distribution, a nd to facilitate performance of the anastomosis. Other measures taken to reduce tension on the anastomosis include creation of a sagittal slit in the right side of the greater omentum (required in up to 30% of cases in our experience) to facilitate antecolic passage of the alimentary limb. It is very rare that retrocolic passage is required when these measures are taken. Additionally, we do not hesitate to "cheat" 5 cm proximally or distally on the ileum from the site selected for anastomosis if tension is ameliorated. Finally, rather than transecting the ileum prior to creation of the duodenoileostomy, we now perform the anastomosis as a loop configuration prior to Roux limb construction. We feel that this reduces traction-related injury to the ileum as it is brought cephalad to the duodenal cuff, allows better distribution of the tension at the anastomosis, creates a smaller Petersen hernia defect by requiring minimal division of the ileal mesentery for Roux creation, and finally serves as a natural "stopping point" as dictated by intraoperative clinical safety considerations. Given these advantages, we strongly advocate for the "loop before Roux" approach to DI. In addition to the technical advantages of this approach, the practical reality is that many patients who will undergo DS in the near future may have "loop DS" as a "final" destination rather than as the first stage of standard DS. Although medium- and long-term outcomes of case series data are lacking, preliminary results for loop DS suggest weight loss and comorbidity improvement reasonably comparable to standard DS. As such, the interest in loop DS on the part of bariatric surgeons and patients, particularly as a revision option for inadequate weight loss in patients who h ave previously undergone sleeve gastrectomy as a primary procedure, has significantly increased in the past several years. While one might not predict a d ifference in the incidence of DI leak between loop and Roux anastomoses, in the setting of an anticipated enthusiastic adoption of an operation (loop DS) that avoids the creation of a second anastomosis, shortens operative time, and eliminates a potential internal hernia (Petersen) defect, however, it is important to anticipate potential differences in the nature and sequelae of leaks that will inevitably occur. Bariatric surgeons will readily recall similar lessons learned during widespread adoption of sleeve gastrectomy, whereby although the incidence of leak after sleeve gastrectomy and gastric bypass were comparable, in many instances, leak after sleeve was found to be more complex to manage, requiring greater time and number of interventions to resolve, and occasionally resulted in severe complications (gastropulmonary fistula, etc.) rarely seen with gastric bypass. As such, there are three key differences between standard and loop DI anatomy that may likely contribute to important qualitative differences in the 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). The Roux reconstruction in standard DS, with its typical alimentary limb length of at least 150 cm, generally prevents biliopancreatic secretions from reaching the DI, and the volume of secretions at the DI is limited primarily to saliva and gastric secretions. In contrast, secretions at the level of the DI in loop DS are of significantly greater volume given that they include both salivary and gastric secretions as well as the biliopancreatic secretions a rriving from the afferent limb. Accordingly, it is quite probable that the proteolytic and detergent properties of biliopancreatic secretions in combination with the oropharyngeal f lora of the gastric sleeve could result in a significantly greater local and systemic inflammatory response, resulting in a DI leak of much greater clinical consequence and one that is more complex to manage. Given the relative rarity of DI leak, it is unlikely that an adequately powered study comparing loop DS vs. standard DS DI leak can or will be conducted, and hence these theoretical concerns are arguably of even greater importance. Indeed, although the general principles of DS leak management are not significantly different from other gastrointestinal leaks (source control, adequate drainage, supportive care with nutrition and antibiotics, re-exploration with clinical deterioration), surgeons considering adding DS to their armamentarium should give these factors careful consideration. REFERENCES 1. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011.Obes Surg. 2013;23(4):427–436. 2. Hedberg J, Sundstrom J, Sundbom M. Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons. Obes Rev. 2014;15(7):555–563. 3. Biertho L, Lebel S, Marceau S, et al. Perioperative complications in a consecutive series of 1000 duodenal switches. Surg Obes Relat Dis. 2013;9(1):63–68. Epub 2011 Nov 15. 4. Søvik TT, Taha O, Aasheim ET, et al. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg. 2010;97(2):160–166. 5. Marchesini JB. A safer and simpler technique for the duodenal switch. Obes Surg. 2007;17(8):1136.