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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November 2016 • Supplement B • Bariatric Times B19 FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH T he search for the ideal bariatric or metabolic procedure has remained an elusive goal. The best method to calibrate the stomach and the intestine remains an area of conjecture. Similarly, there is no consensus on how the intestine should be reconstructed. Although duodenal switch procedures have the highest reported weight loss, lowest rate of recidivism and greatest likelihood for diabetes remission, 1 they remain a minority of procedures. Issues include the technical difficulty and the risk of micronutrient deficiencies. 2 Stomach, Intestine, and Pyloric Sparing Surgery or SIPS is an attempt to create a reproducible calibrated modification of DS that preserves the majority of the efficacy and reduces the complexity and long-term risk. SIPS combines a vertical sleeve gastrectomy (VSG) performed over a 40-44 bougie with a duodenal enteral anastomosis to the small bowel 300 cm from the ilio- ceccal valve. The goal is to combine modest restriction with an intestinal shortening procedure. Food enters the mid intestine. To explain, an expressway has 10 exits and food normally enters on exit 1. With SIPS, food enters on exit 5 or 6. Furthermore, since the attachment is post pyloric, there is no need for a Roux limb. At most, bile can reflux into the post pyloric duodenum where it is normally present. This would occur several meters downstream and would be dilute and partially absorbed. There is only a single anastomosis and no mesenteric deficit (Figure 1). 3 An area that is unclear in bariatric surgery is the relative contributions of the stomach or intestinal aspects for weight loss and metabolic control. Historical analysis reveals that both weight loss and diabetes remission vary directly with the length of the biliopancreatic (BP) limb. 4 In a classic meta-analysis, Buchwald et al compared the percent resolution of type 2 diabetes for the major bariatric procedures. 1 They reported that laparoscopic adjustable gastric banding (LAGB) was approximately 50 percent effective. 1 In comparison, RYGB resulted in resolution in 75 percent of cases and BPD or BPD-DS in 95 percent. 1 A diabetes remission score for RYGB has been studied and • Stomach, Intestine, and Pyloric Sparing Surgery (SIPS) is an effective weight loss procedure that is based on sound surgical concepts and mechanisms of action that have been shown to be effective. There is nothing novel and it is based on techniques that have been employed for more than 50 years. • Percentage weight loss and rate of diabetes remission vary directly with the length of the biliopancreatic limb or the portion of the bowel not exposed to food. • For those with poor Beta cell function, biliopancreatic diversion with duodenal switch (BPD-DS), SIPS, and SADI (Single-anastomosis Duodeno-ileal Bypass with Sleeve Gastrectomy) can still result in diabetes remission • Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) have similar results at three years, yet RYGB is far more complex to revise to BPD-DS or similar procedures for inadequate weight loss if diabetes recurs or progresses. • Patient stratification will be important for optimal results. KEY POINTS "SIPS" Stomach, Intestine, and Pyloric Sparing Surgery: A Modified Duodenal Switch Mitchell Roslin, MD, FACS, and Sarah Sabrudin, MD Bariatric Times. 2016;13(11 Suppl B):B19–B22. AUTHOR AFFILIATIONS: Mitchell Roslin, MD, FACS, is Professor of Surgery, Chief of Bariatric and Metabolic Surgery, Lenox Hill Hospital, New York, New York; Chief of Bariatric and Metabolic Surgery, Northern Westchester Hospital Center, Northwell/Hofstra School of Medicine, Hempstead, New York. Sarah Sabrudin, MD, is from the Department of Surgery, Lenox Hill Hospital and The Feinstein Institute of Medical Research, Northwell Health, Manhasset, New York. ADDRESS FOR CORRESPONDENCE: Dr. Mitchell S. Roslin, 186 East. 76th Street, 1st Floor, New York, NY, 10021; Phone: 212-434-3285; Fax: 212- 434-3250; E-mail: firstname.lastname@example.org FUNDING AND DISCLOSURES: No funding was provided. Dr. Mitchell Roslin reports the following conflicts of interest: Teaching consultant of Medtronic (New Haven, Connecticut), Johnson & Johnson (Cincinnati , Ohio), and W.L. Gore and Associates, Inc. (Flagstaff, Arizona) and Scientific Advisory Board for ValenTx, Inc. (Maple Grove, Minnesota). Dr. Sarah Sabrudin reports no conflicts of interest relevant to the content of this article.