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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November 2016 • Supplement B • Bariatric Times B23 FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH O ne of the most prominent articles discussed at the recent International Consensus Conference on Duodenal Switch (ICCDS) was not an article about DS at all, but about the paper by Alvarenga et al 1 titled "Safety and efficacy of 1020 consecutive laparoscopic sleeve gastrectomies performed as a primary treatment modality for morbid obesity. A single-center experience from the metabolic and bariatric surgical accreditation quality and improvement program." In this meticulously researched article the authors showed that their excess weight loss (EWL) at eight years was only 52 percent. 1 This was a truly brave presentation of data that many already know: approximately half of all sleeve gastrectomy (SG)patients meet standard definitions of weight loss failure at most long-term follow up points. This is a truly alarming development as the sleeve is the most common procedure performed worldwide with hundreds of thousands being performed annually. 2 With such sobering long-term data, it is incumbent upon bariatric surgeons worldwide to come up with treatment algorithms to address the SG's 50- percent failure rate. Fortunately, the skillful surgeons in Quebec City, Quebec, Canada, have already been thinking of this problem. They shared data at the ICCDS conference which showed that staged sleeve to DS patients lost the same amount of weight long term as primary DS patients. This remarkable data allow surgeons the flexibility to do the SG first in many instances with the conversion only happening when failure is identified in the future. Our own experience in Salt Lake City confirms this. When we have converted the SG to a SIPS (stomach and intestinal pylorus sparing surgery [Figure 1]), which is a modification of a traditional RY-DS to a loop DS, we have found that patients go on to lose similar amounts of weight as primary surgeries when performed in the first year after the SG (Table 1). However, this operation (SG to SIPS) is far safer with no chance of ulcers, strictures, or internal hernia formation when compared to RY-GBP or RY-DS. 3,4 Technically, the conversion from SG to SIPS requires no new skills over doing a RY-DS or a RY-GBP, and the operation takes place all in planes that have not previously been dissected. Additionally, when a loop approach is taken over a Roux approach, the long- term one-percent incidence per year of internal hernias found in Roux surgeries disappear. 5 The question asked at the conference and by many readers — "so what is the long-term malnutrition rate in SIPS?" Thankfully, authors in Egypt, Germany, Spain, Utah, and New York have shown that in short- and mid-term follow up, the SIPS procedure with at least 250 cm of common channel, has an equal number of metabolic and nutritional defects as a traditional RY- GBP and RY-DS. In other words, if a surgeon feels comfortable with the metabolic effects of RY-GBP as a revisional operation, the metabolic • SIPS (stomach intestinal pylorus sparing surgery) is a good option for people with failed sleeve gastrectomy • Patients who are revised from sleeve to a SIPS go on to lose similar amounts of weight as primary surgeries when performed in the first year after the sleeve. • Sleeve to SIPS is technically simpler with fewer complications as compared to RY-GBP or RY-DS. • SIPS procedure with at least 250 cm of common channel has an equal number of metabolic and nutritional defects as a traditional RY-GBP and RY-DS • Sleeve to SIPS should have fewer long-term complications that other approaches with an equal malnutrition rate and a similar weight loss profile to a primary SIPS procedure. KEY POINTS SIPS is Quickly Becoming an Option for Surgical Revision of Failed Sleeve Gastrectomy Daniel Cottam, MD; Amit Surve, MD; Hinali Zaveri, MD; and Austin Cottam B ariatric Times. 2016;13(11 Suppl B):B23–B24. AUTHOR AFFILIATIONS: Daniel Cottam, MD; Amit Surve, MD; Hinali Zaveri, MD; and Austin Cottam are from Bariatric Medicine Institute (BMI), Salt Lake City, Utah. ADDRESS FOR CORRESPONDENCE: Dr. Daniel Cottam, 1046 East 100 South, Salt Lake City, UT 84102; Phone: 801-419-6072; E-mail: drdanielcottam@yahoo.com FUNDING AND DISCLOSURES: Dr. Cottam is on the speaker bureau for Medtronic (New Haven, Connecticut) and has been awarded research grant by Medtronic for the study of duodenal switch. Dr. Surve, Dr. Zaveri, and Austin Cottam report no conflicts of interest.

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