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SJS0010.1177/1457496914564108Duodenal switch for super obesityM. Sundbom
How we do it
Scandinavian Journal of Surgery 104: 54–56, 2014
Open duodenal switch for treatment of super obesity—surgical technique M. Sundbom
Abstract
Background and Aims: Bariatric surgery is increasing worldwide; however, standard techniques, for example, gastric bypass, are often insufficient in super obese patients, body mass index > 50 kg/m2. Duodenal switch, a more powerful procedure, is often considered technically demanding and is, therefore, underutilized according to some authors. This might result in nonoptimal surgical care for super obese patients, not having the possibility to obtain massive weight loss. Material and Methods: In this report, we present our open duodenal switch technique, which we have found durable in an academic center performing 30–40 cases annually, parallel to other upper abdominal surgery. The present technique, performed through a short upper midline incision, consists of a gastric tube, a 1.5-m alimentary limb, and a 1-m common limb of the distal ileum. Conclusion: With correct follow-up to reduce the risk of malnutrition, we encourage the use of duodenal switch and see no rational surgical obstacles. Key words: Morbid obesity; duodenal switch; operative technique; super obesity
Introduction Obesity is the epidemic of the 21st century, and especially, the cohort at the upper end of the weight spectrum, body mass index (BMI) > 50 kg/m2, has increased (1). Surgeons face several specific problems in handling super obese patients: massive hepatomegaly, reduced intra-abdominal space, and an extreme thick abdominal wall. Interestingly, the chosen type of operation varies in different countries, but gastric bypass (GBP) is often referred to as gold standard. The weight result achieved by GBP in super obese patients is by many considered insufficient. Duodenal switch (DS), developed by Hess and Hess
Correspondence: Magnus Sundbom Department of Surgical Sciences Uppsala University SE-751 85 Uppsala Sweden Email: [email protected]
(2) and Marceau et al. (3), is often advocated. Despite its potential advantages and long history, DS is performed at a limited number of centers, probably due to perceived perioperative difficulties. A modern DS consists of a narrow gastric tube, to reduce food intake, and exclusion of large part of the small bowel, to reduce uptake of ingested nutrients. Most often, a 150-cm alimentary limb and a 100-cm common limb are used. In contrast to the jejunoileal bypass, no limb of the small intestine is left without active intestinal flow, that is, the proximal jejunum, the biliopancreatic limb, carries bile and pancreatic juice from the duodenum, while ingested food passes through the alimentary limb, anastomosed to the gastric tube via the duodenal bulb. After joining of the latter two, the common channel allows absorption of fat-soluble nutrients as it contains both bile and food. In 2003, we adopted DS at our institution to overcome the problem with insufficient and nonsustained weight loss in super obese patients. After metabolic and dietary evaluation, super obese patients, judged to be complaint with the postoperative regime, are free to choose between DS and GBP. Patients with obstructive sleep apnea are treated by continuous
Duodenal switch for super obesity
Fig. 1. Schematic drawing of our duodenal switch (DS) procedure. (A) The small bowel is divided 250 cm oral to the ileocecal valve (between A and B) to create an alimentary (red) and a biliopancreatic limb (green). (B) The common limb is constructed by anastomosing the distal end of the biliopancreatic limb (B) at C, situated 100 cm oral to the ileocecal valve. (C) The duodenal bulb is divided, and the stomach is reduced into a gastric tube by vertical stapling along the lesser curvature. (D) A end-to-side duodenoileostomy completes the procedure. The openings behind the two anastomoses have been closed by running sutures to prevent internal herniation.
positive airway pressure (CPAP), and other cardiopulmonary investigations are performed only in selected cases. To achieve 10% weight loss prior to surgery and ease the procedure, 4–6 weeks of preoperative low-calorie diet is prescribed. Prophylaxis with low-weight molecular heparin and 1.5 g of metronidazole and cefuroxime is used. Operative technique Patients are placed in the supine position, on a heavyweight operating table, allowing a total weight of 500 kg, with their arms abducted and padded appropriately. Two straps are loosely placed across the patients legs. DS is performed four-handed and in a standardized order with the head surgeon on the patient’s right side and the second surgeon on the left. Access to the abdomen is obtained through an upper midline incision, always sparing the periumbilical region. Fat fracture of the rich subcutaneous fat is used
55
to minimize bleeding and postoperative seroma, and care is taken to identify the linea alba. First, the ileocecal value is identified by the second surgeon, and the small bowel is measured semistretched on the antimesenteric side by a 50-cm cotton tape. Starting distally, two tape lengths will define the 100-cm common limb and later three additional tape lengths for the 1.5-m alimentary limb, and both limbs are marked by a suture (Fig. 1A). The bowel is divided just oral to the second suture, now marking the oral end of the alimentary limb, and later to be anastomosed to the divided duodenal bulb. The unmarked end is turned cranial, and a standard antimesenteric entero-enteroanastomosis is constructed by a linear 60-mm cartridge at the level of the first suture (Fig. 1B). The opening in the mesentery is closed by a running suture, and by incorporating the serosa of the bowel in the last stitches, an antiobstruction mechanism is obtained. Second, to improve visualization in the upper part of the abdomen, a fixed retractor is used to lift the sternum. The surgeon, standing on the patient’s righthand side, opens the gastro-colic ligament using a 36-cm Harmonic ACE (Johnson & Johnson, Cincinnati, OH, USA), and the greater curvature is dissected. Extra care has to be taken when dividing the short gastric vessels at the superior pole of the spleen, as the distance can be very short. Before taking down the fundus, the gastrophrenic ligament is opened digitally to prevent esophageal damage. When the second surgeon mobilizes the greater curvature 4–5 cm past the pylorus, a DeBakey–Cooley clamp or similar is most helpful in separating the well-vascularized tissue between the proximal duodenum and the head of the pancreas. As the operative space is limited, the duodenal bulb is divided by a roticulating linear stapler 4 cm distal to the pylorus. After passing a 36-Fr bougie per orally and placing it along the lesser curvature, the gastric tube is stapled, starting 5 cm proximal to the pylorus. Care has to be taken to avoid narrowing of the gastric tube at the angular notch on the lesser curvature, as the stomach has a natural bend in this area. The remaining stapling can easily be done lateral to the bougie, often at the end of the small serosal vessels emanating from the lesser curvature. Tension should be avoided at the last firing as this is a potential place of leakage, and we always leave 1 cm of gastric tissue to the right of the esophagus, giving the tube a pyramid-like tip (Fig. 1C). In the third and final step, the transverse colon is elevated, and the distal part of the gastric tube is passed retrocolically. The suture-marked, oral end of the alimentary limb is located, and to prevent internal hernias behind the coming duodenoileostomy, a purse-string suture is placed along of small bowel to the opening in the colonic mesentery. An end-to-side anastomosis is hand-sewn with running absorbable suture (Vicryl, polyglactin 910; Ethicon, Johnson & Johnson, Cincinnati, Ohio, US) in two layers (Fig. 1D). The purse-string suture is tied, and the gastric tube is secured to the opening in the colonic mesentery by 2–3 interrupted stitches. The midline incision is closed by two polydioxanone (PDS) loops and the skin by clips, without subcutaneous sutures or drains.
56
M. Sundbom
After a couple of hours, patients return to the surgical ward with a patient controlled analgesia (PCA) pump with intravenous morphine. Due to frequent postoperative ileus, 3 L of 10% glucose are given intravenously, as well as proton pump inhibitors in patients experiencing initial acid reflux. Patients are encouraged to early mobilization and checked by one of the operating surgeons daily. Without routine control of the anastomosis, peroral intake is started on day 2 with 500 mL of fluids. After a gradual increase, patients are discharged on a full diet, however, reduced to a quarter of a normal-sized meal because of the new anatomy. Thomboprophylaxis is given for an additional 14 days, and patients are started on vitamin B12 injections and multivitamin supplements. As DS patients are in need of intensified follow-up to reduce the risk of malnutrition (4), they should be cared for by a specialized team. Conclusion Bariatric surgery is well established in relieving morbidly obese patients of their comorbidities; however, in super obesity, the perfect procedure is pending. DS is technically demanding but can be performed at acceptable risks, even in rather small numbers, with, for example, the technique described in this report.
With intensified follow-up to reduce the risk of malnutrition, DS patients are known to have superior long-term weight result. Declaration of conflicting interests I have no conflicts of interest to disclose.
Funding I have not received any specific grants or the work with this article.
References 1. Sturm R: Increases in morbid obesity in the USA: 2000–2005. Public Health 2007;121:492–496. 2. Hess DS, Hess DW: Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8:267–282. 3. Marceau P, Hould FS, Simard S et al: Biliopancreatic diversion with duodenal switch. World J Surg 1998;22:947–954. 4. Laurenius A, Taha O, Maleckas A et al: Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity-weight loss versus side effects. Surg Obes Relat Dis 2010;6:408–414.
Received: July 25, 2014 Accepted: November 16, 2014
SJS0010.1177/1457496914564108Duodenal switch for super obesityM. Sundbom
How we do it
Scandinavian Journal of Surgery 104: 54–56, 2014
Open duodenal switch for treatment of super obesity—surgical technique M. Sundbom
Abstract
Background and Aims: Bariatric surgery is increasing worldwide; however, standard techniques, for example, gastric bypass, are often insufficient in super obese patients, body mass index > 50 kg/m2. Duodenal switch, a more powerful procedure, is often considered technically demanding and is, therefore, underutilized according to some authors. This might result in nonoptimal surgical care for super obese patients, not having the possibility to obtain massive weight loss. Material and Methods: In this report, we present our open duodenal switch technique, which we have found durable in an academic center performing 30–40 cases annually, parallel to other upper abdominal surgery. The present technique, performed through a short upper midline incision, consists of a gastric tube, a 1.5-m alimentary limb, and a 1-m common limb of the distal ileum. Conclusion: With correct follow-up to reduce the risk of malnutrition, we encourage the use of duodenal switch and see no rational surgical obstacles. Key words: Morbid obesity; duodenal switch; operative technique; super obesity
Introduction Obesity is the epidemic of the 21st century, and especially, the cohort at the upper end of the weight spectrum, body mass index (BMI) > 50 kg/m2, has increased (1). Surgeons face several specific problems in handling super obese patients: massive hepatomegaly, reduced intra-abdominal space, and an extreme thick abdominal wall. Interestingly, the chosen type of operation varies in different countries, but gastric bypass (GBP) is often referred to as gold standard. The weight result achieved by GBP in super obese patients is by many considered insufficient. Duodenal switch (DS), developed by Hess and Hess
Correspondence: Magnus Sundbom Department of Surgical Sciences Uppsala University SE-751 85 Uppsala Sweden Email: [email protected]
(2) and Marceau et al. (3), is often advocated. Despite its potential advantages and long history, DS is performed at a limited number of centers, probably due to perceived perioperative difficulties. A modern DS consists of a narrow gastric tube, to reduce food intake, and exclusion of large part of the small bowel, to reduce uptake of ingested nutrients. Most often, a 150-cm alimentary limb and a 100-cm common limb are used. In contrast to the jejunoileal bypass, no limb of the small intestine is left without active intestinal flow, that is, the proximal jejunum, the biliopancreatic limb, carries bile and pancreatic juice from the duodenum, while ingested food passes through the alimentary limb, anastomosed to the gastric tube via the duodenal bulb. After joining of the latter two, the common channel allows absorption of fat-soluble nutrients as it contains both bile and food. In 2003, we adopted DS at our institution to overcome the problem with insufficient and nonsustained weight loss in super obese patients. After metabolic and dietary evaluation, super obese patients, judged to be complaint with the postoperative regime, are free to choose between DS and GBP. Patients with obstructive sleep apnea are treated by continuous
Duodenal switch for super obesity
Fig. 1. Schematic drawing of our duodenal switch (DS) procedure. (A) The small bowel is divided 250 cm oral to the ileocecal valve (between A and B) to create an alimentary (red) and a biliopancreatic limb (green). (B) The common limb is constructed by anastomosing the distal end of the biliopancreatic limb (B) at C, situated 100 cm oral to the ileocecal valve. (C) The duodenal bulb is divided, and the stomach is reduced into a gastric tube by vertical stapling along the lesser curvature. (D) A end-to-side duodenoileostomy completes the procedure. The openings behind the two anastomoses have been closed by running sutures to prevent internal herniation.
positive airway pressure (CPAP), and other cardiopulmonary investigations are performed only in selected cases. To achieve 10% weight loss prior to surgery and ease the procedure, 4–6 weeks of preoperative low-calorie diet is prescribed. Prophylaxis with low-weight molecular heparin and 1.5 g of metronidazole and cefuroxime is used. Operative technique Patients are placed in the supine position, on a heavyweight operating table, allowing a total weight of 500 kg, with their arms abducted and padded appropriately. Two straps are loosely placed across the patients legs. DS is performed four-handed and in a standardized order with the head surgeon on the patient’s right side and the second surgeon on the left. Access to the abdomen is obtained through an upper midline incision, always sparing the periumbilical region. Fat fracture of the rich subcutaneous fat is used
55
to minimize bleeding and postoperative seroma, and care is taken to identify the linea alba. First, the ileocecal value is identified by the second surgeon, and the small bowel is measured semistretched on the antimesenteric side by a 50-cm cotton tape. Starting distally, two tape lengths will define the 100-cm common limb and later three additional tape lengths for the 1.5-m alimentary limb, and both limbs are marked by a suture (Fig. 1A). The bowel is divided just oral to the second suture, now marking the oral end of the alimentary limb, and later to be anastomosed to the divided duodenal bulb. The unmarked end is turned cranial, and a standard antimesenteric entero-enteroanastomosis is constructed by a linear 60-mm cartridge at the level of the first suture (Fig. 1B). The opening in the mesentery is closed by a running suture, and by incorporating the serosa of the bowel in the last stitches, an antiobstruction mechanism is obtained. Second, to improve visualization in the upper part of the abdomen, a fixed retractor is used to lift the sternum. The surgeon, standing on the patient’s righthand side, opens the gastro-colic ligament using a 36-cm Harmonic ACE (Johnson & Johnson, Cincinnati, OH, USA), and the greater curvature is dissected. Extra care has to be taken when dividing the short gastric vessels at the superior pole of the spleen, as the distance can be very short. Before taking down the fundus, the gastrophrenic ligament is opened digitally to prevent esophageal damage. When the second surgeon mobilizes the greater curvature 4–5 cm past the pylorus, a DeBakey–Cooley clamp or similar is most helpful in separating the well-vascularized tissue between the proximal duodenum and the head of the pancreas. As the operative space is limited, the duodenal bulb is divided by a roticulating linear stapler 4 cm distal to the pylorus. After passing a 36-Fr bougie per orally and placing it along the lesser curvature, the gastric tube is stapled, starting 5 cm proximal to the pylorus. Care has to be taken to avoid narrowing of the gastric tube at the angular notch on the lesser curvature, as the stomach has a natural bend in this area. The remaining stapling can easily be done lateral to the bougie, often at the end of the small serosal vessels emanating from the lesser curvature. Tension should be avoided at the last firing as this is a potential place of leakage, and we always leave 1 cm of gastric tissue to the right of the esophagus, giving the tube a pyramid-like tip (Fig. 1C). In the third and final step, the transverse colon is elevated, and the distal part of the gastric tube is passed retrocolically. The suture-marked, oral end of the alimentary limb is located, and to prevent internal hernias behind the coming duodenoileostomy, a purse-string suture is placed along of small bowel to the opening in the colonic mesentery. An end-to-side anastomosis is hand-sewn with running absorbable suture (Vicryl, polyglactin 910; Ethicon, Johnson & Johnson, Cincinnati, Ohio, US) in two layers (Fig. 1D). The purse-string suture is tied, and the gastric tube is secured to the opening in the colonic mesentery by 2–3 interrupted stitches. The midline incision is closed by two polydioxanone (PDS) loops and the skin by clips, without subcutaneous sutures or drains.
56
M. Sundbom
After a couple of hours, patients return to the surgical ward with a patient controlled analgesia (PCA) pump with intravenous morphine. Due to frequent postoperative ileus, 3 L of 10% glucose are given intravenously, as well as proton pump inhibitors in patients experiencing initial acid reflux. Patients are encouraged to early mobilization and checked by one of the operating surgeons daily. Without routine control of the anastomosis, peroral intake is started on day 2 with 500 mL of fluids. After a gradual increase, patients are discharged on a full diet, however, reduced to a quarter of a normal-sized meal because of the new anatomy. Thomboprophylaxis is given for an additional 14 days, and patients are started on vitamin B12 injections and multivitamin supplements. As DS patients are in need of intensified follow-up to reduce the risk of malnutrition (4), they should be cared for by a specialized team. Conclusion Bariatric surgery is well established in relieving morbidly obese patients of their comorbidities; however, in super obesity, the perfect procedure is pending. DS is technically demanding but can be performed at acceptable risks, even in rather small numbers, with, for example, the technique described in this report.
With intensified follow-up to reduce the risk of malnutrition, DS patients are known to have superior long-term weight result. Declaration of conflicting interests I have no conflicts of interest to disclose.
Funding I have not received any specific grants or the work with this article.
References 1. Sturm R: Increases in morbid obesity in the USA: 2000–2005. Public Health 2007;121:492–496. 2. Hess DS, Hess DW: Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8:267–282. 3. Marceau P, Hould FS, Simard S et al: Biliopancreatic diversion with duodenal switch. World J Surg 1998;22:947–954. 4. Laurenius A, Taha O, Maleckas A et al: Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity-weight loss versus side effects. Surg Obes Relat Dis 2010;6:408–414.
Received: July 25, 2014 Accepted: November 16, 2014
