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Home , Bowel resection

for Obesity and Related Diseases 3 (2007) 94–96

Video case report Hand-sewn laparoscopic Aniceto Baltasar, M.D.* Clínica San Jorge y Hospital “Virgen de los Lirios,” Alcoy, Alicante, Alcoy, Alicante, Spain Received September 25, 2006; revised October 16, 2006; accepted October 24, 2006

Keywords: Duodenal switch; ; Sleeve ; Biliopancreatic diversion

The duodenal switch (DS) is an alternative operation to the legs separated. Three surgeons perform the operation: the Scopinaro biliopancreatic diversion. Hess and Hess [1] one in between the legs and one on each side. The direct performed the first case in March 1988 in 1 woman with a vision approach is always used for the first trocar, with an body mass index (BMI) of 60 kg/m2 and a BMI of 29 kg/m2 Ethicon Endopath No. 12 (Ethicon Endosurgery, Cincinnati, 17 years later. Marceau et al. [2] published the first report on OH) on the lateral border of the right rectus muscle, 3–4 the procedure, followed by Baltasar et al. [3,4], who pub- fingerbreadths below the right costal margin. This is the lished additional series. Ren et al. [5] performed the first only large trocar, the working trocar (WT); the other 4 laparoscopic DS (LDS) in July 1999 and Baltasar et al. [6,7] trocars are 5 mm (Fig. 2). The 30° camera is placed in the published the second world experience. midline. A silk suture is passed from the right costal margin The LDS used in our technique is a laparoscopic sleeve around the falciform ligament to bring the to the right, gastrectomy with Ͻ60-cm3 gastric volume and a pylorus- exposing the gastric antrum and . Cholecystec- preserving biliopancreatic diversion with a common chan- tomy is performed at this time. nel (CC) of 65 cm, an alimentary loop (AL) of 185 cm and The harmonic ultrasound (HUS) is used to devascularize the remaining biliopancreatic loop (BPL) as the proximal the greater curvature of the , starting opposite the small bowel. incisura angularis, and progressing to the left of the gastro- esophageal junction, and freeing the stomach from the left Methods crura. Sometimes, adhesions from the posterior stomach wall and have to be divided. Patients The surgeon on the left side devascularizes the distal We have treated 300 morbidly obese patients with the stomach, passes the pylorus, for Ն3 cm, and creates a tunnel LDS hand-sewn technique starting May 10, 2000. An ad- posterior to the pylorus, in between duodenum and the ditional 74 underwent the laparoscopic , pyloric artery. as the first stage of the DS. The mean BMI was 50.6 kg/m2 The surgeon on the right passes the stapler through the (range 38–71). Conversion to an open procedure was re- WT, divides the duodenum with a linear, white (2.5-mm) quired in 12 of the first 60 patients. No conversions were stapler with a single 6-cm cartridge. The surgeon stationed required in the last 100 cases. in between the legs places a seroserosal continuous running suture of 3-0 PDS to prevent duodenal leaks. Video description The anesthetist inserts a No. 12-mm nasogastric tube into First, general endotracheal anesthesia is given. Fig. 1 is a the antrum with a guidewire inserted within and to the drawing of the procedure. The patient is placed supine with tip. The surgeon on the right partially divides the antrum through the WT, starting 1 cm proximal to the pylorus with a blue (3.5-mm) and 4.5-cm-long cartridge very close to the *Reprint requests: Aniceto Baltsara, M.D., Clínica San Jorge y Hos- pital “Virgen de los Lirios,” Alcoy, Alicante, Cid 61, Alcoy, Alicante gastric stent. From the incisura angularis, a 6-cm-long, blue 03803 Spain. cartridge is used to sequentially divide the stomach, very close E-mail: [email protected] to the stent up to, and lateral to, the angle of His fat pad.

1550-7289/07/$ – see front matter © 2007 American Society for . All rights reserved. doi:10.1016/j.soard.2006.10.014 A. Baltasar / Surgery for Obesity and Related Diseases 3 (2007) 94–96 95

The BPL is divided transversely with the HUS, the distal bowel is identified again, and the BPL-CC is constructed as a single-layer, end-to-side, hand-sewn anastomosis with 2 PDS threads united in the middle as a continuous running suture. The mesenteric defect is closed with a running 3-0 running suture. The patient and surgical team return to the reverse Tren- delenburg position. The duodenoileal anastomosis (DIA) is completed end-to-end in 2 layers. The first layer brings together the posterior wall of the duodenum to the posterior one of the with interrupted silk suture. The anterior aspects of the ileum and duodenum are divided transversly with the HUS. A circumferential, all-layer, continous, dou- ble PDS 3-0 suture is then used. An anterior suture line of interrupted silk completes the anastomosis. The pouch is tested for leaks with the nasogastric tube placed in the antrum using . The stomach is removed by enlarging the No. 12 WT without a bag. Two drains are placed under vision posteriorly and anteriorly to the stomach and the DIA. The WT opening is closed with Maxon No. 1 suture and the skin with silk suture. The operative times ranged from 2.15 to 4 hours (mean 2.45). The patients were extubated in the recovery room and usually transferred to a regular ward in which incentive spirometry and active leg exercises are encouraged. They have an upper gastrointestinal radiographic series with water- soluble contrast the next day and discharged with drains. Patients drank a diluted methylene blue solution daily to Fig. 1. Laparoscopic DS. rule out a leak; the drains were removed on the seventh postoperative day. They are allowed to drink liquids starting the day after surgery for 2 weeks, pureed food for another The anesthetist removes the stent, leaving the guidewire week, and then a regular diet thereafter. Supplementation in place and then passes a small 7-mm nasogastric tube to with calcium, iron, and fat-soluble vitamins (A, D, E, and the antrum. This maneuver saves time, because it can be K) are recommended for life. very cumbersome to try to pass a nasogastric tube without a guidewire. The surgeon who is stationed between the legs Results places a running Lembert 3-0 seroserosal PDS suture from the gastroesophageal junction to the middle of the staple Two patients died within 30 days postoperatively of a line and a second to the distal end. This suture effectively duodenal stump leak (without seroserosal reinforcement) and a controls bleeding at the pouch suture line and decreases the formation of leaks. The remaining lesser curvature-based pouch is tested for leaks with diluted methylene blue. The surgical team changes position to the head of the patient. The patient is placed in a Trendelenburg position. The greater omentum is split in the middle with the HUS up to the transverse colon. The first 65 cm of the CC is measured with 2 marked, smooth clamps in 5-cm steps. One clip is placed to mark the place for the CC-BPL anastomosis, and 2 clips are placed proximal to this. The distal bowel is measured for 250 cm from the ileocecal valve. The mesentery of the small bowel is divided with the HUS. The bowel is divided transversely with a linear, white (2.5-mm) cartridge, passed through the WT. The distal AL is held by a clamp from the xiphoid and kept superior to the transverse colon. Fig. 2. Location of trocars. 96 A. Baltasar / Surgery for Obesity and Related Diseases 3 (2007) 94–96 pulmonary embolus, for a .66% mortality rate. Another patient scopic gastric bypass). Early complications are expected at with a BMI of 69 kg/m2 died at home 34 days after surgery of the beginning of the experience, but it can be an excellent pulmonary embolism. In addition, 21 patients had leaks (6%), procedure with an improved quality of life and long-term 10 at the gastroesophageal junction, 9 at the DIA, and 1 at the significant weight loss for the patient. duodenal stump leak (the patient who died). The gastroesophageal junction leaks required several in 4 patients and total gastrectomy in 2. Two Supplementary data patients required a patch with the BPL and both healed. Supplementary data associated with this article can be Four of the DIA leaks were asymptomatic, 3 were drained found, in the online version, at www.SOARD.org. adequately and resolved with conservative treatment and 2 required resection and a new DIA. One patient underwent Roux-en-O (2 unconnected cir- cles—upper and lower small bowel) and required reopera- References tion. One patient had gastroparesia and did not respond to any therapy and ultimately required total gastrectomy. Two [1] Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. patients had functional stenosis at the jejunojejunostomy Obes Surg 1998;8:267–82. and were treated by interventional radiology with decom- [2] Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard S. pression of the AL with a long tube. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 1993;3:29–35. Three patients with intestinal obstructions required lap- [3] Baltasar A, del Río J, Bengochea M, et al. Cirugía híbrida bariátrica: arotomy; 2 of these required bowel resection. None had Cruce duodenal en la derivación bilio-pancreática. Cir Esp 1996;59: internal . Three patients developed protein-caloric 483–6. malnutrition, and 1 of these underwent a laparoscopic [4] Baltasar M, Bou R, Bengochea M, Serra C, Pérez N. Mil operaciones lengthening procedure (side-to side BPL-AL proximal anas- bariátricas. Cir Esp 2006;79:349–55. tomosis). One patient died, 4 months after surgery, of un- [5] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic bilio- diagnosed acute appendicitis in another community. pancreatic diversion with duodenal switch: a case series of 40 consec- utive patients. Obes Surg 2000;10:514–23. Our study had short-term follow-up, and the percentage of [6] Baltasar A, Bou R, Miró J, Pérez N. Cruce duodenal por laparoscopia excess weight loss and percentage of excess BMI loss [8] are en el tratamiento de la obesidad mórbida: técnica y estudio preliminar. expected to be similar to open surgery. Our long-term open DS Cir Esp 2001;70:102–4. patients have had a percentage of excess weight loss of 69% [7] Baltasar A, Bou R, Miro J, Bengochea M, Serra C, Perez N. Laparo- and percentage of excess BMI loss of 73% at 5 years [9]. scopic biliopancreatic diversion with duodenal switch: technique and initial experience. Obes Surg 2002;12:245–8. [8] Deitel M, Greenstein RJ. Editorial: recommendations for reporting Conclusion weight loss. Obes Surg 2003;13:159–60. [9] Perez N, Baltasar A, Serra C, Ferri L, Bou R, Bengochea M. Com- The hand-sewn LDS is a very complex procedure with a parative analysis of the vertical banded gastroplasty and duodenal very difficult learning curve (more than that for laparo- switch at five years follow-up. Obes Surg 2005;15:1061–5.