ABCDDV/1211 ABCD Arq Bras Cir Dig Original Article – Technique 2016;29(Supl.1):85-90 DOI: /10.1590/0102-6720201600S10021 SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS SADI-S com ligadura da artéria gástrica: sistematização técnica e os primeiros resultados Jordi Pujol GEBELLI1, Amador Garcia Ruiz de GORDEJUELA1, Almino Cardoso RAMOS2, Mario NORA3, Ana Marta PEREIRA3, Josemberg Marins CAMPOS4, Manoela Galvão RAMOS2, Eduardo Lemos de Souza BASTOS2, João Batista MARCHESINI5 From the1Hospital Universitari de Bellvitge, ABSTRACT –Background: Bariatric surgery is performed all over the world with close to 500.000 Barcelona, Spain; 2Gastro-Obeso-Center procedures per year. The most performed techniques are Roux-en-Y gastric bypass and Advanced Surgical Institute, São Paulo, sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion Brazil; 3Centro Hospitalar Entre Douro with or without duodenal switch, represents only no more than 1.5% of the procedures. e Vouga, Portugal; 4Federal University Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to of Pernambuco, Recife, Brazil; 5Clínica the procedure are the main fears that prevent most universal acceptance. Aim: To explain Marchesini, Curitiba, PR, Brazil the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch.Methods : Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the HEADINGS - Bariatric surgery. Morbid classical duodenal switch are reproducible and may allow this procedure to be more popular. obesity. Biliopancreatic diversion. All the complications in this series were not related to the ligation of the right gastric artery. Correspondence: RESUMO – Racional: Cerca de 500.000 cirurgias bariátricas são realizadas a cada ano em todo Almino Cardoso Ramos o mundo. As técnicas mais realizadas são o bypass gástrico em Y-de-Roux e a gastrectomia E-mail: [email protected] vertical. A derivação biliopancreática, com ou sem duodenal switch, é considerada técnica mais eficaz no tratamento cirúrgico do paciente obeso mórbido; entretanto, representa não mais do Financial source: none que 1,5% dos procedimentos na atualidade, pois sua complexidade técnica, morbimortalidade Conflicts of interest: none e graves efeitos adversos nutricionais impedem aceitação mais universal. Objetivo: Descrever os aspectos técnicos e os benefícios do SADI-S com ligadura da artéria gástrica direita como Received for publication: 14/10/2015 um modo simplificado do duodenal switch original. Métodos: Foram incluídos todos os Accepted for publication: 23/05/2016 pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Além da descrição da sistematização da técnica operatória, foram analisadas as complicações precoces associadas ao procedimento. Resultados: Uma série de 67 pacientes foi operada no período analisado; 46 eram mulheres (68,7%) e a média de idade foi de 44 anos (33-56). O IMC médio foi de 53,5 kg/m2 (50-63,5). O tempo cirúrgico médio foi de 115 min (80-180) e a permanência hospitalar média foi de 2,5 dias (1-25). Complicações foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluíram com fístula, uma no coto duodenal e outra na junção esofagogástrica. Não houve mortalidade. Conclusão: SADI-S com ligadura da artéria gástrica direita é procedimento seguro com poucas complicações precoces. A simplificação técnica em relação ao duodenal switch clássico pode permitir que DESCRITORES: Cirurgia bariátrica. este procedimento se torne mais popular. Todas as complicações observadas nesta série não Obesidade mórbida. Desvio biliopancreático. estavam relacionadas com a ligadura da artéria gástrica direita. INTRODUCTION onsidering the first historical cases of jejunoileal bypass done in the beginning of the 1950s by Victor Henriksson in Sweden and Richard Varco in United States of America, bariatric surgery has completed a long medicalC history with the proposition of several surgical alternatives, reaching global numbers around 500.000 cases yearly2,7,9. Influenced by the jejunoileal bypass serious side effects involving severe nutritional problems, liver and kidney complications and poor quality of life related to this pure malabsortive cluster of procedures, the evolution of the bariatric surgery was divided in two main pathways. The first one, with Mason and Ito in1967 launching the first generation omega gastric bypass, that overtime resulted in the nowadays-leading Roux-en-Y gastric bypass (RYGB)2,20,22,25.Since the first series in 1994 by Wittgrove, the laparoscopic RYGB has been the most performed bariatric procedure in the last 22 years and was ABCD Arq Bras Cir Dig 2016;29(Supl.1):85-90 85 ORIGINAL ARTICLE – TECHNIQUE considered as the gold standard in this field34.For the last five Preoperative set-up years sleeve gastrectomy has emerged and gained surgeon’s After adequate selection and appropriate surgical preference exponentially up to reaches the position of the recommendation all patients were submitted to multidisciplinary most performed surgery in some countries, including USA2,6. team preparation. During the preoperative work up patients had Despite their success both procedures achieve moderate also specialized evaluations depending on their comorbidities results in terms of weight loss and have a relative high 20-25% in order to have the proper control targeting a surgery in the index of weight loss failure or weight regain increasing the best condition as possible. All patients were submitted to worldwide data of revisional surgery in the recent years6,10,15. psychological and psychiatric if necessary, evaluation prior to The second pathway for development of bariatric surgery surgery. Once the patient was considered suitable to surgery was based in the improvement attempts of the original was also evaluated by anaesthesiology and was required to jejunoileal bypass with different lengths of bowel exclusion perform a very low calorie diet, pulmonary physiotherapy and association with moderate gastric restriction resulting in and physical education during two weeks prior to surgery. a second generation of malabsortive operations: the classic The patients were then informed about the routines for the biliopancreatic diversion proposed by Nicola Scopinaro et al. procedure and sign the informed consent. in 197932. In the next years Marceau and Hess added some technical changes resulting in another type of biliopancreatic Surgical procedure diversion: the sleeve gastrectomy with duodenal switch (DS)12,18. Position of the patient and the surgical team These procedures have also more than 35 years of history and The patients were placed in the supine position with have demonstrated the best results ever in terms of durable open legs. The table tilts changed between Trendelenburg weight loss and comorbidities resolution4,12,18. Nevertheless and reverse-Trendelenburg position depending on the step in the last International Federation for Surgery of Obesity of the surgery. Patient was secured to the operative table (IFSO) bariatric surgery survey they only represented 1.5% by foot tops, two belts at the height of the knees and an of the worldwide series2. abdominal brace. The surgeon stood between patient’s legs, The main reasons for such conservative recommendation except for the counting of the small bowel when changed numbers is that both, biliopancreatic diversion and DS are to the left side of the patient. The first assistant remained usually associated with the high morbidity and mortality on the left side of the patient and the second on the right rates, high technical complexity and elevated long-term side. Central venous access and urine catheters were not nutritional sequelae. However, if we carefully examine the used. Antibiotic prophylaxis was routinely done. Prevention more recent literature about DS we may find studies with large of thromboembolism was made with use of graduated follow-up pointing for good results and few complication compression stockings, intermittent pneumatic boots, numbers but even though this literature is unanimous, this enoxaparin and early walking. is the technically most demanding and complex bariatric procedure23,28. Pneumoperitoneum and placement of the trocars Based in the excellent results of DS butlooking for Pneumoperitoneum was created by direct Veress needle some easier and safer surgical technical alternative, Sánchez- puncture at the Palmer’s point. A 15 mmHg CO2 abdominal Pernauteet al. proposed in 2007 the single-anastomosis pressure was set for all the procedure with a 5-6 trocars duodenoileal