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Three Different Duodeno-Ileal Anastomotic Techniques and Initial Experience

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Three Different Duodeno-Ileal Anastomotic Techniques and Initial Experience Obesity Surgery, 14, 334-340 Laparoscopic Biliopancreatic Diversion with Duodenal Switch:Three Different Duodeno-ileal Anastomotic Techniques and Initial Experience R. A. Weiner1;R.Blanco-Engert 2; S. Weiner3; I. Pomhoff1; M. Schramm1 1Department of Surgery,Krankenhaus Sachenhausen,F rankfurt am Main; 2Division of Surgery, Rotes Kreuz Krankenhaus,F rankfurt am Main; 3University of Würzburg, Germany Background: The duodenal switch (DS) is a variant of Introduction the biliopancreatic diversion (BPD) for surgical treat- ment of morbid obesity.Absence of dumping syn- drome leads to a high quality of life in these patients. The duodenal switch (DS) is a well established tech- The complexity of the laparoscopic BPD-DS is high, nique for the surgical treatment of morbid obesity, and the technical aspects of the duodeno-ileostomy as a modification of the hybrid or mixed Scopinaro are still under consideration. biliopancreatic diversion (BPD). 1-6 This operation Materials and Methods: Laparoscopic BPD-DS is combines the early restriction of a pylorus-preserv- described, with early surgical outcomes of 63 patients ing vertical subtotal gastrectomy with the malab- reported. We used 3 different techniques for creation sorption of a BPD (exclusion of the first half of the of the duodeno-ileostomy,which were compared. Results: 2 staple-line leaks at the gastric sleeve and small bowel,with a 100-cm common limb). Gagner 1 anastomotic leak after circular stapling of the duo- in New York,performed the first laparoscopic duo- 7,8 deno-ileostomy occurred. In the same patient with the denal switch in September 1999. In Europe,the leak, a marginal ulcer was registered 4 months after first DS was performed by Baltasar in Spain. 4-6 We surgery.There were no differences in the operating- studied Baltasar’s technique and performed 3 differ- time between the 3 groups. The combined linear sta- ent techniques to create the duodeno-ileostomy. We pled and totally hand-sewn anastomosis were the present our experience with laparoscopic DS,using safest methods to perform the duodeno-ileostomy. 3 different techniques for creation of the duodeno- Local wound infection at a trocar site (insertion of the circular stapler) was the most common local compli- ileostomy. cation, occurring in 3 patients after using the circular stapling technique only.Postoperative stay was 4 to 8 days, except for the 3 patients with complications. Conclusion: Laparoscopic BPD-DS is an advanced, Materials and Methods complex and feasible technique in bariatric surgery. The combined linear stapled and total hand-sewn Sixty-three morbidly obese patients underwent anastomosis are not only the technically easiest pro- laparoscopic BPD-DS as a primary procedure for cedures to perform,but also appear to be the safest morbid obesity from March 2002 to June 2003 by a techniques. single surgeon (RAW). All patients were considered morbidly obese as classified by the NIH Consensus Key words: Morbid obesity, bariatric surgery, biliopancre- 9 atic diversion, duodenal switch, laparoscopy, techniques Conference, and had failed medical therapy for of duodeno-ileostomy weight reduction. Body mass index (BMI) was >40 kg/m2 in all patients. Complete information con- Reprint requests to:Prof. Dr. med.Rudolf Weiner, Schulstrasse cerning risks and benefits of this surgical approach 31, Frankfurt am Main, Germany.E-mail:[email protected] was given,and patients gave informed consent. 334 Obesity Surgery,14, 2004 ©FD-Communications Inc. Lap Duodenal Switch:Three Anastomotic Techniques Fifty-six of the patients were female and six male, retraction and access to the hiatus. Two trocars were with age 24 to 52 years,weight 122 to 237 kg,and placed in the epigastric region 10 cm to the left and BMI 40.7 to 71.8 kg/m 2. The patient characteristics 10 cm to the right of the mid-line (12-mm each). are summarized in Table 1. For the different tech- One trocar was placed at the left lateral border of the niques for creating the duodeno-ileal anastomosis, anterior rectus muscles above the umbilicus (right we followed the patients in three groups. The circu- 15-mm,and a left 5-mm). For cholecystectomy,an lar stapled anastomosis (Gagner) 7,8 was performed additional 5-mm trocar was used in the right upper in group A,the combination of linear stapling and quadrant. All operations were video-documented. hand-sewn in group B,and the total hand-sewn The operating-time of the different surgical steps anastomosis in group C. were analyzed retrospectively by means of the video-documented time-sequences. The surgical Operative Technique steps were standardized in all operations,except for the three techniques of creating the duodeno- All patients were operated on with the following ileostomy (Table 2). techniques. Antithrombotic prophylaxis was per- The greater curvature of the stomach and the first formed in all patients, consisting of applying lower segment of the duodenum were devascularized with limb elastic bandage,early postoperative mobiliza- the harmonic scalpel. The duodenum was divided tion (3 h),and administering subcutaneous heparin. with a linear cutter. Injuries of the common bile duct At induction,3 g cephalosporin I.V. was adminis- must be avoided. The vertical subtotal gastrectomy tered as antibiotic prophylaxis in a single dose. (sleeve gastrectomy) commenced 6 cm proximal to The patient was placed supine,under general the pylorus at the greater curvature by serial appli- anesthesia, with the legs separated. We used a six- cation of a series of linear cartridges parallel to the trocar approach. The camera trocar was placed in lesser curvature,using a nasogastric tube stent (40 the left supraumbilical area. Another trocar at the Fr bougie). The rest of the stomach was divided with right subcostal position (10-mm) allowed liver linear staplers serially to the cardia. Thus,a gastric tube was constructed based on the lesser curvature, Table 1. Patient characteristics including co-morbidity and 70-80% of the stomach at the greater curvature at time of surgery. was resected. The gastric remnant was filled with methylene blue to detect leaks. There was no Gender 56 females 6 males Age mean: 40.25 SD: 73, range 24-52 yrs. attempt to measure the volume of the tube,although BMI mean: 55.80 kg/m 2, SD: 8.73, it could be done easily by clamping the proximal range 40.7-71.8 kg/m 2 Chronic venous Table 2. Time-periods of laparoscopic DS incompetence 30 cases(46.9%) Chronic obstructive Steps Surgical Procedure bronchopathy 19 cases(29.7%) Hyper-cholesterolemia/ 1creation of pneumoperitoenum, trocar triglyceridemia 18 cases(28.1%) placement, adhesiolysis Arthropathies 16 cases(25.0%) 2dissection of greater curvature, sleeve Effort dyspnea 15 cases (21.7%) gastrectomy, oversuturing staple-line Hiatal hernia 15 cases(21.7%) 3 dissection of duodenum, cutting the duodenum Gastroesophageal 4 cholecystectomy, operative cholangiography reflux disease 12 cases(18.8%) 5 appendectomy Hypertension 12 cases(18.8%) 6 measurement of bowel length, marking Diabetes 10 cases(15.6%) 7 entero-entero anastomosis Sleep apnea 8 duodeno-ileostomy syndrome 10 cases(15.6%) 9 removal of resected stomach, gallbladder, Cholelithiasis 8 cases(12.5%) appendix Ischemic or hypertensive 10 trocar-site and minilaparotomy closure cardiopathy 5 cases (7.7%) 11 placement of drains and skin closure Obesity Surgery,14, 2004 335 Weiner et al and distal ends of the stomach while filling the tube. Group C: The third technique was the complete In two patients a leak in the staple-line (blue car- hand-sewn anastomosis (21 patients), as we learned tridges) in the antrum was detected,and oversutur- from Baltasar. 6 The duodeno-ileal end-to-side anas- ing was necessary. The resected part of the stomach tomosis was hand-sutured by a continuous suture of was removed by means of a bag through the 15-mm 2-0 polypropylene. After suturing the backside,a port or a suprasymphysial incision. Hemostasis of naso-transgastric tube was placed into the efferent the suture-line was accomplished with a running loop. Thereafter,the front-side was sutured by a suture of Vicryl ®. In two patients, staple-line rein- running suture with 2-0 polypropylene. In every forcement was used,and no staple-line bleeding was case we also inserted stay-sutures (Vicryl ®) . seen. The mesenteric defects were left open during the In order to perform the duodeno-ileostomy,the first 42 operations. Thereafter,we closed the surgical team moved cranial, and the TV-monitor Peterman space by single stitches of silk. Suture- was positioned to the patient’s right. The common lines were checked for bleeding,and intraluminal channel (CC) measurement started at the ileocecal irrigation was done with methylene blue to detect junction without stretching the bowel. A suture was any leaks. Additional cholecystectomies were per- placed at 100 cm,indicating what was to become formed in 42 patients (in 21 patients the gallbladder the CC. The bowel was divided with a linear cutter had been previously removed). In only 12 patients 250 cm proximal of the ileocecal valve to form the were there pathological findings in the gallbladder. alimentary limb (AL). The mesentery was partly Forty-nine additional appendectomies were per- divided with the harmonic scalpel. The biliopancre- formed. Two soft closed-suction drains were placed atic limb (BPL) and AL were connected by a hand- and brought out through port sites; one was placed sutured side-to-end anastomosis at the 75-cm (first 5 over the proximal anastomosis and duodenal stump, patients) and 100-cm mark,to prevent obstruction and one over the distal anastomosis. Fascial closure of the small bowel lumen caused by narrowing the of all trocar sites >12 mm was accomplished with a small diameter. suture-passing device. The use of Versastep ®-trocars The duodeno-ileostomy was performed by three (US Surgical Corp) produced small fascial defects.
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