Page 23 - World Journal of Laparoscopic Surgery

Safety and Feasibility of Sleeve Gastrectomy with Loop Duodenal Switch
None of our patients had an anastomotic leak or marginal ulcers.
None of our patients required readmission because of major
postoperative complications. Patients who underwent BPD-DS
Significance a p < 0.001 (A–C) a p < 0.001 (A–C) a p = 0.016 (A–C) a p = 0.308 (A–C) a p < 0.001 (A–C) a p < 0.001 (A–C) b p < 0.001 a p < 0.001 (A–C) b p < 0.001 c p < 0.001 d p = 0.005 or LDS surgeries have a unique risk of duodenal stump leakage,
though incidence is very low. The superior quality of staplers and
the presence of anastomosis farther away from the duodenal
stump probably reduce risk of stump leak. Nelson et al. reported
1 year follow-up (C) Mean ± SD 699.1 ± 548.85 27.54 ± 21.15 9.08 ± 0.52 72.72 ± 31.19 12.17 ± 1.86 6.46 ± 0.77 5.74 ± 0.94 6.66 ± 0.57 3.5 ± 0.66 2.93 ± 0.66 3.66 ± 0.57 <3 g/dL 40% (8/20) 7.14% (5/70) a duodenal stump leak of 1.45% (1/69). None of our patients had
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duodenal stump leakage.
Since all of our patients were kept on regular vitamin and
mineral supplements, we noticed significantly increased serum
vitamin D total and B12 levels at 6 months and 1 year follow-up.
Moon et al. noted low levels of serum vitamin D at 6 and 12 months
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following SADS. Shoar et al. reported that serum vitamin A,
selenium, and iron deficiency were the most common nutritional
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deficiencies after LDS surgeries with 3 m common channel. Surve
≥3 g/dL 60% (12/20) 92.86% (65/70) et al., in the pooled data analysis of SADS surgeries, did not find any
statistically significant difference between most of the pre- and
N 70 74 73 74 75 90 20 70 90 20 70 postoperative nutritional data. 28
In our patients, the extent of hypoalbuminemia significantly
reduced from 40 to 7.14%, when the common channel was
Significance a p < 0.001 (A–B) a p < 0.001 (A–B) a p = 0.012 (A–B) a p = 0.4 (A–B) a p = 0.043 (A–B) a p < 0.001 (A–B) b p = 0.009 a p < 0.001 (A–B) b p = 0.006 c p = 0.003 d p = 0.012 increased from 2.5 to ≥3 m. Sánchez-Pernaute et al. showed
low levels of protein in 34% of patients and albumin in 13.7% of
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patients after SADI-S with 2 to 2.5 m common channel. Enochs
reported protein and albumin deficiency in 7.6 and 3.1% of the
6 months follow-up (B) Mean ± SD 584.17 ± 414.02 26.71 ± 20.47 9.22 ± 0.47 70.14 ± 28.99 13.01 ± 1.68 6.67 ± 0.68 6.32 ± 0.84 6.75 ± 0.61 3.65 ± 0.46 3.4 ± 0.5 3.71 ± 0.43 <3 gm/dL 25% (5/20) 4.65% (4/86) follow-up. Surve et al. showed that 6.6 and 6.2% of the patients
SADS patients with 3 m common channels, respectively, at 1 year
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had abnormal protein and albumin levels, respectively, after
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LDS surgeries with 3 m common channel. Our study showed
that Indian patients are at significantly higher risk of protein
deficiency after LDS surgeries when the common channel was 2.5
m compared to those with ≥3 m. Since all the patients who had
serum albumin levels <3 gm/dL had biliopancreatic limb length
of >55%, we recommend measuring total jejunoileal length in all
≥3 g/dL 75% (15/20) 95.35% (82/86) the patients and restrict biliopancreatic limb length to ≤55%, to
prevent protein malnutrition.
Increasing biliopancreatic limb beyond 2 m in RYGB or
N 89 89 88 90 91 106 20 86 106 20 86 OAGB increases the risk of protein-energy malnutrition, nutrient
d Logistic regression with common channel length as an independent variable
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malabsorption, and diarrhea. Biliopancreatic limb length is
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directly proportional to the efficacy of surgery. Preservation of
Preoperative (A) Mean ± SD 394.1 ± 278.33 14.01 ± 9.23 9.39 ± 0.56 71.71 ± 28.59 13.43 ± 1.82 7.34 ± 0.55 7.33 ± 0.57 7.34 ± 0.55 4.03 ± 0.38 4 ± 0.34 4.04 ± 0.39 pylorus and the first part of the duodenum perhaps play a role
in reducing malabsorption in LDS surgeries. Pylorus controls
gastric emptying, allowing a greater length of the intestine to be
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bypassed without malabsorptive consequences. Preservation
109 102 110 110 115 132 20 112 132 20 112 of pylorus reduces the risk of dumping syndrome. This is again
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related to the control of gastric emptying. Pylorus also prevents
N
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the reflux of ileal contents into the stomach. With our technical
modification, once anastomosis is completed — sleeve, pylorus,
the first part of the duodenum, and anastomosis lie in a straight
vertical line. This theoretically reduces the risk of reflux into the
esophagus as well as reflux of ileal contents into the sleeve. We
presume this adds extra protection against reflux in addition to
of esophageal reflux.
Table 4: Investigations Investigation Serum vitamin B 12 (pg/mL) Serum vitamin D total (ng/mL) Serum calcium (mg/dL) Serum iron (μg/dL) Blood hemoglobin (g/dL) Total protein (g/dL) in 2.5 m common channel subgroup in ≥3 m common channel subgroup Serum albumin (g/dL) in 2.5 m common channel subgroup in ≥ 3 m common channel subgroup Albumin deficiency with <3 g/dL cut off in 2.5 m common channel subgroup in ≥3 m common channel subgroup a Paired samples t test b In
One disadvantage of LDS surgeries is the loss of endoscopic
access to the biliary tract. If anyone develops cholangitis or
choledocholithiasis, the only option is laparoscopic common
bile duct exploration. To reduce the incidence of cholelithiasis,
all our patients were kept on prophylactic ursodeoxycholic acid.
Studies showed that fewer complications like chronic diarrhea,
smelly stools, and flatulence were reported in LDS surgeries with

122 World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020)