Robotic Revisional Single Anastomosis Duodenoileal Bypass After Sleeve Gastrectomy

Abstract

Introduction:

Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a metabolic operation emerging as an option for patients with morbid obesity. It is a promising revisional procedure for weight regain or suboptimal weight loss after sleeve gastrectomy (SG). Currently, there is limited literature describing robotic revisional SADI-S. This study describes the safety, feasibility, and early outcomes of robotic revisional SADI-S after previous SG.

Methods:

This is a retrospective review from May 26 2019 to January 31 2021. Perioperative outcomes were analyzed.

Results:

A total of 16 patients underwent the procedure. There were 11 females (69%) with a mean age of 39 ± 11 years. Mean body mass index (BMI) was 44.0 ± 5.1 kg/m² and median ASA was two. Comorbidities included hypertension (25%), hyperlipidemia (19%), and obstructive sleep apnea (13%). Mean interval from primary to revisional surgery among patients was 5.5 ± 1.4 years. Median operative console time was 110 minutes (IQR = 103–137). There were no intraoperative complications. The median hospital stay was 2 days (IQR = 2–3). Perioperative outcomes included no reoperations, perioperative complications, or deaths. There were two (12.5%) emergency department visits for wound checks without infection but no readmissions. At a median follow-up of 4.5 months (IQR = 1–10), patients had a mean BMI of 38.3 ± 7.3 kg/m² and a mean percent total body weight loss (%TBW) of 12.7%.

Conclusions:

Initial outcomes suggest that robotic revisional SADI-S after previous SG is feasible and safe. Future studies are needed to evaluate intermediate- and long-term postoperative outcomes.

Introduction

Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) was first introduced in 2007 by Sanchez-Pernaute as a variant of the traditional biliopancreatic diversion with duodenal switch (BPD/DS).¹ SADI-S has gained popularity as it is a theoretically less demanding procedure due to fewer anastomoses needed, which decreases the technical complexity of the operation. Also, it reduces the potential complications in comparison with BPD/DS.² Over the years, several studies have demonstrated that SADI-S is an effective procedure for weight loss and resolution of comorbidities.^3–5 It is currently endorsed by the International Federation for the Surgery of Obesity and Metabolic Surgery (IFSO) and American Society for Metabolic and Bariatric Surgery (ASMBS).^6,7 SADI-S can be performed as a primary or revisional procedure. Several authors have utilized SADI-S as a revisional surgery, either for suboptimal weight loss after sleeve gastrectomy (SG) or for comorbidities recidivism, mainly uncontrolled type 2 diabetes mellitus T2DM.^8,9 SADI-S is traditionally performed laparoscopically and more recently it has been reported to be safely done robotically.^10,11 Robotic bariatric surgical procedures have risen from 6% in 2013 to 15% in 2018 of all bariatric procedures that have doubled in number.^12,13 At present, there is limited literature describing robotic revisional SADI-S. Our aim is to report early outcomes of robotic revisional SADI-S for suboptimal weight loss and weight regain.

Materials and Methods

Study design and ethical considerations

This retrospective study was conducted at a single academic medical institution located in the United Arab Emirates (UAE). All patients who underwent revisional robotic SADI-S surgery between May 2019 and January 2021 were reviewed. The da Vinci Si surgical system (Intuitive Surgical, Sunnyvale, CA) was used until the first quarter of 2020 and then, the Da Vinci Xi surgical system was used thereafter. All surgeries were performed by two experienced consultant bariatric surgeons. Data were collected from a prospectively maintained registry and a retrospective analysis was performed. This study has been approved by our Institutional Review Board, under the study name A-2017-029.

Inclusion/exclusion criteria

We included all patients who underwent robotic revisional SADI-S after a failed SG. Patients undergoing primary SADI-s or any other revisional procedure were excluded. Patients with significant anatomic abnormalities of the SG, or Los Angeles (LA) Grade C or higher esophagitis, were not selected for conversion to SADI-S. We offer these patients conversion to a Roux-en-Y gastric bypass (RYGB).

Preoperative care

Patients are evaluated in a multidisciplinary obesity clinic following a standardized protocol. At our institution, it consists of preoperative evaluation with bariatric surgery, internal medicine, psychiatry, and nutrition services. Selection for robotic versus laparoscopic operation is determined by the operating surgeon and patient. All patients had an esophagogastroduodenoscopy (EGD) and gastrograffin swallow study before surgery to evaluate for anatomy and presence of esophagitis. All patients are given preoperative antibiotics, pneumatic compression devices applied, and all pressure points padded in the operating room.

Baseline and surgical outcomes

Patient's demographics including age, gender, body mass index (BMI), and comorbidities were collected. Operation details such as duration of surgery, intraoperative complications, and conversion to laparoscopic or open surgery were described. Perioperative outcomes, including length of stay, intensive care unit (ICU) admissions, emergency department (ED) visits, readmissions, reoperation, early complications, and mortality within 30 days, were also analyzed. Postoperative weight change parameters were calculated, including changes in weight, BMI, and percent total body weight loss (%TBWL).

Statistical analysis

Baseline descriptive statistics were calculated for demographic and clinical variables. Continuous variables are presented as means with standard deviations (SDs), or medians with interquartile ranges (IQRs). Categorical data are presented as frequencies and percentages.

Surgical technique

We have previously published our technique performing robotic SADI-S.⁸ In brief, after placing the five robotic trocars, a diagnostic laparoscopy is performed and a liver retractor is placed. The ileum is then traced back to 250 cm proximal to the ileocecal valve and the area is marked. The robot is docked afterward and the patient is placed in reverse Trendelenburg position. The prepyloric sleeved stomach and duodenum are carefully dissected preserving the gastroduodenal artery and right gastric artery. The dissection results in 2–3 cm of duodenum past the pylorus. Finally, the duodenum is transected and the premarked ileum is brought up to an end-to-side duodenoileal diversion with an omega loop of ileum, which is created in a handsewn manner with two layers of absorbable suture.

Postoperative care

After surgery, patients are admitted to the surgical floor. They are encouraged to have sips of water, ambulate early, and initiate incentive spirometry. Multimodal analgesia and venous thromboembolism prophylaxis are administrated. A contrast swallow study is performed the day after surgery and a clear liquid diet is initiated if the study is normal. The second postoperative day the diet is advanced to full liquid diet and patients are discharged if there are no complications. They are discharged on low-molecular weight heparin for 2 weeks. Multivitamins are prescribed and the patient is scheduled for follow-up in the surgery and nutrition clinic.

Results

Our study included 16 patients, 69% were female (n = 11) with a female:male ratio of 2.2:1. Mean age of patients was 39 ± 11 years and a mean BMI of 44 ± 5 kg/m². The median American Society of Anesthesiologists (ASA) was two. Indication for revisional surgery was weight regain in 14 patients and suboptimal weight loss in two. Comorbidities of patients included four patients with hypertension (25%), three patients with hyperlipidemia (19%), and two patients with obstructive sleep apnea (13%). One patient was an active smoker (6%), whereas one patient was a former smoker. All revisions were from standard SG to SADI-S. Seven patients (44%) had their index surgery performed at our institution. Mean interval from primary to revisional surgery among patients was 5.5 ± 1.4 years.

All cases were completed robotically without conversions to laparoscopic or open approach. Median operative console time was 110 minutes (IQR = 103–137). There were no intraoperative complications or intraoperative bleeding; therefore, blood transfusion was not warranted. All duodenoileal anastomoses were done in a handsewn manner, 250 cm proximal to the ileocecal valve. An assistant port was needed in three cases (19%). There were no system failures (e.g., arm or camera malfunction, power error, monocular or binocular loss, metal fatigue, or software incompatibility). The median length of hospital stay was 2 days (IQR = 2–3). Thirty-day perioperative outcomes were evaluated. We had no postoperative complications or need for reoperation or ICU admission. There were no deaths. There were two (12.5%) ED visits for wound checks, without infection, and no readmissions. At a median follow-up period of 4.5 months (IQR = 1–10), patients had a mean BMI of 38.3 ± 7.3 kg/m², which corresponded to a mean %TBWL of 12.7%. They reported median of two bowel movements per day (IQR = 1–4).

Discussion

Since the approval by the Food and Drug Administration (FDA) in 2000,¹⁴ the use of the robotic platform has continued to grow and have become more common in different surgical specialties, including bariatric surgery.¹⁵ Ergonomics are improved on the robotic platform allowing better freedom of movement, suppression of hand tremor, technical precision with 3-D imaging, and enhanced dexterity for surgical tasks such as intracorporeal suturing.¹⁶ Those technological advances may show promise especially in the more demanding and difficult cases such as revisional bariatric surgeries. The precision afforded by the articulating instruments would suggest improved ability for the fine dissection required in revisional surgery.¹⁷

Robotic revisional bariatric surgery has proven to be safe. A large study using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database included 37,917 patients found that robotic revisional surgery is as safe as laparoscopic revisional surgery.¹⁸ Another single institution's retrospective study supports those findings, however with reportedly longer operative time in the robotic cohort.¹⁹

Data on outcomes after robotic SADI-S are limited. Thus, we searched for outcomes after robotic BPD/DS, SG, and RYGB. Robotic BPD/DS has comparable results with laparoscopic BPD/DS according to a recent MBSAQIP study that included 7235 patients. The authors concluded that robotic BPD/DS may reduce the need for advanced intraoperative assistance and minimize hospital stay in select cases, without increasing morbidity.²⁰ In addition, Antanavicius et al. found that robotically assisted duodenoileal anastomosis during laparoscopic BPD-DS is a feasible, well-tolerated, and an effective alternative to assist in this technically challenging part of the operation.²¹

Revisional bariatric surgery is a quickly growing segment of bariatric procedures according to ASMBS.¹³ One possible option for revisional surgery after SG is SADI-S. It is a relatively new procedure that is increasing in popularity worldwide. It is a simpler operation with a shorter learning curve in comparison with the standard RYGB or BPD/DS. In a large multicenter study including 1328 patients from three countries (USA, Spain, and Australia), the reported anastomotic leak, ulcer, and bile reflux after SADI-S is 0.6%, 0.1%, and 0.1%, respectively.²² Furthermore, the authors of this study compared the incidence rate of anastomotic complications after SADI-S with the reported incidence rate after RYGB and BPD/DS and found them to be lower overall. As an example, the reported anastomotic ulcer rates after RYGB are between 0.6% and 20% and for BPD/DS they are between 0.2% and 1.9% in comparison with 0.1% after SADI-S.²²

Little is known about the safety of robotic revisional SADI-S. To this date, only one publication has briefly described the perioperative outcomes after robotic revisional SADI-S in three patients after SG.²³ Another video publication described a case of robotic revisional SADI-S after SG without postoperative complications.²⁴ In our review of the existing literature, this is the largest series reporting on robotic revisional SADI-S.

Perioperative outcomes in our study are promising. As demonstrated, no reoperations were needed in this series. This is consistent with other studies; Moon et al. found no difference in 30-day reoperation rate between laparoscopic and robotic revisional surgeries.²⁵ We did not compare robotic with laparoscopic SADI-S in this study; however, interestingly, a large analysis of the MBSAQIP comparing 30-day perioperative complications after robotic SG versus laparoscopic SG found that the reoperation rate was significantly less in the robotic cohort attributing those findings to greater surgeon's experience and technological advancements.²⁶ They did, however, find a higher occurrence of organ space infections in the robotic cohort, without increase in mortality, accrediting those results to a yet uncategorized learning curve.²⁶

Furthermore, no complications occurred in this study. In fact, Snyder et al. explored outcomes after laparoscopic RYGB and robotic RYGB and found a statistically significant greater anastomotic leak rate in the laparoscopic group.²⁷ They speculated that the clear three-dimensional view of the operative field allows for a better visualization of tissue planes and placement of more precise sutures, resulting in improved surgical performance and lower leak rates.

The surgeons who performed the robotic revisional surgeries in our series are well-trained bariatric surgeons with experience in complex laparoscopic bariatric surgery and are currently performing robotic SG, RYGB, and SADI-S. This demonstrates that performing robotic bariatric surgery after extensive experience in laparoscopic surgery is advantageous. Angell et al. found that formal laparoscopic training improves the performance of complex robotic tasks.²⁸ In addition, Mohr also found that the learning curve for robotic RYGB is shorter than that for laparoscopic RYGB.²⁹

Although we had two ED visits, we had no readmissions to the hospital. Similarly, Moon et al. found no difference in 30-day readmission rate between laparoscopic and robotic revisional surgeries.²⁵ The two ED visits were due to surgical wound concerns that required assurance and follow-up with the operating surgeon in clinic. Finally, our study showed a median length of stay of 2 days, which is similar to other robotic and revisional bariatric surgeries.^25,27 The length of hospital stay is similar to laparoscopic revisional SADI-S as reported in a retrospective study including 181 SADI-S patients with a mean hospital stay of 2.6 days.³⁰ Interestingly, one study showed a shorter hospital stay for the robotic group that reached statistical significance when comparing robotic and laparoscopic RYGB (2 versus 3 days).³¹

Our study has several limitations as with any other retrospective study. Overall, this is a small number of patients reported in a retrospective nature. Perioperative outcomes were only studied in this series and long-term studies are crucial to understand the metabolic effects of this operation on bariatric patients.

Conclusion

SADI-S is gaining popularity worldwide as a primary procedure and is showing potential as a revisional procedure for suboptimal weight loss or weight regain. Robotic revisional SADI-S after previous SG is feasible and safe with appropriate expertise in bariatric surgery. Future studies are needed to evaluate intermediate- and long-term outcomes after this novel approach, including weight loss, improvement of weight-related comorbidities, and nutritional effects.

Footnotes

Disclosure Statement

The authors declare that they have no conflict of interest.

Statement Regarding Ethics and Consent

For this type of study formal consent is not required.

Funding Information

No funding was received for this article.

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