Methods
Patients
From October 2011 to September 2012, 16 patients underwent loop duodeno-enterostomies for bariatric surgery. Explicit written informed consent for operation and data recording was obtained from all patients. Data recording and evaluation was approved by the ethics committee of the University of Freiburg (ref. number 321/13) and was in accordance with the Declaration of Helsinki. A proximal duodeno-jejunostomy with sleeve gastrectomy (DJOS) was conducted as an alternative to RYGB in 7 selected patients eligible for bariatric surgery with a body mass index (BMI) range from 35.7 to 47.9 kg/m (median BMI 42.7 kg/m). In case of previous gastric banding and relevant perigastric scar tissue, instead of a sleeve gastrectomy, a gastric plicature was performed (n = 3/7) to minimize operative risk. Two-step DIOS was performed as revisionary surgery after failed RYGB due to dumping syndrome (n = 2/9) or after sleeve gastrectomy with insufficient weight loss alone (3/9) or in combination with persisting type 2 diabetes (T2DM, 4/9). All operations were performed by the same senior surgeon. In order to prevent vitamin deficiencies, besides a multivitamin, patients are prescribed Calcium (500 mg twice daily), Vitamin D3 (1000 IU daily), folic acid (5 mg daily) and iron (100 mg daily) supplementation.
Data recording included length of hospital stay, preoperative BMI, presence of medical comorbidities, intra- and postoperative complications, management of complications, total operative time, common channel length and weight loss. Total intestinal length was recorded only after February 2012. All data were entered prospectively into a custom-designed database. The patients had the same follow-up protocol at the outpatient clinic at 1, 3, 6, and 12 months after surgery, followed by an annual visit.
Operative Technique
The patient is placed in the split-leg position with the operating surgeon standing between the legs. Trocar positions are similar to those used for banded sleeve gastrectomy.
Sleeve gastrectomy is conducted as described earlier. In case of a stomach plication, we use a modified technique described by Talebpour et al. applying at least two rows of plication using a 3-0 V-Loc™ Suture (Covidien, Dublin, Ireland). The second part of the operation (second step, when performing a two-step procedure) begins with separation of the duodenum with an endostapling device (GIA- Roticulators, Covidien, Dublin, Ireland, violet cartridge) under preservation of the right gastric artery. Before performing the duodeno-enterostomy, the length of the small bowel is determined to account for inter-individual differences. After measurement, the omega loop should be placed near the postpyloric duodenum with special attention to intestinal alignment to avoid mesenteric malrotation. The position of the duodeno-enterostomy is determined to be aboral to the Treitz ligament, 1/3 of total small bowel length for DJOS (Figure 1), and 2/3 for DIOS (Figure 2). The duodeno-enterostomy is performed as an antecolic, continuous end-to-side hand-sewn anastomosis using 3-0 V-loc™ sutures (Covidien, Dublin, Ireland, Figure 3). Diluted half-strength methylene blue dye (150–200 ml) is used for leak testing. Finally, a drain is put towards the duodenal stump. In case of a two-step procedure, the second part of the operation is conducted separately, then sparing the top left 5 mm trocar needed for sleeve gastrectomy.
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Figure 1.
Diagram of a duodeno-jejunostomy with sleeve gastrectomy (DJOS). The bypassed intestinal length (1/3 of overall intestinal length) is labelled in red.
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Figure 2.
Diagram of a duodeno-ileostomy with sleeve gastrectomy (DIOS). The bypassed intestinal length (2/3 of overall intestinal length) is labelled in red.
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Figure 3.
Final aspect of the duodeno-enterostomy.
Statistical Analysis
Prism 5 for Mac OS X (GraphPad Software, Inc.) was used for all statistical analyses. Statistical significance was set at an alpha of 0.05 for all analyses.