Single-Loop Duodenal Switch (SADi-S) vs Duodenal Switch (DS)

Duodenal Switch (DS) surgery is one of the most efficacious and powerful tools currently available to battle the issue of obesity and aiding in weight loss. The Single Anastomosis Duodeno-Ileal bypass with Sleeve Gastrectomy (loop DS or SADi-S) is a similar procedure using only one connection to the intestine, instead of two like the standard duodenal switch surgery.

You will be learning about physiological differences between DS and SADi-S as well as a comparison of outcomes, such as weight loss, T2DM, and nutritional deficiencies.
Duodenal Switch

Standard Duodenal Switch (DS)

The Biliopancreatic Diversion (BPD), an earlier version of Duodenal Switch, was a surgery similar to a gastric bypass – the only differences were a much longer Y-shaped intestine and a bigger stomach pouch. The biggest part of the intestines was bypassed, and only the most distal piece was reattached to the stomach.

The fact that pancreatic juices and bile were only introduced into the intestines very late in the digestion process resulted in malnutrition. After experiencing the long-term problems caused by the BPD, the procedure was modified to the Duodenal Switch-Biliopancreatic Diversion (DS-BPD) in 1988.

Part 1 – Sleeve shape stomach formed (80% removed)

Part 2 – The intestinal bypass portion of the surgery is performed (after some time in higher BMI patients)

After seeing the results and the subsequent weight loss from the first part, some patients opted not to continue with the second part. That is how Gastric Sleeve or Sleeve Gastrectomy became popular as a stand-alone treatment option in weight loss and obesity management.

Performing the surgery can take a great many numbers of hours, which greatly increases the chance of complications, it was split up into a step-wise procedure.
Loop Duodenal Switch

Single Loop Duodenal Switch

Single Anastomosis Duodeno-Ilean bypass with Sleeve Gastrectomy (SADI-S), also known as a single-loop duodenal switch or Stomach Intestinal Pylorus Sparing (SIPS), is a variation of standard duodenal switch. The purpose of the single-loop duodenal switch (SADi-S) was to reduce this risk by having only one anastomosis.

The risk of leaking and spilling potentially harmful matter into the peritoneum is significantly increased with every anastomosis (or intestine connection). Additionally, fewer connections directly translate into a possibly shorter surgery, making it easier to perform in one step and reducing intra-operative risks such as hemorrhage and infection.

In the Single Anastomosis Duodenal Switch, or SADi’s, the gallbladder is usually removed during the surgery. Patients that lose a large amount of weight after bariatric surgery may need gallbladder removal at a future date.

Comparison Between Duodenal Switch and Single-Loop Duodenal Switch (SADi-S)

Type of Surgery

Duodenal Switch

Duodenal Switch Digestive Tract

Single Anastomosis Duodenal Switch

SADI-S Digestive Tract - Single Loop Duodenal Switch

What It Does

Restrictive and MalabsorptiveRestrictive and Malabsorptive

Description

– Reduces stomach size
– Double anastomosis for Malabsorption
– Reduces stomach size
– Single anastomosis for Malabsorption

Purpose

Reduces the nutrients and calories absorbedReduce the risk of the DS by having one anastomosis

Advantages

  • Less hungry and less urge to eat
  • Body absorbs fewer nutrients or calories
  • Lose most weight in the first year
  • Long-term weight loss
  • Improvement of glucose control
  • One fewer anastomosis or mesenteric window
  • Low complication rate
  • Lower degree of GI Side-effects

Disadvantages

– Some foods may not digest well or cause discomfort
– Patients can have dumping syndrome if eat poorly
– Stomach can be stretched
– Patients need Vitamins rest of their life
– Must take all essential nutrients that are not absorbed

Complications

  • Stomach or abdominal pain
  • Acid reflux
  • Lack of important nutrients
  • Nutrient and essential vitamin deficiency
  • Newer bariatric procedure with less data

Risks

– Very complex surgery: risk of leak, etc
– High Malnutrition
– Complex surgery: risk of leak, etc
– Malnutrition

Recovery

2 to 4 days2 to 3 days

Time Off Work

2 to 3 weeks recommended1.5 to 2.5 weeks

Complete Recovery

5 to 6 weeks4 to 6 weeks

TBWL

45% at 2 years35% at 2 years

Malnutrition

  • Protein malnutrition 14% at 2 years
  • Albumin mean (SD) 40.7
  • Vitamin A 27.2% abnormal
  • PTH 33% abnormal
  • Vitamin D 55% abnormal
  • Protein malnutrition 10% at 2 years
  • Albumin mean (SD) 39
  • Vitamin A 53% abnormal
  • PTH 54% abnormal
  • Vitamin D 46% abnormal

Metabolic Outcome

  • T2DM remission: Over 89% cures Type II Diabetes
  • T2DM on insulin: 75%
  • T2DM remission: Over 72% cures Type II Diabetes
  • T2DM on insulin: 50%

Health Benefits

  • Sleep Apnea
  • Resolves irritable bowel syndrome

Similarities Between DS and SADI-S:

Both surgeries are performed using the laparoscopic technique, but on some rarer occasions, some patients may require a laparotomy (cutting the abdomen wide open) for reasons that are usually determined pre-operatively. Both operations can be performed in two stages, which is potentially advantageous to patients at high risk for developing complications.

For both the DS and SADI-S the first part would be the Sleeve Gastrectomy and the second part would be the intestinal connection. It has actually been shown to be safer to perform the second stage of the surgery once the patient has lost some weight. These options are both less complicated that typical Gastric Bypass surgery. The risk of protein malnutrition is still present in loop duodenal switch.

Differences Between DS and SADI-S

The Duodenal Switch procedure has been around for quite some time, and when it was typically performed, it was done as in open procedure rather than a laparoscopic one. This has led to a lack of evidence supporting positive outcomes if the DS surgery is to be performed laparoscopically. Also, the Y-shape connection in the Duodenal Switch surgery allows avoidance of bile from getting into the stomach, resulting in the avoidance of stomach discomfort and irritation.

The Loop Duodenal Switch, also known as SADI-S or SIPS, on the other hand, has a reduced operative time which leads to the reduction in the risk of complications related to prolonged surgery, purely due to the fact that there are fewer anastomotic connections that need to be made. The risk of leaking or blockage is also reduced. Since the bowel is not being divided into 2 segments, there is less chance to develop intestinal entrapment in the dead spaced between segments of the mesentery.

Surgery Outcomes

There has been evidence published that having a Duodenal Switch is a better option for weight loss surgery in candidates with a BMI of over 50. The gastric bypass has also been found to be an inferior option in the improvement of glucose control in diabetes which compared to either a DS or SADI-S operation.

While the long-term evidence suggesting that the actual weight loss has not been found to be better or worse in the DS/SADI-S option compared to gastric bypass surgery, there are other benefits of SADI-S and DS that does not occur in gastric bypass which also contributes to weight loss and weight control.

There is also a reduction in cholesterol due to the inability for it to be absorbed in both surgeries. This does, however, cause one of the most common side effects of the surgery which is malabsorption of fats. The result is abdominal cramps, frequent stools which are difficult to flush, and flatulence which is particularly foul-smelling. This is not the only malabsorption that occurs in patients who have had the DS/SADI-S surgery.

They are also prone to becoming vitamin deficient, specifically for vitamins D, E, A and K since these are all fat-soluble. It is important to remember to be supplemented with these vitamins.

Conclusion

The DS and the SADI-S are both surgeries which have shown positive outcomes in many studies, proved themselves as an efficient way for achieving significant body weight reduction and reduction of problems and medical concerns related to obesity such as diabetes.

In general, SADI-S is more suitable for smaller patients with nutritional or GI concerns. While the evidence is clear that both options have the desired outcomes, there is no long-term comparative data dictating which option is actually the best. Therefore, the decision of the surgery lies in the hands of the surgeon and what they are comfortable performing.