Differences Between a Sleeve Reconstruction and 2nd Step DS
December 15, 2016If you have already had a high-efficiency bariatric surgery, such as the Gastric Sleeve (VSG), and had insufficient weight loss, there are options available that can help you. You have the options of a 2nd step Duodenal Switch (DS) or a Sleeve Reconstruction. To determine which option is best for you, each case needs to be assessed individually. The first step is to evaluate the type of Gastric Sleeve that the patient has, along with their eating habits.
The Sleeve Gastrectomy emerged as a stand-alone procedure when a DS was to be performed on patients that had a very high BMI. In these cases, the second step was left as a later separate procedure to minimize surgical risks.
Currently, most patients do very well when they have a Sleeve that is done technically correct and they do not need to have the 2nd step procedure.
In some cases, patients have had a VSG with some success but did not achieve adequate weight loss or they are regaining weight. The main questions are, “Is my Sleeve failing?” or “Was the surgery performed properly and I am not working with it?” Depending on the answers, we must discern what type of procedure is best for each case going forward.
Key Aspects of Long-Term VSG Success
Technically, during a Gastric Sleeve surgery, there are several key aspects that need to be in place to have an efficient Sleeve long-term. It is necessary that the fundus is removed totally. It is the area of the stomach that produces the hormone ghrelin. It is also necessary to have a good pyloric function and that the distance between the pylorus and gastric antrum is not greater than 5 cm.
Lastly, the stapling should leave a good size sleeve without areas of stenosis nor pouches. However, some patients who have a good quality Sleeve (meeting all technical aspects), and have made changes in their diet and lifestyle, do not lose the appropriate amount of weight. There are several factors that may explain this such as metabolism, the length of intestines and absorptive capacity.
Most patients seeking a surgical option for weight loss have associated diseases such as diabetes, hypertension, high cholesterol or high triglycerides. These are very important points to take into consideration before making a decision on the correct revisional surgery to have done because most patients that have surgery will have long-term improvement not only in weight loss but in the resolution of their co-morbidities.
Once we evaluate all these factors, then a decision can be made. A scenario that leads to a Sleeve reconstruction is the following:
- The sleeve is flawed (we usually see very large antrums and/or very large fundus)
- The patient’s BMI is low
- The patient does not have co-morbidities despite the unsatisfactory weight loss.
We can then proceed with a Sleeve reconstruction after making sure we have enough stomach tissue to work with to perform a proper reconstruction. This is determined by a pre-surgery contrast x-rays which are key in determining if the reconstructions are a viable option.
Proper Sleeve Reconstruction Surgery
In a Sleeve reconstruction, we use the same probe size as for a regular Sleeve, which is a 36 Fr. During the surgery, we measure the pylorus and start complete dissection of the entire tissue adhesions. Once we measure the pylorus and start separating these adhesions, we have a fully released Gastric Sleeve to evaluate the tissue to be stapled.
Gastric pouches are often hidden, so it is important to do a good dissection. When we start stapling, it is important to use proper staples, since a revision surgery tissue is thicker so the type/size of staples are decided upon once the tissue is evaluated. Usually, on revision surgeries, we use black and green color coded staples which are for thicker tissue.
We staple to the top of the stomach which we have completely dissected to release the diaphragmatic pillars and to expose the tissue that remains hidden. This is how you achieve a good Sleeve size. The idea is that the Sleeve is uniform in its path. After stapling and removing the excess tissue that was not removed during the first surgery, we over-suture the staple line and perform the relevant leak tests.
Conditions that May Lead to a 2nd Step DS
Conditions that are considered is if the patient has a decent size Sleeve (confirmed thru a fluoroscopy x-ray), has changed their eating habits, has not reached adequate weight loss, co-morbidities are still present and may be regaining some of their weight loss. We must determine if redoing the Sleeve is necessary. This is very important because a larger Gastric Sleeve is going to allow the patient to eat more food than desired. If we are proceeding with a malabsorptive surgery, such as a DS, which is the most malabsorptive of the surgery procedures, we must ensure that we have sufficient long-term restriction through the Sleeve as well.
In all DS cases, it is very important to first check the patient’s medical history, not just talking about bariatric surgery, but also of pelvic surgeries, since the great majority of the tissue that will be worked on is in the pelvic area.
During a 2nd step DS, we will measure the full length of the intestines to achieve proper malabsorption. We use an individualized Hess method to determine the length of the common channel, which usually ends up measuring between 75 to 100 cm. This will allow patients to have adequate fat malabsorption.
Since these patients will also malabsorb vitamins and protein, it is important not to be excessively aggressive with the malabsorption which may cause nausea, vomit, diarrhea, flatulence or malnutrition. The total measurement of the intestines is done and we verify that they have the elongation capacity to be able to work. That is, we do not have adhesions from previous surgeries that limit them.
The alimentary limb which goes all the way from the ceccum to the stomach should not be more than 40% of the total length of the intestines.
Protein and Fat Absorption
According to studies by Dr. Scopinaro, it is said that the longer the alimentary limb is, protein absorption increases, but there’s also a reduction in the absorption of fat. This means that we attack two of the aspects that may give us problems long-term with a malabsorptive procedure.
Patients who malabsorb more fat may have better long-term weight loss results but they need to have a good control of their diet. Nonetheless, if we leave a very short common channel and a very long alimentary limb, carbs are absorbed more easily which jeopardizes weight loss and diarrhea will be greater.
Before closing, all anastomosis or unions are checked to make sure the tension is not excessive. A blue dye leak test is done to check for leaks at the anastomosis. Lastly, a hydropneumatic test is done to check for leaks at the duodenum. Mesentery areas are closed to prevent a hernia long-term.
Basically, the differences long-term with a Sleeve reconstruction is a patient will only have further restrictions and must continue with a good diet and change of habits. In many cases, this is all that is needed. If the patient is not properly committed to change their lifestyle, we seek to give malabsorption. There are few specific cases, despite the patients having good eating habits, a restrictive surgery such as a VSG is not enough.
In these cases, we perform a complete analysis and seek to give malabsorption. If we look for long-term results, the standard is the Duodenal Switch. Keep in mind that the Gastric Sleeve was born as the first step for Duodenal Switch patients. The point is that not all patients are candidates for a Sleeve reconstruction as a secondary surgery, and not all are candidates for a malabsorptive surgery.
 | ABOUT THE AUTHOR Dr. Antonio Esquerra studied under Dr. Gilberto Ungson, Mexico's No. 1 DS surgeon and is now operating alongside him at Mexicali Bariatric Center. He received specialized laparoscopic training under Dr. Gilbergo Ungson with expertise on single anastomosis gastric bypass, gastrointestinal bleed and anastomosis leaks in gastric bypass, as well with post-op complications of the bilopancreatic diversion with nutritional support needed. |
 | ABOUT THE AUTHOR Dr. Edgar Campos is a clinical bariatric doctor and nutritionist with over 10 years of experience with pre-op and post-op bariatric patients. He also supports patients with non-surgical options for weight loss such as the balloon procedure and nutritional guidance. Dr. Campos practices medicine at Mexicali Bariatric Center as the medical advisor and bariatric doctor. He is an 8-year post-op gastric sleeve patient himself.Read more articles from Dr. Edgar Campos! |
