(Image of SADI-S copyright 2013 Dr. Levent Efe.)

 

By Monica J. Smith

 

BOSTON—The past couple of years have seen the arrival of new American Society of Metabolic and Bariatric Surgery–endorsed procedures as well as FDA-approved bariatric procedure?related devices. At the 2023 Clinical Congress of the American College of Surgeons, Shaina Eckhouse, MD, talked about new primary bariatric procedures that might gain ground in U.S. ORs soon.

Single-Anastomosis Duodenal Ileostomy

The single-anastomosis duodenal ileostomy (SADI) was first described in 2010, as a sleeve gastrectomy with a duodenal ileal bypass and endorsed by the ASMBS in 2019. The common channel of 200 cm was associated with high rates of malnutrition, diarrhea and a need for revision, so the procedure was modified to increase the common channel to about 300 cm, said Dr. Eckhouse, an associate professor of surgery at Duke University, in Durham, N.C.

“It has stood the test of time based on the data that’s out there. Compared with the biliopancreatic diversion [BPD] with biliary switch, a procedure we’ve had since the 1980s, the weight loss is similar at two years. At five years, SADI doesn’t have quite the weight loss as BPD, but improvements in all the comorbidities bariatric surgeons talk about,” she said, noting that SADI is associated with some of the best outcomes in diabetes remission or resolution of up to 80%, as well as improvements in hypertension and sleep apnea.

The advantage of SADI over BPD is largely one of technical ease, said Anthony T. Petrick, MD, the director of the Division of Bariatric and Foregut Surgery at Geisinger Health System, in Danville, Pa.

“BPD has probably the highest efficacy of any procedure in prompting diabetes improvements. But it is quite challenging to create two anastomoses in patients with a body mass index [BMI] of 60 or 70 kg/m2, which is why it may account for only about 1% of bariatric surgeries in the [United States]. The SADI creates essentially the same anatomy with a single anastomosis.”

Regarding complications, 30-day readmissions are relatively rare, and anastomotic leaks occur in 1% to 3% of patients, Dr. Eckhouse said. “But the Achilles’ heel of SADI is bile reflux, which has a risk of about 7.5%. Only about 2.5% of patients will need a conversion based on impedance probe testing and symptoms; most respond to medical management.”

One-Anastomosis Gastric Bypass

The one-anastomosis gastric bypass (OAGB), which is the third-most commonly performed bariatric surgery worldwide, may gain popularity in the United States as insurance companies are starting to cover it, sDr. Eckhouse said. The OAGB was endorsed by the ASMBS in 2022.

“We basically create a long, narrow pouch that goes 2 to 3 cm below the crow’s foot along the lesser curve. Then it’s a long B2 loop, averaging 200 cm. Weight loss long-term, from one to 12 years out, is about 73% to 75% excess body weight loss, and there are significant improvements in comorbidities,” she said.

The main complication of concern with OAGB is marginal ulcer, with a risk of 2.7%. Factors associated with marginal ulcer include tobacco and alcohol use and Helicobacter pylori infection. “These ulcers can lead to complications like perforation and bleeding. I would treat them emergently the same way I would manage marginal ulcers in a patient who had gastric bypass,” Dr. Eckhouse said.

Dr. Petrick predicted that the SADI will have more appeal to surgeons who currently perform BPD than the OAGB will have for surgeons who perform Roux-en-Y gastric bypass. “But time will tell,” he said.

Endoscopic Bariatric Procedures

In her discussion of endoscopic procedures, Dr. Eckhouse mentioned several FDA-approved intragastric balloons, some filled with liquid, others with gas, with variations in how they are placed and removed. The balloons typically result in weight loss of 6% to 9%, up to 20% for the fluid-filled balloons, but “the durability of that weight loss is controversial depending on the study,” she said.

A main concern with the balloons is the high rate of adverse events—6% to 18% of patients need balloons removed within the first four weeks due to nausea and abdominal pain, and bowel obstruction requiring surgery can occur if the balloons rupture. The same types of complications are associated with the transpyloric shuttle, which can cause nausea, vomiting, abdominal pain and dyspepsia. “Ultimately about 14% of patients with a transpyloric shuttle need early explantation due to those symptoms,” Dr. Eckhouse said.

There is also the question of durability of weight loss because intragastric balloons are FDA-approved for only six months; if left in longer, they can cause thickening of the stomach.

Endoscopic sleeve gastrectomy (ESG), an incisionless plication of the stomach that simulates sleeve gastrectomy without removing a portion of the stomach, leads to total body weight loss of up to 20%, with persistence up to five years, Dr. Eckhouse said. Of the endoscopic procedures, ESG is the one she thinks is the most durable, “because you can repeat it.”

Dr. Petrick had doubts about ESG, noting that it’s highly provider dependent. He himself has revised a number of endoscopic sleeves that became entirely dehisced, with no trace of the sleeve remaining.

“Then it becomes a question of the value of the procedure,” he noted. “You avoid an incision, but you’re doing a procedure that’s less precise and often takes considerably more time. Right now, it doesn’t seem to add a lot of value to bariatric care, but there might be a subset of patients for whom surgery is too risky that this may benefit. Time will tell.”