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SADI-S (TIPS AND TRICKS)
Posted in Lectures on 11 July 2019

Jordi Farguell Piulachs
General Surgery resident.
Hospital Clinic (Barcelona, Spain)

SADI-S (TIPS AND TRICKS)

Laparoscopic bariatric surgery has become the gold standard treatment for morbid obesity. Even though sleeve gastrectomy and the Roux-en-Y bypass (RYGB) have both proved to have long-term outcomes, weight regain and comorbidity relapse are making surgeons look for modifications and new techniques.

The single-anastomosis duodeno-ileal switch (SADIS) is a new bariatric technique that has appeared as a modification of the biliopancreatic diversion with a duodenal switch, as it has a lower morbidity rate and is technically easier.

Compared to the duodenal switch it:

  • Decreases postoperative complications
  • Decreases secondary effects
  • Maintains weight and metabolic effects

WHAT SADI-S IS ALL ABOUT

SADI-S is based on a sleeve gastrectomy that is combined with a single duodeno-ileostomy and a 250 cm common channel. This procedure only creates one anastomosis, is easier to perform, and there is no mesentery opening.

  • Reduced calorie intake
  • Bypass of the duodeno-pancreas
  • Pylorus preservation
  • Anastomosis between foregut and hindgut

When is SADI-S indicated

  • The IFSO SADI-S taskforce recommendations have recently mentioned SADI-S as a recognized bariatric/metabolic procedure when performed as a first option treatment, but more RCTs are needed in the future.
  • It can also be used as a revisional procedure when there is an insufficient weight loss or there is weight regain, or as part of a sequential treatment.

What are the differences in the metabolic effect in SADI-S and RYGBP ?

When a SADI-S is performed, the Vagus nerve and the pylorus are preserved, which reduces bile reflux. As the whole jejunum is bypassed, hexose transporters are eliminated from the alimentary route (SGLT-1, GLUT-2, GLUT-5). Finally, the shortening of the common channel makes it possible to reduce fat absorption.

SURGERY PROCEDURE (TIPS and TRICKS)

  • The surgery starts by dividing all the short gastric vessels up to the left crus of the diaphragm to allow us to perform a complete fundus removal, which is necessary. Then we come down to the pancreaticoduodenal groove, where the gastroduodenal artery lies, which is the distal limit for the dissection (as you can see in the video the artery is marked with a red line and the pancreas in yellow)
  • Then we complete the Sleeve gastrectomy over a 54 Fr intragastric bougie, then go back and perform the duodenal division, preserving the pylorus, which is marked in green.
  • Then we go to the ileocecal junction counting 250cm upward, and the selected loop is brought to be anastomosed to the proximal duodenal stump by means of a hand-sewn anastomosis.

TAKE-HOME MESSAGES

  • SADIS has similar rates of EWL and metabolic effects to those of the Duodenal Switch (DS).
  • The simplified procedure reduces the postoperative risks and long-term secondary effects of malabsorptive operations.
  • SADI-S can be used either as a primary or as a revisional procedure for bariatric surgery.