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Background: Early small bowel obstruction (eSBO) (within 30-days) is a rare but important complication that is associated with high rates of morbidity, including readmission, reintervention, and reoperation., Objectives: To identify patient-specific and operation-specific characteristics that predispose patients to eSBO and to identify at-risk individuals preoperatively., Setting: 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)., Methods: Utilizing the 2015-2021 MBSAQIP PUF, 1,016,484 records were analyzed. Pediatric, revisional, open-conversion, and cases with incomplete data in sex, body mass index, operative-time, 30-day-follow-up variables were excluded. Case details were compared using Fisher's exact & Wilcoxon -Mann -Whitney tests to identify at-risk patients. The likelihood of eSBO was modeled with rare event logistic regression., Results: Incidence of eSBO was .40%. Of the 4103 occurrences of eSBO, RYGB (Roux-en-Y gastric bypass), SG (sleeve gastrectomy), and DS (duodenal switch) accounted for 79.4%, 19.3%, and 1.3%, respectively. Many patient-specific characteristics were significantly associated with eSBO. History of prior foregut surgery, a non-metabolic surgery trained operator, and longer operative times were all associated with increased eSBO (P < .0001). While simultaneously controlling for these factors, eSBO remained higher in DS (OR 9.55, P < .0001) and RYGB (OR 5.18, P < .0001) compared to SG. Increased length of operation (OR 1.03, P < .0001) and non -MS-trained operators (OR 1.33, P < .0001) remained highly significant. Male-sex (OR .70, P < .0001) and diabetes (OR .78, P < .0001) were both protective., Conclusions: In the largest analysis to date, eSBO remains a rare event. RYGB accounts for the largest proportion of eSBO, however, DS has a higher risk adjusted rate of eSBO., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite the overall safety of metabolic and bariatric surgery (MBS), the potential for postoperative complications such as acute kidney injury (AKI) remains a critical concern. Decade-old studies from our institution reported rates of AKI following MBS between 5.8% and 8.6%, with factors such as higher body mass index (BMI), diabetes, and hypertension identified as potential contributors. However, the incidence and factors associated with AKI following MBS have remained underexplored in contemporary literature., Objectives: To investigate the incidence and risk factors associated with postoperative AKI, as well as the potential for progression to CKD and renal failure., Setting: Quaternary academic medical center with a high-volume MBS practice., Methods: A retrospective review of adult patients undergoing primary laparoscopic MBS between 2008 and 2022 to identify patients who developed AKI, defined as postoperative increase in serum creatinine (sCr) by .3 mg/dL within 72 hours. A multivariable logistic regression was constructed to identify potential AKI risk factors., Results: Among 1697 patients, the incidence of AKI was 3.0% (n = 51). The distribution of AKI was not significantly different between procedure types. There was no significant correlation between anesthesia medications given and the occurrence of AKI. Male gender was the most significant predictor of AKI (adjusted odds ratio [aOR] = 3.87, 95% confidence interval {CI} [2.14-6.99]), followed by hypertension (aOR = 2.12, 95% CI [1.03-4.83]) and longer surgical duration (aOR = 1.19, 95% CI [1.05-1.35]) per 30 minutes. Of those who developed AKI, 7 (13.7%) required dialysis acutely for management, while 3 patients (5.9%) progressed to chronic renal failure and required transplant., Conclusions: AKI is a rare but serious complication following MBS that occurs in approximately 3% of cases. AKI incidence is higher in male patients, those with hypertension, insulin-requiring diabetes, renal insufficiency, and longer procedure durations. Heightened awareness of the identified risk factors should help guide patient selection, and additional efforts should be directed towards refining postoperative follow-up., Competing Interests: Disclosures Omar M. Ghanem is a consultant for Olympus, Regeneron and Medtronic. All other authors (Kamal Abi Mosleh, Lauren Lu, Marita Salame, Noura Jawhar, Juraj Sprung and Toby N. Weingarten) have no conflicts of interest or financial ties to disclose. These disclosures have no effect on the results of this study., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Duodenal switch (DS) is a recent MBS procedure with increasing attention in recent years, however the risk of anastomotic or staple line leaks and the lack of efficient surgical expertise hinders the procedure from becoming fully adopted., Objectives: To determine the 30-day predictors of leaks following DS and explore their association with other 30-day postoperative complications., Setting: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database., Methods: Patients who underwent a primary biliopancreatic diversion with DS or single-anastomosis duodenoileostomy with sleeve procedure, categorized as DS, were assessed for 30-day leaks. A multivariable logistic regression was constructed to identify the predictors of leaks. The assessment of postoperative complications arising from leaks was also performed., Results: A total of 21,839 DS patients were included, of which 177 (.8%) experienced leaks within 30 postoperative days. The most significant predictor of leaks was steroid immunosuppressive use (adjusted odds ratio [aOR] = 3.01, 95% confidence interval [CI] [1.56-5.13], P < .001) and age, with each decade of life associated with a 26% increase in risk (aOR = 1.26, 95% CI [1.09-1.45], P = .001). Operative length was also associated with leaks, with every additional 30 minutes increasing the odds of a leak by 23% (aOR = 1.23, 95% CI [1.18-1.29], P < .001). The occurrence of leaks was correlated with postoperative septic shock (Crude Odds Ratio [COR] = 280.99 [152.60-517.39]) and unplanned intensive care unit (ICU) admissions (COR = 79.04 [56.99-109.59]). Additionally, mortality rates increased 17-fold with the incidence of leaks (COR = 17.64 [7.41-41.99])., Conclusions: Leaks following DS are a serious postoperative complication with significant risk factors of steroid use, prolonged operative time and advanced age. Leaks are also associated with other severe complications, highlighting the need for early diagnosis and intervention along with additional studies to further validate our results., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite the fact Roux-en-Y gastric bypass (RYGB) is one of the most efficient bariatric procedures, postoperative weight regain still can be seen., Objectives: To retrospectively assess the early outcomes and up to 10-year weight results of the conversion of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS)., Setting: French private hospital, 2-surgeon practice in a bariatric surgery center with an experience of >20 RYGB procedures., Methods: Analysis was conducted on patients who had a conversion of RYGB to BPD-DS performed since 2010 for a percentage of excess weight loss (%EWL) <50% with a small gastric pouch., Results: A total of 65 females and 9 males aged 46.8 ± 8.8 years had an RYGB procedure done 110.6 ± 38.8 months earlier for a body mass index of 47.4 ± 7.8 kg/m 2 . Conversion was always performed in 1 stage and laparoscopically for 93% of the patients. The 30-day complication rate was 25.7%, with 14.8% of patients undergoing reoperation. Maximum results were seen 2 years after conversion, outranging RYGB: %EWL of 78.3% ± 24% with percent total weight loss (%TWL) of 35.9% ± 11.9% and %EWL of 72% ± 24.1% with %TWL of 32.6% ± 11%, respectively. The 5-year weight of all the patients (85.7% follow-up) remained lower than the pre-conversion weight. Over time, 1 reversal and 4 revisions were required, and frequent stools and gastroesophageal reflux were the most frequent complaints., Conclusion: Despite its complexity, conversion of RYGB to BPD-DS can be performed in 1 stage, although the use of an unconventional technique could not reduce the high complication rate. BPD-DS remains an efficient procedure after RYGB in selected patients, comparable to distalization of RYGB, which can be less risky., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Today, bariatric surgery has become the main therapeutic means to fight against the escalating increase in obesity, worldwide. Besides that, non-alcoholic steatohepatitis has inflated its indication for liver transplantation. Liver transplant surgeons are prone to face more and more patients with such background. Here, we described the first case of liver transplantation for hepatocellular carcinoma in a patient with previous history of biliopancreatic diversion with duodenal switch. Biliopancreatic diversion with duodenal switch is nowadays an uncommon bariatric surgery but use to be a second stage surgery following sleeve gastrectomy. Liver transplantation can be challenging as such bariatric procedure reshape the digestive anatomy and can also be responsible for malnutrition. Without such complication and in a center specialized in bariatric surgery and liver transplantation, such cases can be successful and should not alarm liver transplant surgeons. In our case, the bariatric anatomy was conserved, and the liver transplantation was successful, without difficulty of the post-operative immunosuppressive treatment. However, long term follow-up showed an exacerbation of the sarcopenia level and establish even more the need for an association of a well-planned physical and nutritional rehabilitation in the peri-operative period in such candidate.

Background: Sleeve gastrectomy (SG) remains the most performed bariatric surgery. As numbers of SG increase, so do the numbers of patients requiring conversion for insufficient weight loss or weight regain. However, the literature has cited complication rates as high as 30% for reoperative bariatric surgery., Objective: With the recent inclusion of conversion surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of SG conversion to Roux-en-Y gastric bypass (RYGB) versus biliopancreatic diversion and duodenal switch (BPD/DS)., Setting: MBSAQIP database., Methods: Analysis of the 2020 MBSAQIP Participant Use Files revealed 6020 patients who underwent SG conversion to RYGB (5348) and BPD/DS (672). We examined 30-day outcomes including death, anastomotic leak, readmission, any complication, dehydration, and weight loss., Results: There was no statistically significant difference in mortality (.12% versus 0%) or; complication rate (6.5% versus 5.1%) with SG conversion to RYGB or BPD/DS. There was a statistically significant difference in anastomotic leak (.5% versus 1.2%, P = .024). Interestingly, BPD/DS was less likely to require dehydration treatments (4.2% versus 2.2%, P = .009) and had fewer readmissions within 30 days (7.3% versus 5.4%, P = .043)., Conclusions: Complication rates after conversion of SG to RYGB or BPD/DS may be significantly lower than previously reported and only slightly higher than after primary weight loss surgery. SG conversion to either RYGB or BPD/DS remain safe, viable options for patients who had insufficient weight loss or regain, and BPD/DS may be the better option in the appropriate patient., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) has been shown to result in better weight loss than other bariatric procedures. Very limited data are available, especially long term, in terms of the resolution of diabetes., Objective: The objective of this study was to evaluate the long-term resolution (>5 years) of type 2 diabetes after BPD-DS., Setting: Academic hospital., Methods: This is a retrospective chart review of patients with diabetes who underwent primary BPD-DS at our institution from 2010 to 2015. Data for that cohort were collected until January 2021., Results: A total of 151 patients who had met the criteria were included in the final analysis. More than 1 year of follow-up data was available for 94% of patients, and more than 5 years of follow-up data was available for 51%. Most of the patients (98.1%) had either partial or complete resolution or improvement., Conclusion: Patients with type 2 diabetes who underwent BPD-DS had profound improvement of their diabetes postoperatively. A significant percentage experienced complete resolution, with most of the remaining patients having demonstrated much improvement in their condition., (Copyright © 2022 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastrointestinal anatomical changes after restrictive and malabsorptive bariatric surgery lead to important disturbances in the process of digestion and absorption of nutrients and could lead to exocrine pancreatic insufficiency (EPI)., Objective: The aim of the present study was to evaluate and to compare pancreatic function and the dynamic of digestion and absorption of nutrients after restrictive and malabsorptive bariatric surgical procedures., Setting: University Hospital of Santiago de Compostela, Santiago de Compostela, Spain., Methods: A prospective, observational, cross-sectional, comparative study of patients after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD/DS) was carried out. Patients with obesity who did not undergo surgery were included as control group. Pancreatic function and the dynamic of digestion and absorption of nutrients were evaluated by the 13 C-mixed triglyceride ( 13 C-MTG) breath test. Six-hour 13 C-cumulative recovery rate ( 13 C-CRR), 13 C exhalation peak, and 1-hour maximal 13 C-CRR were calculated., Results: One-hundred five patients were included (mean age, 49.8 yr; 84 women). Six-hour 13 C-CRR was significantly reduced after BPD/DS (P < .001) but not after SG and RYGB. EPI was present in 75% of patients after BPD/DS, 8.3% of patients after RYGB, and 4.3% of patients after SG. Compared with the control group who did not undergo surgery, digestion and absorption of nutrients tended to occur earlier after SG, whereas it was delayed after RYGB and mainly after BPD/DS (P < .001)., Conclusion: Bariatric surgery significantly alters the dynamic of the digestive process. EPI is very common after BPD/DS, frequent after RYGB, and less frequent after SG. This information is clinically relevant since EPI is a treatable condition associated with symptoms, nutritional deficiencies, and complications., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Duodenal switch (DS) still comprises less than 1% of the overall primary procedures in the United States. Our aim is to explore the reasons behind surgeons' reluctance to DS adoption., Objectives: To determine perceived reasons for the widespread lack of adoption of the DS., Setting: Worldwide survey of closed bariatric surgery social media groups., Methods: A standardized questionnaire was posted on 2 closed social media bariatric groups. DS was used as an umbrella term that includes traditional BPD with duodenal switch, single anastomosis duodeno-ileostomy (SADI) and loop DS. The questionnaire link was accessible to bariatric surgeons only for a period of 1 week., Results: Survey responses (n = 193) were analyzed. The majority (75%) were fellowship-trained bariatric surgeons, and 58% were practicing in the United States. Although 72.9% believed DS to be a good bariatric procedure, it was not being performed by 64% of the respondents. The main reasons behind DS nonadoption included a perceptible high long-term complication rate (43.5%), lack of training (38.1%), and procedure seldomly demanded by patients (31.5%). For surgeons who perform DS, 16.4% use it as a revisional procedure, mainly following sleeve gastrectomy (40.5%). Finally, 29.5% of surgeons believed that the American Society of Metabolic and Bariatric Surgery endorsement of SADI will encourage them to add DS to their practice. They are mostly planning to do so by visiting other surgeons and getting proctored (42.6%)., Conclusion: This survey will help guide bariatric societies and governing bodies in addressing the issues and concerns preventing surgeons from adopting DS in their practice by elucidating the chief reasons and circumstances behind this occurrence., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the classic duodenal switch (DS). These modifications are intended to address concerns about DS, including malnutrition, longer operative times, and technical challenges, while preserving the benefits., Objectives: To evaluate safety and outcomes of SADI-S as it compares to classic DS procedure., Setting: Bariatric Surgery Center of Excellence, University Hospital, Montreal, Canada., Methods: In a single-institution prospective cohort study, we compared safety and outcomes of the SADI-S versus DS procedures (ClinicalTrials.gov: NCT02792166; registered: 06/2016). Data is depicted as count (percentage) or median (interquartile range)., Results: There were 42 patients who underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). There were 20 patients who underwent DS, of whom 12 had it as second-stage procedures (60%). Both groups were similar at baseline. The median age was 45 (14) years, 39 (63%) were female, the median body mass index (BMI) was 48.2 (7.7) kg/m 2 , and 29 (47%) patients had diabetes. The operative time was shorter for 1-stage SADI-S versus DS surgery (211 [70] versus 250 [60] min, respectively; P = .05) but was similar for second-stage procedures (P = .06). The 90-day complication rates were 11.9% (N = 5/42) after SADI-S and 5.0% (N = 1/20) after DS surgery (P = .64). There were no mortalities. Median follow-ups for 1-stage SADI-S and DS were 17 (11) and 12 (24) months, respectively (P = .65). Similar BMI changes were observed after 1-stage SADI-S (17.9 kg/m 2 [8.7]) and DS (17.5 kg/m 2 [16]; P = .65). At median follow-ups of 10 (20) and 14 (16) months after second-stage SADI-S and DS, respectively (P = .53), surgical procedures yielded added 5.0 kg/m 2 (5.8) and 6.5 kg/m 2 (7.1) changes in BMI, respectively (P = .26). Complete remission rates for diabetes were 91% after SADI-S (n = 21/23) and 50% after DS (n = 3/6). Compared with the SADI-S procedure, DS surgery was associated with higher frequencies of deficiencies in some fat-soluble vitamins, especially vitamin D., Conclusions: The SADI-S procedure is safe, and its short-term outcomes, including weight loss and the resolution of co-morbidities, are similar to those of DS. SADI-S surgery also has promising potential as a second-stage procedure after sleeve gastrectomy., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking., Objectives: The aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS., Setting: Public hospital., Methods: Obese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared., Results: The mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m 2 for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances., Conclusion: SADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Insufficient weight loss is common in super-obese patients (body mass index >50) after Roux-en-Y gastric bypass (RYGB). Duodenal switch (DS) is more effective; however, it is considered to have an increased complication rate., Objectives: To compare early complications (≤30 d), long-term adverse events, and quality of life (QoL) between primary DS and RYGB., Setting: Sweden., Methods: National cohort-study of super-obese patients after primary DS or RYGB in Sweden 2007 to 2017. Propensity-score matching was used to reduce confounders. Five national registers were cross-matched., Results: The study population consisted of 333 DS and 1332 RYGB (body mass index 55 ± 5 kg/m 2 , 38.5 ± 11 yr, and 60.7% females). Laparoscopic approach was used in 25% of DS and 91% of RYGB. Early complications were more common after DS (15.3% versus 8.1%, P < .01), mainly because of more open surgery and related surgical site infections. During 4.6 ± 2.3 years mean follow-up, hospital admission rate was 1.4 ± 2.3 versus 1.1 ± 3.3 (P = .18), with 6.7 ± 18.3 versus 7.0 ± 43.0 in-hospital days, for DS and RYGB, respectively. An increased risk of malnutrition/malabsorption requiring inpatient care (2.8% versus .2%, odds ratio 12.3 [3.3-45.7]) and greater need for additional abdominal surgery (25.8% versus 15.3%, odds ratio 2.0 [1.5-2.7]) was observed for DS. However, QoL was more improved after DS., Conclusion: DS was associated with more early complications because of more open surgery, but long-term requirement of inpatient care was similar to RYGB. The increased risk of malnutrition/malabsorption and need for additional abdominal surgeries was contrasted with a greater improvement in QoL for DS., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995-2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Unsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m 2 ). Unfortunately, this group of patients is increasing worldwide., Objective: The aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients., Setting: University hospital, Sweden, national cohort., Methods: This observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m 2 ) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery., Results: The study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m 2 at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids., Conclusion: This study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation., Objectives: We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting., Setting: Data were gathered at an international conference with attendees from a variety of different institutions and settings., Methods: Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement)., Results: Consensus was present in 10 of 16 lines of questioning, with several key points most prominent., Conclusions: As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

With the culture of safety and lowering risks that took place 20 years ago, sleeve gastrectomy has emerged as a procedure of choice. Hence, for super- and super-super-obese patients, there is a tendency these days to perform surgeries in 2 stages, and sleeve is the procedure of choice. Because sleeve is not part of a classic bilio-pancreatic diversion, it is unlikely that this operation will be done as a second stage, making this operation obsolete., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Duodenal switch and single anastomosis modifications continue to gain greater interest among bariatric surgeons. Limiting factors to adoption include concerns around the nutritional management, patient compliance and follow-up, and the technical challenge of the operation. The majority of techniques offered currently use a hand-sewn duodenoileostomy. This approach is limited by the steep learning curve as well as longer operating times., Objectives: We present a video demonstrating the fully stapled technique for duodenoileostomy and ileileostomy. We offer technical pearls around the technique, specifically focused on maintaining a widely patent anastomosis, open biliopancreatic limb, safe duodenal dissection, and correct loop orientation., Methods: Laparoscopic fully stapled duodenoileostomy for duodenal switch and single anastomosis modification., Setting: Community hospital, single institution, 3 surgeons., Conclusion: Triple staple offers a reproducible and safe technique for the duodenoileostomy and specifically for construction of a Roux or loop anastomosis in duodenal switch., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (DS) is known to be superior in weight loss to other bariatric procedures, but with the disadvantage of increased complication rates. Single-anastomosis duodenal-ileal bypass (SADI-S) is reported to have similar weight loss with lower complication rates compared with traditional DS., Objectives: The aim of this study was to compare weight loss and complication rate between SADI-S and double-anastomosis DS at a single institution., Setting: Academic hospital, United States., Methods: A retrospective chart review was performed on 185 patients who underwent laparoscopic or robot-assisted laparoscopic DS between March 1, 2015 and December 10, 2017. A total of 111 patients had SADI-S, and 74 patients underwent double-anastomosis DS., Results: Baseline patient characteristics were comparable between the 2 groups. The mean preoperative body mass index was 56.3 kg/m 2 and 54.4 kg/m 2 in SADI-S and double-anastomosis DS patients, respectively. Thirteen (11.7%) and 4 (5.4%) patients were readmitted within 30 days after SADI-S and double-anastomosis DS, respectively (P = .16). Percentage of total weight loss was 22.0%, 38.5%, and 44.2% in the SADI-S group and 20.2%, 38.0%, and 48.4% in the double-anastomosis DS group at 6, 12, and 24 months, respectively. The majority of patients had vitamin A and E levels in the normal range. However, 40% to 60% of the patients had low levels of vitamin D after the procedure., Conclusions: SADI-S and double-anastomosis DS are comparable in terms of weight loss and complication rate. However, close nutritional follow-up is warranted for both procedures., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve gastrectomy (SG) has become the predominant bariatric surgery worldwide. However, the surgical management in case of failure is still debated., Objectives: To evaluate the risks and benefits of converting SG to biliopancreatic diversion with duodenal switch (BPD-DS) for suboptimal outcome after SG., Setting: University-affiliated tertiary care center., Methods: We included all patients who underwent a laparoscopic second-stage duodenal switch (DS) for weight loss failure after SG and had a minimal follow-up of 2 years. Patients were matched 1:1 for age, sex, body mass index, and year of surgery with a group of patients who underwent a single-stage laparoscopic BPD-DS. Data were obtained from our prospective electronic database and are reported as the mean ± standard deviation, comparing 2- versus 1-stage BPD-DS., Results: A total of 118 patients were included (59 in each group). There was no significant difference in initial body mass index (53.8 ± 9.7 versus 52.7 ± 7.8 kg/m 2 , P = .4), age (44.0 ± 10.2 versus 43.4 ± 9.6 yr, P = .5), and sex ratio (37 female/22 male, P > .9) between the 2 groups. Mean follow-up was 59.9 ± 27 months, with an 85% (n = 100) follow-up rate. Patients were converted to BPD-DS after a mean 24.4 ± 10.2 months. There was no short- or long-term mortality. Major 90-days complications occurred in 2%, 5%, and 5% after SG, second-stage DS and single-stage BPD-DS, respectively (P > .05). At the time of conversion, the excess weight loss for SG was 39 ± 17% and total weight loss was 20 ± 9%. After DS or single-stage BPD-DS, the excess weight loss was 74.8 ± 18% versus 87.9 ± 18% at 1 year (n = 107, P = .00021), 80.2 ± 17% versus 92.3 ± 14% at 2 years (n = 100, P = .002), and 80.2 ± 18% versus 87.2 ± 16% at 3 years (n = 70, P = .6). Total weight loss was 38.7 ± 9% versus 44.5 ± 8% at 1 year (P = .0004), 41.2 ± 9% versus 46.8 ± 7% at 2 years (P = .001), and 42.3 ± 9% versus 45.1 ± 9% at 3 years (P = .2). The incidence of type 2 diabetes and hypertension before surgery were 61% versus 54% and 58% versus 47%. Remission rate for type 2 diabetes increased from 59% to 94% after second-stage DS (P = .001), which is identical to first-stage BPD-DS (94%). Remission of hypertension increased from 42% to 77% after second-stage DS (P = .03) and was 71% after first-stage BPD-DS (P = .8)., Conclusion: Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric procedures are increasingly being used, but data on bowel habits are scarce., Objectives: To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS)., Setting: University hospital in Sweden., Methods: We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation., Results: Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P<.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P<.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P<.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected., Conclusion: RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is one of the most effective bariatric surgeries, in terms of weight loss and remission of co-morbidities. It is however associated with a significant risk of protein and nutritional deficiency, as well as gastrointestinal side effects., Objectives: To assess the effect of increasing the strict alimentary limb on weight loss, nutritional deficiency and quality of life, compared with standard BPD-DS., Settings: University-affiliated tertiary care center., Methods: Prospective randomized double blind (patient-evaluator) trial in which patients were assigned in a 1:1 ratio to undergo a modified BPD-DS with a long alimentary limb (1 m from Treitz ligament, n = 10) or a standard biliopancreatic diversion (strict alimentary limb of 1.5 m, n = 10). Common channel was kept at 100 cm in both groups. Follow-up at 12 months was completed in all patients., Results: Initial weight (126 ± 10 versus 125 ± 17, P = .92), age (40 ± 7 versus 37 ± 8, P = .35), and sex ratio (1 female/9 males) were similar in both groups. Excess weight loss and total weight loss were significantly higher in the standard BPD-DS group (93.4 ± 12% versus 73.3 ± 7%, P = .0007 and 46 ± 5.6% versus 37 ± 3.4%, P = .0004). The study group had significantly higher vitamin D, manganese, and copper levels at 12 months. Both groups had similar drop in glycated hemoglobin, cholesterol levels, and resolution of co-morbidities at 12 months. Long alimentary limb was associated with significantly less bowel movements a day (1.6 ± .97 versus 2.55 ± 1.01, P = .01), less gastrointestinal side effects (bloating and gas, P<.05) and required less pancreatic enzymes supplements (0 versus 40%, P = .04) and calcium supplement. Quality of life was significantly improved in both groups in all domains (all P<.05)., Conclusion: At 12 months, weight loss was lesser in the long alimentary limb group. There was however no difference in the remission of co-morbidities and higher levels of vitamin D, manganese, and copper. Gastrointestinal adverse effects and the need for pancreatic enzymes were less with similarly excellent quality of life at 12 months. Longer follow-up is necessary to evaluate long-term weight loss and nutritional deficiencies., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Venous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS., Objective: To determine the risk factors for VTE after BPD-DS at 90-day follow-up., Setting: A nonprofit regional referral center and teaching hospital in Pennsylvania., Methods: A retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed., Results: A total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20-72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34-98) kg/m 2 . Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post-BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048-1.285), P value = .004., Conclusion: With proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post-BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bile acids have been proposed as key mediators of the metabolic effects after bariatric surgery. Currently no reports on bile acid profiles after duodenal switch exist, and long-term data after gastric bypass are lacking., Objective: To investigate bile acid profiles up to 5 years after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch and to explore the relationship among bile acids and weight loss, lipid profile, and glucose metabolism., Settings: Two Scandinavian University Hospitals., Methods: We present data from a randomized clinical trial of 60 patients with body mass index 50-60 kg/m 2 operated with gastric bypass or duodenal switch. Repeated measurements of total and individual bile acids from fasting serum during 5 years after surgery were performed., Results: Mean concentrations of total bile acids increased from 2.3 µmol/L (95% confidence interval [CI], -.1 to 4.7) at baseline to 5.9 µmol/L (3.5-8.3) 5 years after gastric bypass and from 1.0 µmol/L (95% CI, -1.4 to 3.5) to 9.5 µmol/L (95% CI, 7.1-11.9) after duodenal switch; mean between-group difference was -4.8 µmol/L (95% CI, -9.3 to -.3), P = .036. Mean concentrations of primary bile acids increased more after duodenal switch, whereas secondary bile acids increased proportionally across the groups. Higher levels of total bile acids at 5 years were associated with lower body mass index, greater weight loss, and lower total cholesterol., Conclusions: Total bile acid concentrations increased substantially over 5 years after both gastric bypass and duodenal switch, with greater increases in total and primary bile acids after duodenal switch. (Surg Obes Relat Dis 2017;0:000-000.) © 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Weight regain after Roux-en-Y gastric bypass (RYGB) is a frustrating long-term complication in some patients. Revision of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS) is an appealing option. There is a paucity of information in literature regarding this type of conversion., Setting: Regional referral center and teaching hospital, Pennsylvania, United States; nonprofit., Methods: Between 2013 and 2016, a retrospective chart review was performed on all our revision cases. Patients who underwent conversion from RYGB to BPD-DS were selected and analyzed., Results: Conversion from RYGB to BPD-DS was performed on 9 patients (8 females, 1 male; mean age: 49.2±7.6 [36-61] years). The mean body mass index (BMI) before the initial RYGB was 54.2±14.2 (36.2-79) kg/m 2 . The lowest mean BMI reached before conversion was 33.9±6.2 (27.9-43.3) kg/m 2 before it increased to 45.6±8.7 (28.8-60.2) corresponding to excess weight loss (EWL) of 33.1%±17.7% (10.6%-68.1%), before conversion. The average operative time was 402.6±65.8 (328-515) minutes for 1-stage conversions. No morbidities, reoperation, or readmission over 30 days postoperatively were reported. No leaks or mortalities were identified. The mean duration of follow-up postconversion is 16.3±13.6 (3-42) months. After conversion surgery, the mean BMI was 35.8±8.2 (27.6-49.5) kg/m 2 , while mean EWL loss was 64.1%±18.8% (45.9%-88.7%). The BMI of the cohort decreased by a mean of 9.8±5.1 (0.5-16.8) and the EWL increased by 31%±23.1% (4%-76.6%)., Conclusion: Our results indicate that conversion of failed RYGB to BPD-DS is laparoscopically or robotically safe and effective. A large cohort study with long-term follow-up is necessary to further assess the safety and efficacy of this method., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The traditional duodenal switch is performed using a Roux-en-Y configuration. This procedure has proven to be the most effective procedure for long-term weight loss and co-morbidity reduction. Recently, stomach intestinal pylorus sparing surgery (SIPS) has been introduced as a simpler and potentially safer variation of the duodenal switch (DS). It is a single anastomosis end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. In this study, we compare our outcomes between biliopancreatic diversion with duodenal switch (BPD-DS) and SIPS at 2 years., Setting: This is a retrospective analysis from a single surgeon at a single private institution., Methods: We analyzed data from 182 patients retrospectively, 62 patients underwent BPD-DS while 120 other patients underwent SIPS between September 2011 and March 2015. A subset analysis was performed comparing data from both procedures to evaluate weight loss and complications., Results: Of 182 patients, 156 patients were beyond 1 year postoperative mark and 99 patients were beyond 2 year postoperative mark. Five patients were lost to follow-up. None of our patients had complications resulting in death. BPD-DS and SIPS had statistically similar weight loss at 3 months but percent excess weight loss (%EWL) was more with BPD-DS than SIPS at 6, 9, 12, 18, and 24 months. Patient lost a mean body mass index (BMI) of 23.3 (follow-up: 69%) and 20.3 kg/m 2 (follow-up: 71%) at 2 years from the BPD-DS and SIPS surgery, respectively. However, patients who had undergone SIPS procedure had significantly shorter operative time, shorter length of stay, fewer perioperative and postoperative complications than BPD-DS (P<.001). Interestingly, even though BPD-DS patients lost slightly more weight, the actual final BMI for SIPS group was lower than BPD-DS group (25.6 versus 26.9) (P<.05). There was no statistical difference between 2 groups for postoperative nutritional data such as vitamins D, B1, B12, serum calcium, fasting blood glucose, glycosylated hemoglobin (HbA1C), insulin, serum albumin, serum total protein, and lipid panel., Conclusion: The SIPS is a simplified DS procedure. The SIPS eliminates one anastomosis and compared with BPD-DS has fewer perioperative and postoperative complications, shorter operative time and length of stay, and similar nutritional results at 2 years. However, weight loss was more with BPD-DS. A fair criticism is that the vast majority of BPD-DS cases were done before the SIPS cases. As a result, experience and learning curve cannot be completely dismissed when viewing postoperative complications., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Setting: Spectrum Blodgett and Mercy Health St. Mary's hospitals in Grand Rapids, Michigan OBJECTIVE: To compare the 30-day outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) to laparoscopic sleeve gastrectomy (SG)., Background: Laparoscopic BPD/DS has been shown to be superior to SG in terms of excess weight loss. Despite this superiority, BPD/DS accounts for a small percentage of all metabolic surgeries due partly to the perception that BPD/DS has a higher complication rate than SG., Methods: Retrospective review of all patients who underwent BPD/DS or SG from January 2008 to August 2014 by 1 surgeon was completed. These patients were used to construct cohorts matched via propensity score matching and compared by surgical type. Data collected included patient demographic characteristics; hospital length of stay (LOS); and 30-day rates of leak, bleed, reoperation, readmission, and mortality., Results: Of the 741 patients who underwent BPD/DS or SG, 2 cohorts of 167 patients each were matched for age, sex, and BMI. LOS was longer in the BPD/DS cohort (2.5±.9 days versus 2.1±.7 days, P<.001). There were no significant differences between the groups in relation to 30-day postoperative rates of leak (.3% versus .6%, P>.99), bleed (0% versus .3%, P>.99), reoperation (1.2% versus .6%, P>.99), or readmission (3% versus 1.2%, P = .45). There were no mortalities., Conclusion: After matching for age, sex, and BMI, BPD/DS found no significant differences from SG with regard to 30-day postoperative rates of leak, bleed, reoperation, readmission, or mortality., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastroesophageal reflux (GERD) is a symptom frequently found in obese patients, and often is related to the presence of a hiatal hernia (HH). Surgeons may evaluate for the presence of HH on esophagogastroduodenoscopy (EGD). However, preoperative endoscopic presence or absence of a significant HH does not always correlate with intraoperative findings., Objective: To compare the rate of detection of repairable HH between clinical, endoscopic, and intraoperative methods SETTING: Independent, university-affiliated teaching hospital METHODS: A retrospective chart review of all consecutive patients who had undergone a primary bariatric procedure sleeve gastrectomy, gastric bypass, or biliopancreatic diversion/duodenal switch with routine preoperative EGD in a single institution from 2009-2013 was performed. Data points included the diagnosis of GERD/heartburn/proton pump inhibitor or histamine antagonist from history, the diagnosis of HH from preoperative EGD, and the diagnosis of HH intraoperatively that merited repair., Results: 1570 consecutive patients were included in the study. Eight hundred fifty-seven (55%) had diagnosis of GERD or heartburn, and 713 (45%) were asymptomatic (negative for GERD or heartburn). Hiatal hernia repair was performed in 153 (18%) patients with the diagnosis of GERD or heartburn and in 107 (15%) patients without the diagnosis of GERD and or heartburn. In all, 434 (28%) out of 1570 patients had a finding of HH on EGD; 204 (47%) were repaired. On endoscopy, 326 (75%) were defined as small, 87 (20%) as moderate, and 21(5%) as large HH. Of these, repairs were done on 128 (39%), 60 (70%), and 16 (76%). The sensitivity of detecting repairable HH by clinical indicators such as GERD or heartburn was 55% (P = .123) and sensitivity of EGD findings was 78% (P = .000). Specificity was 46% and 82%, respectively., Conclusion: Small HH are over-diagnosed with EGD, as most do not require repair. However, moderate and large HH are accurately detected., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS)., Objectives: To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS., Setting: An academic, university hospital in the United States., Methods: We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction., Results: One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m 2 . Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m 2 versus≥50 kg/m 2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery., Conclusion: This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Insufficient weight loss (percentage of excess weight loss [%EWL]<50%) is observed in approximately 20% of patients after Roux-en-Y gastric bypass (RYGB). Surgical revision can be performed by various procedures including malabsorptive techniques. Conversion to a biliopancreatic diversion with duodenal switch (BPD/DS) remains a complex technique which cannot always be performed as a one-stage procedure., Objectives: This study evaluates the conversion of RYGB to BPD/DS using a novel gastric reconstruction technique based on a "hybrid sleeve" using the existing gastrojejunal anastomosis of the RYGB., Setting: All the procedures were performed at a private hospital., Methods: The consecutive patients who were eligible for conversion since 2010 were reviewed; eligibility included %EWL≤50% and normal gastric pouch. The gastrojejunal anastomosis of the RYGB was untouched and the gastric fundus was resected. The gastric continuity was restored by an anastomosis between a short segment of the alimentary limb and the gastric antrum. A standard BPD/DS was then performed without restoration of the jejunal continuity., Results: Fourteen patients were converted to BPD/DS for a mean body mass index (BMI) of 44.3±6.0 kg/m 2 , a mean %EWL of 33.4%, and a percentage of total weight loss (%TWL) of 15.3±11.7%. The BMI before RYGB was 54.4±13.1 kg/m 2 , with half of the patients being super-obese. All but 3 conversions were completed as a single stage and laparoscopically in a mean of 177 minutes. The 30-day complication rate was 28.5%. No patient was lost to follow-up over a mean 25.8 months and the BMI of the 12 patients with a follow-up≥3 months is 33.2±7.2 kg/m 2 . With reference to the initial weight of the patients, the mean %EWL is 73.5% and %TWL is 37.6±16.0%. On average, patients benefited from a 21.1% TWL through the conversion of their RYGB., Conclusions: This procedure allows for an easier conversion of RYGB to BPD/DS and appears to be the most effective procedure for resuming weight loss. Nutritional consequences and weight loss are similar to the primary BPD/DS results. However, the benefits and risks must be carefully assessed according to the definition of weight loss failure., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) with a 100-cm common channel has been our treatment of choice for morbid obesity since the early 1990s. This procedure offers excellent long-term weight loss but can be associated with significant side effects., Objectives: To assess the effect on clinical and nutritional parameters of increasing the common channel to 200 cm., Settings: University-affiliated tertiary care center., Methods: Patients who underwent a BPD-DS with a 200-cm common channel (study group, n = 36) were matched 1:1 for age, sex, body mass index (BMI), and main co-morbidities with patients who underwent a BPD-DS with a 100-cm common channel (control group). The strict alimentary limb was 150 cm in both groups., Results: The mean age was 55±9 versus 53±7 years (P = .3), with 50% women and a BMI of 49±8 kg/m(2) versus 50±6 kg/m(2) (P = .9). Follow-up rate was 97%, with a minimum follow-up of 3 years. There were no significant differences in the remission rate of major co-morbidities between the 2 groups. At 3 years, the excess weight loss was 61±22% versus 68±18% (P = .18) and the total weight loss was 33±11% versus 38±9% (P = .055) in the study group versus control group, respectively. The study group had a lower incidence of severe protein deficiency (11% versus 19%, P = .3) and hyperparathyroidism (17.1% versus 35.3%, P = .17); required a lower amount of vitamins A and D (P<.05); and had a decreased number of daily bowel movements (2.0 versus 2.9, P = .03)., Conclusion: In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Reduced serum vitamin K levels are frequently observed after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). The criteria for treatment are not precisely defined., Objectives: To assess the effects of standardized vitamin K supplementation in patients who develop vitamin K deficiency after BPD or BPD/DS., Setting: Teaching hospital specializing in bariatric surgery., Methods: Serum vitamin K levels, clotting times, and vitamin K-dependent coagulation factors were measured after an overnight fast at baseline and then at 4 days and 1, 4, and 52 weeks after the start of vitamin K supplementation in 10 consecutive patients who had developed severe vitamin K deficiency after BPD or BPD/DS. Vitamin K was administered in a dose of 5 mg/d for 1 week, followed by a maintenance dose of 5 mg once a week., Results: At baseline, all patients had serum vitamin K1 levels below the limit of detection, but none reported symptoms of easy bleeding. Minor prolongation of the prothrombin time and minimal decreases of some coagulation factors were observed in a minority of patients. During the first week of vitamin K loading, median serum vitamin K1 levels rose into the high normal range. During maintenance treatment, median vitamin K1 levels settled in the low normal range., Conclusion: Vitamin K1 deficiency in patients with BPD or BPD/DS is not commonly associated with bleeding or clinically relevant decreases in coagulation factor activity. We hypothesize that vitamin K2 production in the large intestine is usually sufficient to compensate for vitamin K1 deficiency and to maintain total liver vitamin K stores within the range required for (near) normal coagulation factor production., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Preoperative type 2 diabetes mellitus (T2 DM) has previously been reported as an independent predictor for suboptimal (≤40%) weight loss after Roux-en-Y gastric bypass in patients with T2 DM compared with patients who do not have T2 DM. This association has not been shown to apply to patients who undergo biliopancreatic diversion with duodenal switch (BPD/DS). BPD/DS is currently the most effective bariatric operation to treat T2 DM., Objectives: We designed a study to determine if the reported suboptimal weight loss seen in patients with T2 DM undergoing Roux-en-Y gastric bypass is also seen in those undergoing BDP/DS., Setting: Independent, university-affiliated teaching hospital., Materials and Methods: Retrospective chart review of a prospectively maintained database was performed on data on 152 patients who underwent robotically assisted laparoscopic BPD/DS from 2008 to 2012. Patients were divided into 2 groups: those with a preoperative diagnosis of T2 DM (Group 1, n = 51) versus those without a preoperative diagnosis of T2 DM (Group 2, n = 101). Perioperative complications and postoperative weight loss between the 2 groups were compared., Results: At 1 month postoperatively, Group 1 had a higher percentage of excess weight loss (%EWL) of 20.9% compared with Group 2 of 17.9% (P<.05). At 3, 6, 9, 12, and 18 months postoperatively, both groups had statistically comparable %EWL (P>.05). Thirty-day perioperative complications were higher in Group 1 compared with those in Group 2 (7.8% and 3.9%, respectively). Reoperation rates were similar in both groups (1.9%). No mortality was recorded in this series., Conclusion: Patients with diabetes had a similar weight loss outcome after BPD/DS compared with those who did not have diabetes., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric operations achieve a high remission rate of type 2 diabetes in patients with morbid obesity. Malabsorptive operations usually are followed by a higher rate of metabolic improvement, though complications and secondary effects of these operations are usually higher., Objectives: Analyze the results of a simplified duodenal switch, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) on patients with obesity and type 2 diabetes mellitus (T2 DM)., Setting: University Hospital, Madrid, Spain., Methods: Ninety-seven T2 DM patients with a mean body mass index (BMI) of 44.3 kg/m(2) were included. Mean preoperative glycated hemoglobin was 7.6%, and mean duration of the disease was 8.5 years. Forty patients were under insulin treatment. SADI-S was completed with a sleeve gastrectomy performed over a 54 French bougie and a 200 cm common limb in 28 cases and 250 cm in 69., Results: Follow up was possible for 86 patients (95.5%) in the first postoperative year, 74 (92.5%) in the second, 66 (91.6%) in the third, 46 (86.7%) in the fourth and 25 out of 32 (78%) in the fifht postoperative year. Mean glycemia and glycated hemoglobin decreased immediately. Control of the disease, with HbA1c below 6%, was obtained in 70 to 84% in the long term, depending on the initial antidiabetic therapy. Most patients abandoned antidiabetic therapy after the operation. Absolute remission rate was higher for patients under oral therapy than for those under initial insulin therapy, 92.5% versus 47% in the first postoperative year, 96.4% versus 56% in the third and 75% versus 38.4% in the fifth. A short diabetes history and no need for insulin were related to a higher remission rate. Three patients had to be reoperated for recurrent hypoproteinemia., Conclusion: SADI-S is an effective therapeutic option for obese patients with diabetes mellitus., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)