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DOI 10.1007/s11695-017-2931-z
VIDEO SUBMISSION
Technical Options for Malabsorption Issues After
Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
Ramon Vilallonga 1 & José Maria Balibrea 1 & Anna Curell 1 & Oscar Gonzalez 1 &
Enric Caubet 1 & Andrea Ciudin 2 & Angel Michael Ortiz-Zúñiga 3 & José Manuel Fort 1
# Springer Science+Business Media, LLC 2017
Abstract
Background Laparoscopic single anastomosis duodenoileal
bypass with sleeve gastrectomy (SADI-S) is a recently devel-
oped one- or two-stage operation based on biliopancreatic
diversion that is used to treat morbid obesity. Some midterm
outcomes suggest that malabsorption is a possible complica-
tion following the procedure. Therefore, conversion to a less
malabsorptive procedure may be required. We aim to describe
and analyze the outcomes after laparoscopic conversion of
SADI-S to non-malabsorptive or less malabsorptive
procedures.
Methods From January 2015 to April 2017, five patients
underwent laparoscopic conversion to single anastomosis
duodenojejunal bypass with sleeve gastrectomy (SADJ-S)
(video) following SADI-S, and one female patient underwent
laparoscopic conversion to gastric bypass (GBP) following
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11695-017-2931-z) contains supplementary
material, which is available to authorized users.
* Ramon Vilallonga
vilallongapuy@hotmail.com
1
Endocrine, Metabolic and Bariatric Unit, Vall d’Hebron University
Hospital, Universitat Autònoma de Barcelona, Center of Excellence
for the EAC-BC, Passeig de la Vall d’Hebron 119-129,
08035 Barcelona, Spain
2
Endocrinolgy and Nutrition Department, Vall d’Hebron University
Hospital, Universitat Autònoma de Barcelona, CIBER Instituto de
Salud Carlos III, Passeig de la Vall d’Hebron 119-129,
08035 Barcelona, Spain
3
Endocrinolgy and Nutrition Department, Vall d’Hebron University
Hospital, Universitat Autònoma de Barcelona, Center of Excellence
for the EAC-BC, Passeig de la Vall d’Hebron 119-129,
08035 Barcelona, Spain
SADI-S, after presenting with severe protein-calorie malnutri-
tion, nutritional deficiencies, poor quality of life, or increased
number of bowel movements.
Results Mean preoperative BMI was 24.0 kg/m2 (20.4–
27.5 kg/m2). Four patients underwent SADI-S to SADJ-S
conversions and one underwent a SADI-S to Roux-en-Y
duodenojejunal bypass. All cases were performed
laparoscopically. No relevant postoperative complications or
mortality was reported and the mean hospital stay was
4.6 days. Malabsorptive symptoms resolved in all patients.
All patients experienced weight regain. Mean BMI increase
was 7.1 kg/m2 (5–10.8 kg/m2).
Conclusions Outcomes of laparoscopic conversion to SADJ-
S or GBP after SADI-S were acceptable, showing clinical
improvement of malnutrition, nutritional deficiencies, and
quality of life in all cases. Weight regain must be advised.
These techniques appear feasible and free of severe long-
term complications. Further investigation is warranted to un-
derstand the best common channel length for patients under-
going SADI-S.
Keywords SADI-S . Malabsorption . Conversion .
Revisional procedure . Complication
Introduction
Laparoscopic sleeve gastrectomy (LSG) was originally pro-
posed as a first step towards a biliopancreatic diversion duo-
denal switch (BPD-DS). LSG as primary bariatric procedure
has excellent results but also potential drawbacks. These in-
clude insufficient weight loss, weight regain, dysphagia, and
gastroesophageal reflux disease. In selected patients, LSG can
be considered as a primary stage procedure [1]. There are
multiple accepted options that can be considered for

secondary surgery, including BPD-DS, and more recently,
one- or two-stage single anastomosis duodenoileal bypass
with sleeve gastrectomy (SADI-S) has been considered as an
option [2, 3].
An increasing number of experiences have shown SADI-S
to be an attractive procedure [4]. This new operation to treat
morbid obesity is based on biliopancreatic diversion, in which
a LSG is followed by an end-to-side duodenoileal diversion.
The preservation of the pylorus makes reconstruction possible
in one loop, which reduces operating time and eliminates the
need for a mesentery opening. It is a promising operation that
offers excellent weight loss and metabolic results. The elimi-
nation of one anastomosis reduces operative time and de-
creases the possibility of surgery-related complications [5].
However, as is the case with other bariatric procedures,
some midterm outcomes suggest that in some cases
malabsorptive complications can appear after SADI-S. In such
cases, conversion to a less malabsorptive procedure may be
required [6]. Thus, the aim of this communication is to de-
scribe our experiences and the technical options for converting
a SADI-S procedure to a less malabsorptive procedure to treat
nutritional deficiencies. Currently, there are no guidelines for
deciding whether a patient needs conversion, revision, or re-
versal of prior surgery.
Although reversal will lead to weight regain and the possi-
ble return of comorbid conditions, procedure reversal is some-
times necessary because of complications [7].
Patients and Methods
From January 2015 to June 2017, five patients underwent
conversion of SADI-S because of severe protein-calorie mal-
nutrition (4 patients) and multiple nutritional deficiencies (1
patient).
There were four female patients and one male patient. In
keeping with our institutional protocol, all patients had previ-
ously undergone a LSG and a second-step SADI-S procedure.
Age ranged from 33 to 54 years (mean 41.6 years). BMI at the
time of the procedure ranged from 20.4 to 27.5 kg/m2 (mean
24.1 kg/m2). All five patients had undergone LSG and then
conversion to SADI-S in a second stage surgery to improve
weight loss and reverse previous metabolic conditions.
Duodenoileostomy was performed 200 cm proximal to the
ileocecal valve in two patients, and at 250 cm in the remaining
three.
Indications for conversion surgery were severe protein-
calorie malnutrition and multiple nutritional deficiencies, poor
quality of life, or increased diarrhea. During the follow-up
after conversion from LSG to SADI-S (mean follow-up
26 months), four patients required parenteral nutrition, vita-
min and mineral supplements, and hospitalization at some
point. One of these required ICU admission for epileptic status
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due to metabolic disorders. The fifth patient suffered self-
limiting diarrhea (6–7 daily bowel movements) without im-
pairment of laboratory nutritional values (Table 1).
A systematic review of each patient’s chart was performed.
Special focus was placed on relevant data such as surgical
history, initial BMI, technical aspects of the previous SADI-
S, and postsurgical follow-up (including complications).
Postoperative complications of the conversion procedure,
details of hospital stay, follow-up time, and final outcomes
were also reported. Data on preoperative and postoperative
nutritional status including total serum proteins and albumin
were also included. Patients’ records were reviewed according
to our institutional ethics committee’s recommendations for
observational studies.
Surgical Technique (Video Presentation)
A standard approach and pneumoperitoneum was performed.
An 11-mm trocar was placed in the midline just above the
umbilical area to perform an initial exploratory laparoscopy.
Trocars were placed according to Fig. 1. As a first step, pre-
viously performed procedures were carefully revised and the
length of the common channel was measured. Later, dissec-
tion of the duodenoileal anastomosis was performed and com-
plete transection of the duodenum over the previous anasto-
mosis was done using an endoscopic linear cutter (Echelon 60
Endopath stapler, straight, Ethicon-Endo-Surgery, Cincinnati,
OH, USA) with a green cartridge. Once transected, the re-
maining duodenum was left in place and a two-layer running
manual duodenojejunal anastomosis was performed at 60 cm
from the Treitz angle. First, a posterior duodenojejunal anas-
tomosis with 3/0 suture (Prolene, Ethicon Endo-Surgery) layer
was done, and then the duodenum and the ileum were opened
using monopolar. A posterior continuous resorbable suture
(Vicryl 3/0 Ethicon-Endo-Surgery) was used, and then, the
anterior layer was constructed in similar fashion, with first a
continuous layer of vicryl and finally a polypropylene 3/0
anterior closure. A routine methylene blue test was performed
and a drain was left in place under the anastomosis and close
to the duodenal stump.
Following transection of the duodenum, a distance of
< 1 cm between the staple line and the pylorus was observed
in one patient. Because of the high risk of bile reflux, a Roux-
en-Y duodenojejunal bypass (RYDJBP) with a long gastric
pouch was performed.
Results
Conversion to single anastomosis duodenojejunal bypass with
sleeve gastrectomy (SADJ-S) after SADI-S was performed in
four patients (Video) and Roux-en-Y GBP was performed in
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Table 1 Patients’ preoperative

BMI, previous surgical Gender Age Initial BMI Procedures Cause for Total proteins Albumin
procedures, and reason for (M/F) (years) (kg/m2) (types) conversion (g/dL)a (g/dL)b
conversion
F 33 55.32 SG SADI-S PCM-ND 5.76 3.25
F 38 47.75 SG SADI-S PCM-ND 5.5 3.18
F 54 51 SG SADI-S PCM-ND 4.78 2.19
M 49 52.25 SG SADI-S PCM-ND 6.23 3.19
F 40 43.16 SG SADI-S Severe diarrhea 6.6 3.8

PCM-ND severe protein-calorie malnutrition and multiple nutritional deficiencies, SG sleeve gastrectomy, SADI-
S single anastomosis duodenoileal bypass with sleeve gastrectomy
a
Normal range 6.6–8.01 g/dL
b
Normal range 3.4–4.8 g/dL

the remaining patient. All cases were performed laparoscopically. Discussion

Re-measurement of all common channels during initial revision
showed 175 cm in one patient (initially reported as 250), 200 cm
in two patients, and 250 cm two patients.
No intraoperative complications were observed, and the post-
operative period was uneventful in four patients. However, one
patient presented with intraabdominal fluid collection without
oral contrast leakage near the duodenojejunostomy that required
percutaneous drainage with a pigtail catheter. The mean hospital
stay of all five patients was 4.66 days (4–11 days). There was no
mortality in our series. All patients recovered from the initial
symptoms indicating conversion surgery. However, because of
the conversion to a less malabsorptive procedure, all patients
experienced weight regain: mean BMI increase was 7.1 kg/m2
(5–10.8 kg/m2); mean weight increase was 18.9 kg (11.3–
30.9 kg) (Table 2).
Fig. 1 Image showing the placement of trocars to perform a standard
revisional procedure after SADI-S. Umbilical trocar (11 mm, red), left
side working trocar for stapler (12 mm, blue), subxiphoidal trocar for liver
retraction (sometimes optional, 5 mm, green), two working trocars
(5 mm, green)
There are growing numbers of patients who require revisional
bariatric surgery because of undesirable results of their prima-
ry procedures [8]. The main indications for revision proce-
dures are inadequate weight loss, surgery-related complica-
tions, surgical emergencies, long-term complications caused
by malnutrition, and vitamin deficiencies. Revisional bariatric
procedures are technically more complex and associated with
increased postoperative complications [9].
SADI-S, a novel bariatric operation technique based on the
principles of biliopancreatic diversion, was proposed as a way
of modifying a pre-existing diversion to simplify the proce-
dure, decrease the potential complication rate, and maintain or
improve, if possible, the outcomes of the original
biliopancreatic diversion [5]. However, this new technique
does not prevent possible inherent long-term complications
that can appear after a mixed restrictive and malabsorptive
technique, such as severe malnutrition [4, 10].
The risk of nutritional deficiencies depends on the percent-
age of body weight lost and the type of surgical procedure
performed. Purely restrictive procedures can induce digestive
symptoms, food intolerance, or maladaptive eating behaviors
as a result of pre- or postsurgical eating disorders.
Malabsorptive procedures are commonly associated with mi-
cronutrient deficiencies: iron, calcium, vitamin D, and vitamin
B12 deficiencies are common; rare deficiencies can lead to
serious complications such as encephalopathy or protein-
energy malnutrition. Routine nutritional screening, recom-
mendations for appropriate supplements, and monitoring
compliance are imperative, whatever the bariatric procedure
[11, 12]. When nutritional deficiencies are persistent over time
despite supplements and occasional intravenous treatments,
which necessitate frequent hospital stays, revision surgery
should be considered before severe or irreversible conse-
quences appear. Conversion of the primary bariatric procedure
in our series of patients, SADI-S, was aimed at reducing the
malabsorptive component. In our experience, this has been
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Table 2 Patients’ preoperative and postoperative BMI, type of surgery performed, and postoperative complications

BMI at reversal Type of Hospital stay Complications Time after last follow- Follow-up events and Total proteins Albumin
(kg/m2) procedure (days) up (months) BMI (kg/m2) (g/dL)a (g/dL)b

20.4 SADI-S to 5 None 25 Weight regain, 31.2 6.7 3.5

SADJ-S
24.0 SADI-S to 4 None 19 Weight regain, 33.78 6.6 3.6
RYGB
27.5 SADI-S to 5 None 23 Weight regain, 39.56 6.8 3.9
SADJ-S
23.9 SADI-S to 11 Intraabdominal 14 Weight regain, 30.44 6.6 3.4
SADJ-S abscess
28.2 SADI-S to 5 None 3 N/A 6.6 3.5
SADJ-S

SADI-S single anastomosis duodenoileal bypass with sleeve gastrectomy, SADJ-S single anastomosis duodenojejunal bypass with sleeve gastrectomy,
N/A not applicable
a
Normal range 6.6–8.01 g/dL
b
Normal range 3.4–4.8 g/dL

highly effective in terms of improving the nutritional state of
all patients. Based on our limited experience, we believe that
converting SADI-S to SADJ-S is simple and maintains all the
advantages of a one-anastomosis procedure such as SADI-S,
including the non-closure of mesenteric defects and short op-
erative time [5].
From a theoretical point of view, several options could be
considered for reversal of the malabsorptive component of
BPD [13]. However, specific information regarding SADI-S
reversal remains scant.
Other options include conversion to LSG by performing a
duodenoduodenal anastomosis. This procedure for converting
the SADI-S to a LSG might be the most physiologic option to
reverse the malabsorptive component. This procedure would
require dissection of the previous anastomosis, its transection,
and an end-to-end anastomosis. A third possibility would be to
convert the SADI-S to a biliopancreatic diversion with duode-
nal switch; however, this technical option has not been per-
formed in our department. Instead of performing a transection
on the anastomosis, the transection is performed in the efferent
small bowel loop and a new anastomosis is performed on the
efferent small bowel loop. Attention must be given to the mea-
suring of the small bowel in the afferent side because it will
become the new common channel of the new duodenal switch.
Another option that could be considered is to convert the
SADI-S to a Roux-en-Y GBP by performing an anastomosis
at the level of the antrum, either with a Roux-en-Y anastomo-
sis or without conversion to single anastomosis gastrojejunal
bypass with sleeve gastrectomy (Omega loop gastric bypass,
option 5). SADJ-S is an attractive procedure but if the anasto-
mosis is too close to the pylorus or even at the pylorus, Roux-
en-Y reconstruction should be considered as previously
mentioned.
Many factors contributed to the need for conversion proce-
dures in these five patients. The distance from duodenoileostomy
to ileocecal valve seems to play a pivotal role. In our previously
published experience, the global conversion rate was 13% and all
patients with a SADI-S with a common channel of 200 cm as
initially recommended when the technique was designed [5] ul-
timately required a conversion for malabsorptive issues [6].
Therefore, SADI-S is currently usually performed at 300 cm
from the ileocecal valve. Debate continues with regard to the
ideal length for the common channel. In fact, there is no clear
length, and a strong effort must be made to measure the entire
small bowel to understand which exact procedure is being done
[14, 15]. In our patients, because of serious complications, safety
was our priority, so we favored highly proximal anastomoses.
Possible mistakes in the measurement of the length of the
loop were reported in one of our cases. The presence of other
factors such as supplementation requirements (including par-
enteral nutrition and intravenous iron administration) or the
presence of severe diarrhea can affect the overall quality of life
of patients. Finally, it must be taken into account that two of
our patients had a medical history of eating behavior disorders
during adolescence. Therefore, both strict adhesion to appro-
priate nutritional recommendations and careful patient selec-
tion are mandatory [11].
Conclusions
In expert hands, laparoscopic conversion of SADI-S to less
malabsorptive procedures is feasible and free of severe long-
term complications. It appears to be an effective strategy for
treatment of malabsorptive issues and resulted in clinical im-
provement in all of five patients in this study. However, this
technique is challenging and entails a higher risk of compli-
cations than primary bariatric procedures. Therefore, each in-
dividual case must be carefully analyzed not only after com-
plications of a bariatric procedure appear, but also before the
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initial surgery is performed, to try to predict and prevent pos-
sible complications that could appear during long-term post-
surgical follow-up. Further investigation is warranted to con-
firm our preliminary results.
Compliance with Ethical Standards
Conflict of Interest Author 1 and 2 are occasional consultants for
Ethicon Endo-Surgery. All other authors have no conflicts of interest.
The manuscript has been read and approved by all authors. No financial
support for the manuscript preparation.
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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