Surgery News- July 2008

GENERAL SURGERY SURGERY NEWS • J U LY 2 0 0 8 Single-Stage Duodenal Switch: Safe and Effective The duodenal switch is difficult to perform but gives superior outcomes, including greater weight loss. BY BRUCE JANCIN Else vier Global Medical Ne ws N E W YO R K — The duodenal switch can be performed with reasonable safety as a single-stage bariatric procedure even in superobese patients, according to results from a series of 190 patients. At 30 days after surgery, the mortality rate for patients who underwent the procedure was zero and the overall complication rate was about 20%. The rate of serious complications in superobese patients, who accounted for most of the group, was not significantly higher than that of the less obese patients. “It has been advocated that the procedure is so difficult that you had to do it in two stages: first the sleeve gastrectomy, then the rest of the duodenal switch a year or so later. We do not think doing two operations is a good idea if you can do it in one relatively safe operation,” Dr. Henry Buchwald said at the annual meeting of the American Surgical Association. The duodenal switch is more difficult to perform than other bariatric operations, but previous studies have shown that it gives superior outcomes, including the greatest weight loss, said Dr. Buchwald, an ACS Fellow and professor of surgery at the University of Minnesota, Minneapolis. He reported on the 30-day safety end points for his first 190 consecutive patients to undergo a single-stage duodenal switch procedure. With a mean preoperative body mass index of 53 kg/m2, more than half of the patients were in the superobese category (BMI of 50 or greater), which prior reports by others had identified as a subgroup at markedly increased risk for serious complications with the duodenal switch. A total of 74 patients had concurrent procedures, including cholecystectomy or repair of ventral, umbilical, or hiatal hernia. The overall complication rate at 30 days was 19.5%, including a 10% wound infection rate. Serious complications—mild acute renal failure, gastric outlet obstruction, acute pancreatitis, leak, and duodenoileostomy requiring dilatation—occurred in 18 patients: 6 of 90 with a baseline BMI of less than 50, and 12 of 100 superobese, a nonsignificant difference. The duodenal switch is a modified biliopancreatic diversion procedure that involves creating a common channel 75-100 cm long, performing a sleeve gastrectomy with a roughly 100-mL gastric pouch, closing the duodenal stump, performing endto-side duodenoileostomy hand-sewn in two layers, and closing all mesenteric defects. It is a malabsorptive procedure. Jejunoileal bypass, the prototypical malabsorptive procedure, has fallen into disfavor because of problems such as vitamin deficiencies, electrolyte imbalance, bloating, severe diarrhea, and liver failure. The duodenal switch procedure avoids such problems because of its long ileal segment and good bile flow, he explained. Audience members asked Dr. Buchwald why surgeons should resort to the duodenal switch—the most technically difficult of all bariatric operations—when a simpler procedure, such as laparoscopic Roux-en-Y gastric bypass, gets patients home from the hospital several days sooner and with substantially less morbidity. “The most difficult operations, unfortunately, are often the ones that are most effective,” Dr. Buchwald said, adding that he believes the duodenal switch provides the greatest benefits of any bariatric procedure. He noted that in an earlier 22,094patient meta-analysis, he demonstrated that the duodenal switch achieved the greatest weight loss, the highest rate of resolution of type 2 diabetes, and the greatest reductions in hyperlipidemia of all types of bariatric surgery ( JAMA 2004;292:1724-37). Complete resolution of diabetes occurred in 98.9% of diabetic patients who underwent a duodenal switch and in lesser percentages of patients following gastric bypass, gastroplasty, and gastric banding. (See box.) Diabetes often resolved within days after bariatric surgery, prior to the major weight loss. The mechanism of benefit is unclear, although researchers are focusing on changes in gut-related hormones. Italian surgeons have recently reported very high rates of diabetes resolution after performing the duodenal switch, even in patients who are far less obese (with baseline BMIs in the 30s) than is customary for bariatric surgery, so the benefit isn’t dependent upon the amount of absolute weight loss, according to Dr. Buchwald. All forms of bariatric surgery provided similarly high rates of resolution of hypertension and obstructive sleep apnea (62% and 86%, respectively). Dr. Philip R. Schauer, an ACS Fellow who is professor of surgery and director of the Cleveland Clinic Bariatric and Metabolic Institute, hailed Dr. Buchwald’s study as “a major contribution to our field,” one of many to have come from the University of Minnesota, where the world’s first bariatric operation was performed in 1953. Noting that others have reported perioperative mortality rates of up to 5% with the duodenal switch, as well as markedly increased complications in the superobese, Dr. Schauer asked Dr. Buchwald how he gets such outstanding results. “I think it’s because we pay a lot of attention to careful surgery,” he replied. “And we don’t believe in a learning curve.” “There is an unfortunate tendency today, at least in my opinion, in all of surgery—and particularly in bariatric surgery—to use the term ‘learning curve’ to excuse deaths and significant complications. Well, the patient isn’t learning from this experience. I think we should try to do our work without saying it’s okay to do badly in our first 50 or 100 patients because it’s a learning curve,” Dr. Buchwald said. ■ Duodenal Switch Shows the Most Improvements Among Bariatric Procedures ELSEVIER GLOBAL MEDICAL NEWS Significant hyperlipidemia improvement Duodenal switch 99.5% Gastric bypass 93.6% Gastroplasty 80.9% Gastric banding 71.1% Note: Based on a 22,094-patient meta-analysis. Source: JAMA Diabetes resolution 98.9% 83.7% 71.6% 47.9% Excess weight loss 70.1% 61.6% 68.2% 47.5% IPAA Scores High in Long-Term Retention for Crohn’s Patients BY BRUCE JANCIN Else vier Global Medical Ne ws N E W YO R K — Ileal pouch anal anastomosis has an unexpectedly good long-term retention rate in highly selected Crohn’s disease patients, according to a single-center study of more than 200 patients. The 10-year pouch retention rate was 85% or higher in patients diagnosed with Crohn’s disease before or immediately after the procedure, and about 50% in those whose Crohn’s diagnosis was delayed 3 months or more postoperatively. Ileal pouch anal anastomosis (IPAA) surgery also won very high patient satisfaction marks from individuals with long-term pouch retention, Dr. Genevieve B. Melton-Meaux reported at the annual meeting of the American Surgical Association. IPAA is widely considered the procedure of choice in ulcerative colitis patients whose inflammatory bowel disease requires surgery. However, IPAA is a controversial treatment for Crohn’s patients because of concerns that the pouch itself may develop active Crohn’s disease, as well as a lack of long-term outcome data, said Dr. Melton-Meaux of the Cleveland Clinic Foundation. She reported on 204 Crohn’s disease patients who underwent IPAA at the Cleveland Clinic. These patients represent only 7% of the clinic’s database of nearly 2,900 inflammatory bowel disease patients on whom the procedure was performed. Moreover, only 10% of the 204 patients were known to have Crohn’s disease at the time IPAA was scheduled. Another 47% were diagnosed with Crohn’s disease immediately after surgery, based on surgical pathology, while in 43% the diagnosis was delayed a median of 36 months postoperatively. The overall 10-year pouch retention rate was 71%. It was 85% among patients with known Crohn’s disease at the time of IPAA, 87% in those whose Crohn’s was diagnosed immediately after surgery, and significantly worse (53%) in those with a delayed diagnosis. In a multivariate analysis, pouch loss was associated with delayed diagnosis of Crohn’s disease, abdominopelvic sepsis, and pouch-vaginal fistula, but not with extraintestinal disease manifestations, smoking, postoperative infliximab or corticosteroid therapy, or preoperative pathology, Dr. Melton-Meaux said. At follow-up, patients with pouch retention reported a median of seven bowel movements per day. In all, 72% reported perfect or near-perfect continence, and 68% reported rare or no urgency symptoms. Postoperative manifestations of Crohn’s disease were common. Perianal fistula, pouch-vaginal fistula, IPAA stricture, and pouchitis occurred in 11%-40% of patients without a delayed diagnosis of Crohn’s disease and were two- to fourfold more common in those with delayed diagnosis. Nonetheless, patients with a retained pouch at followup rated their quality of life as a median 9 out of a possible 10 and their happiness with the surgery as a 10. “The functional outcomes aren’t as good as for the pouch in ulcerative colitis patients, but one of the take-home messages of this study is that Crohn’s patients are perhaps willing in some cases to accept less than perfect outcomes,” Dr. Melton-Meaux observed. “These patients—if they retain their pouch—are reporting a happiness with surgery of 10 out of 10.” Why do patients with a delayed diagnosis of Crohn’s disease do so much worse following IPAA? The answer is unknown, but it’s likely they have a phenotypic variant of the disease that, over time, tends to include smallbowel and/or anal involvement, she said. Audience members were eager to learn whether this study’s results will prompt Cleveland Clinic surgeons, who are very experienced with IPAA, to suggest a largescale broadening of the selection criteria for the procedure. Negative, Dr. Melton-Meaux replied. “We’re reluctant to offer it to patients with known Crohn’s dise

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Surgery News- July 2008 Contents The 20/20 Vision: Health Reform Trauma: Airway Anchor News From the College: Jacobson Winner General Surgery: Worth the Trouble

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