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DSIT procedure

DSIT procedure is safe and feasible

Although the efficacy and safety of laparoscopic procedure have been previously reported in diabetic patients with lower BMIs, the authors sought to report the outcomes in a wider range of patients and specifically document the morbidity and mortality

Laparoscopic diverted sleeve gastrectomy with ileal transposition (DSIT) is a technically feasible operation that can be safely performed in type 2 diabetic patients with acceptable complication and mortality rates, according to the findings of a study by investigators from the Metabolic Surgery Clinic, Istanbul, Turkey, and published in Obesity Surgery.

Associate Professor Alper Celik is the president of Turkish Metabolic Surgery Foundation. He has been working in the field of metabolic and bariatric surgery since 2008.

“The metabolic outcomes of the study group will be subjected to future publications. Thus, we have initially intended to report the surgical outcomes of an intervention blamed for surgical complexity,” said the article’s lead author, Associate Professor Alper Celik from the Taksim German Hospital. “The results presented herein demonstrate a fairly high morbidity rate compared to other bariatric procedures (particularly non-stapled/non-anastomotic procedures)…The results of this retrospective study clearly demonstrate that DSIT operation can be safely performed in overweight, obese and morbidly obese type 2 diabetic patients. More objective criteria are certainly necessary for a comparative assessment of different operational techniques and for surgical training to clarify when and who should perform this operation.”

DSIT procedure

During a DSIT procedure, the surgical team will at first perform a sleeve gastrectomy or fundectomy (depending on the BMI) and then a duodenal transection 2–3 cm from the pylorus. The sleeved stomach is then transferred to the lower abdomen through a transverse meso-colic opening. A single stay suture is placed 50cm from the ligament of Treitz and the cecum is identified. The last 30cm of ileum is preserved, and a 170cm segment of the distal ileal segment is prepared for the anastomosis.

The first anastomosis is ileo-ileostomy, the second is duodeno-ileostomy and the third is ileo-jejunostomy. The first and the last anastomoses are perfromed in a functional side-to-side manner and the second anastomosis is hand sewn with a single-layer continuous 3/0 polydiaxanone (PDS) suture. All the mesenteric defects are closed using 3/0 polypropylene sutures. Schematic demonstration of the operation is shown in Figure 1.

Figure 1: Schematic demonstration of the operation. a Sleeve gastrectomy. b Duodenal transection. c Inframesocolic transfer of the sleeve. d Interposition of the ileal segment between distal stomach and the proximal jejunum

Although the efficacy and safety of this laparoscopic procedure have been previously reported in diabetic patients with lower BMIs, the authors sought to report the outcomes in a wider range of patients and specifically document the morbidity and mortality, emphasising the nonsurgical complications.

Outcomes

A total of 360 patients who had a DSIT procedure and were followed up for one year were finally included in the study. The mean HbA1c was 9.41 and included 229 males (63.6%) with a mean age of 51.2 years, with a diabetic duration of 12.6 years. The key outcomes were as follows:

  • The authors report that there were three deaths (ileo-jejunal anastomotic leak. myocardial infarction eight months after surgery and traffic accident ), equating to a procedure-related mortality rate of 0.27%.
  • There were 22 (6.1%) surgery-related complications including eight (2.2 %) leaks; five bleeding; three strictures; three sleeve angulations; one abscess; one wound infection; and one deep vein thrombosis. Seven patients (1.94 %) required immediate surgical re-intervention, whilst the other 15 patients were managed conservatively.
  • There were 20 (5.5%) surgery-related non-surgical complications including ten patients reporting a change in bowel habits, five cases of food intolerance, excessive weight loss (without nausea and vomiting) in two patients, and intractable reflux, hypoglycaemia and itching in three patients (one instant each). Eleven (3.05 %) patients had neurological complications, none of which were fatal.
  • Twenty six (7.22%) patients required an additional surgical procedure including: 15 cholecystectomies, two appendectomies, two were re-operation due to intra-abdominal enlarged lymph nodes, one coronary artery bypass grafting, one spinal surgery, one for frozen shoulder, one for toe amputation (burn injury), one for abscess and necrosis in the leg (after drug injection), one (a female patient) needed a curettage, and another underwent body-contouring surgery.

In addition, post-surgery patients reported an improvement in their nutritional status. Prior to surgery, 24 patients (6.7 %) had iron deficiency anaemia and 87 patients (24.2 %) had vitamin D deficiency, after surgery 22 patients (6.1 %) had iron deficiency anaemia and 71 patients (19.7 %) had vitamin D deficiency. This could be because DSIT is not a malabsorptive operation and also all patients received routine multivitamin supplements for at least six months after surgery.

“Further studies are warranted to assess the efficacy, patient selection criteria and cost-effectiveness of the procedure, and its effects on reproducible weight loss and resolution or improvement of obesity-related comorbidities especially in the long term,” the authors concluded.

To access this paper, please click here

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