Most recent update: Friday, June 14, 2019 - 08:47

Bariatric News - Cookies & privacy policy

You are here

Side-to-side duodeno-ileal anastomosis

Safety and efficacy of a side-to-side duodeno-ileal anastomosis

The main advantage of a duodeno-ileostomy would be the fast ileal stimulation, causing an early incretin release and offering a potential tool for the resolution of type-2 diabetes

A study assessing the safety and efficacy of performing a side-to-side duodeno-ileal anastomosis in a porcine model has concluded that a side-to-side duodeno-ileal anastomosis provides excellent weight loss without apparent nutritional or grossly aberrant histological changes. Written by Professor Michel Gagner from the Hopital du Sacre Coeur, Florida International University, Montreal, Canada, the paper, ‘Safety and efficacy of a side-to-side duodeno-ileal anastomosis for weight loss and type-2 diabetes: duodenal bipartition, a novel metabolic surgery procedure’, is published in the Annals of Surgical Innovation and Research.

The paper states that a jejunoileal bypass (JIB) was one of the earliest types of bariatric surgery introduced with its many variations four and five decades ago. The procedure was performed end-to-side, with the proximal 30cm jejunum anastomosed to the distal 15cm of ileum (or end-to-end), with bypassed small bowel derived end-to-side to the colon. Although excellent weight loss and complete resolution of type-2 diabetes mellitus were reported after JIB, a variety of complications related to JIB were reported, including: hypoalbuminemia, hypokalemia, hypocalcemia, hyperbilirubinemia, migratory polyarthralgias, calcium oxalate urinary calculi, and elevated liver enzymes levels and deaths due to liver failure.

Michel Gagner

Nevertheless, animals models have shown that when a 90% small bowel resection in germ free rats is compared to a 90% small bowel bypass, the resected animals have remained with normal liver histology after a prolonged period.

“This means that any blind limb is possibly responsible for liver insufficiency,” Gagner states. “Therefore the development of a new surgical malabsorptive procedure should not involve any blind segment.”

He explains that a partial malabsorptive bypass is constructed with a side-to-side anastomosis between the 3rd portion of the duodenum and last 50cm of the ileum (anatomically in close proximity, Figures 1, 2 and 3) allowing a partial flow of nutrients to move in the proximal jejunum for normal mineral absorption and caloric intake, while a portion is bypassed into the distal ileum, causing a decreased absorption resulting in weight loss.

Figure 1: Position of the right transverse colon overlying the 3rd and fourth portions of the duodenum, with distal ileum lying in close proximity

Figure 2: EndotractTM device implanted between the lower side of the 3rd portion of the duodenum and upper side of distal ileum, by open enterotomies

Figure 3: After 7–10 days of tissue compression, the Endotract(TM)device has passed with bowel transit, leaving a permanent side-to-side duodeno-ileal anastomosis

Since both limbs have flow, bacterial overgrowth is of a lesser concern theoretically comparable to Roux-en-Y gastric bypass (Figure 4). To perform this anastomosis, a compression anastomotic device was used for its simplicity.

Figure 4: Comparison of digestive flow between a gastric bypass and a side-to-side duodeno-ileal anastomosis. Alimentary flow and biliopancreatic secretions are mixing in a Y channel (100–150 cm in mid jejunum) in a gastric bypass, while in a side-to-side duodeno-ileal anastomosis, the alimentary flow is divided between a regular jejuno-ileal channel and a distal ileal channel, and biliopancreatic secretions are mixing in the proximal duodenum

Therefore, the aim of the study was to evaluate the safety and efficacy of using a compression anastomotic device to create a permanent anastomosis between the small bowel and duodenum, to evaluate the short-term effect of a side-to-side duodeno-ileal anastomosis on weight loss.

Study

The study used seven Yorkshire pigs, which were more than 2 months old, weighing approximately 40–60 kg,. The porcine diet consisted of a fixed formula certified by the manufacturer to be free of environmental contaminants; tap water was given ad libitum.

Four animals had a side-to-side duodeno-ileostomy with the compression anastomotic device and three were allocated to a control group. After laparotomy with a 25cm upper midline incision, a duodenotomy of approximately 2.5cm was created anterior to admit the proximal part of the compression anastomotic device, and an ileotomy approximately 50cm from the ileocecal valve was made to insert the distal part compression anastomotic device. The anastomosis was performed by compression of both parts away from the duodenotomy and ileotomy (Figure 2).

Outcomes

At 28 days post-surgery all pigs were healthy, although one pig had developed a small, external incisional hernia, which had to be corrected. At 28 days duodenoscopy of all animals showed a widely patent healed side-to-side duodeno-ileal anastomosis, with proximal ileum on the right and distal ileum on the left (Figure 5a, b).

Figure 5: Duodenoscopy of the 3rd portion of the duodenum, showing a healed side-to-side duodeno-ileal anastomosis, with proximal ileum on the right and distal ileum on the left of the figure. b Duodenoscopy of the 3rd portion of the duodenum from a different animal, showing a healed side-to-side duodeno-ileal anastomosis, with distal duodenum on the far right of the figure

Further investigation found no evidence of gross ulcerations in all parts of the duodenum or in the ileum, and the anastomosis itself revealed a smooth transition between both mucosae. The mean percentage of weight change from baseline in animals that had a side-to-side duodeno-ileal anastomosis (study group) versus sham controls, over time in days is shown in Figure 6. At 56 days, control animals had gained 33.2% of weight, while study animals had lost 6.8% of weight.

Figure 6: Graph of % of weight change in animals that had a side-to-side duodeno-ileal anastomosis (study group) versus sham controls, over time in days. At 56 days, control animals had gained 33.2% of weight, while study animals had lost 6.8% of weight

“The main advantage of a duodeno-ileostomy would be the fast ileal stimulation, causing an early incretin release and offering a potential tool for the resolution of type-2 diabetes....” Gagner concludes. “Although we did not measure this hormone (glucagon-like peptide-1, GLP-1) in pigs after duodeno-ileostomy, we postulate that an early release of GLP-1 will be a main endocrine feature of this operation. In turn, the increasing concentration of intravenous infusion of Peptide YY (PYY) reduces the glucose stimulated insulin release. This suggests that PYY affects the Beta-cell function by a possible autonomic regulation. Similarly, we are postulating that an early ileal release of PYY will occur after a side-to-side duodeno-ileostomy, and could be one hypothesis behind the effective weight loss seen in these animals.”

To access this article, please click here

Want more stories like this? Subscribe to Bariatric News!

Bariatric News
Keep up to date! Get the latest news in your inbox. NOTE: Bariatric News WILL NOT pass on your details to 3rd parties. However, you may receive ‘marketing emails’ sent by us on behalf of 3rd parties.