Safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of obesity patients / 中华胃肠外科杂志

Objective: To investigate the safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in the treatment of obesity patients. Methods: A descriptive case series study was performed. Clinical data of obesity patients who were treated with Da Vinci robotic SADI-S in China-Japan Union Hospital of Jilin University from March 2020 to May 2021 were analyzed retrospectively. Case inclusion criteria: (1) uncomplicated obese patients with body mass index (BMI)≥37.5 kg/m(2); (2) patients with BMI of 28 to <37.5 kg/m(2) complicated with type 2 diabetes or two metabolic syndrome components, or obesity comorbidities; (3) patients undergoing SADI-S by Da Vinci robotic surgery system. Those who received other bariatric procedures other than SADI-S or underwent Da Vince robotic SADI-S as revisional operation were excluded. A total of 77 patients were enrolled in the study, including 31 males and 46 females, with median age of 33 (18-59) years, preoperative body weight of (123.0±26.2) kg, BMI of (42.2±7.1) kg/m(2) and waistline of (127.6±16.3) cm. According to the order of operation date, the patients were numbered as 1-77. The textbook outcome (TO) and Clavien-Dindo grading standard were used to analyze the clinical outcome of each patient and to classify surgical complications, respectively. The standard of textbook outcome was as follows: the operative time less than or equal to the 75th percentile of the patient's operation time (210 min); the postoperative hospital stay less than or equal to the 75th percentile of the patient's postoperative hospital stay (7 d); complication grade lower than Clavien grade II; no readmission; no conversion to laparotomy or death. The patient undergoing robotic SADI-S was considered to meet the TO standard when meeting the above 5 criteria. The TO rate was calculated by cumulative sum analysis (CUSUM) method. The curve was drawn by case number as X-axis and CUSUM (TO rate) as Y-axis so as to understand the learning curve of robotic SADI-S. Results: The operative time of 77 robotic SADI-S was (182.9±37.5) minutes, and the length of postoperative hospital stay was 6 (4-55) days. There was no conversion to laparotomy or death. Seven patients suffered from complications (7/77, 9.1%). Four patients had grade II complications (5.2%), including one with duodeno-ileal anastomotic leakage, one with abdominal bleeding, one with peritoneal effusion and one with delayed gastric emptying; two patients were grade IIIb complications (2.6%) and both of them were diagnosed with gastric leakage; one patient was grade IV complication diagnosed with postoperative respiratory failure (1.3%), and all of them were cured successfully. A total of 51 patients met the textbook outcome standard, and the TO rate was positive and was steadily increasing after the number of surgical cases accumulated to the 46th case. Taking the 46th case as the boundary, all the patients were divided into learning stage group (n=46) and mastery stage group (n=31). There were no significant differences between the two groups in terms of gender, age, weight, body mass index, waist circumference, ASA classification, standard liver volume, operative time and morbidity of postoperative complication (all P>0.05). The percent of abdominal drainage tube in learning stage group was higher than that in mastery stage group (54.3% versus 16.1%, P<0.05). The length of postoperative hospital stay in learning stage group was longer than that in mastery stage group [6 (4-22) d versus 6 (5-55) d, P<0.05)]. Conclusion: The Da Vinci robotic SADI-S is safe and feasible with a learning curve of 46 cases.

One-year outcomes of laparoscopic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy versus laparoscopic sleeve gastrectomy for the treatment of obesity and obesity-related metabolic diseases / 中华胃肠外科杂志

Objective: To compare the efficacy and safety of laparoscopic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) and laparoscopic sleeve gastrectomy (SG) in the treatment of obesity and obesity-related metabolic diseases. Methods: A retrospective cohort study method was used to analyze the clinical data of 22 patients with obesity who underwent laparoscopic SADI-S in the China-Japan Union Hospital of Jilin university from May 2018 to December 2019 (SADI-S group). Meanwhile, 22 patients with obesity undergoing laparoscopic SG at the same period were selected in this study whose preoperative demographics, including sex, age, body weight, body mass index, metabolic diseases and blood index, were comparable to those of SADI-S group. All the patients were followed up at 3 months, 6 months and 12 months after operation to compare the weight loss [body weight, body mass index, percent of excess weight loss (%EWL) and percent of total weight loss (%TWL), etc.], remission of obesity-related metabolic diseases (hypertension, hyperuricemia, and type 2 diabetes mellitus, etc.) and nutritional deficiency (albumin, retinal-binding-protein, vitamin B12, vitamin D and iron protein, etc.) between the two groups. Results: All the patients successfully underwent laparoscopic bariatric surgery without conversion to laparotomy or death. Compared with SG group, SADI-S group had longer operative time [(204.8±38.3) minutes vs. (109.2±22.4) minutes, t=10.107, P<0.001], higher rate of intraoperative drainage tube [100.0% (22/22) vs. 50.0% (11/22), P<0.001], longer duration of indwelling drainage tube [4 (2-7) days vs. 1 (0-7) days, U=131.000, P=0.008], and the differences were statistically significant (all P<0.05). There was no significant difference between the SG group and the SADI-S group in terms of postoperative hospital stay and complication rate. The weight loss efficacy of SADI-S group and SG group was compared at 3, 6 and 12 months after operation. The results showed that with the increase of follow-up time, the patient's body weight and body mass index gradually decreased, %EWL and %TWL gradually increased (all P<0.05). There were no statistically significant differences in body weight, body mass index and %EWL between the SADI-S group and the SG group at 3, 6 and 12 months after operation (all P>0.05). There was no statistically significant difference of %TWL between two groups at 3 months after operation (F=0.846, P=0.368), but SADI-S group had higher %TWL at 6 and 12 months after operation and the differences were statistically significant (6-month: 34.0±5.1 vs. 30.2±4.3, F=5.813, P=0.025; 12-month: 42.9±6.8 vs. 34.8±7.6, F=14.262, P=0.001). Except for that the remission rate of total cholesterol of SADI-S group was higher than that of SG group, remission rates of metabolic diseases were not significantly different at different follow-up points (all P>0.05). As for the nutrient deficiency (albumin, retinal-binding-protein, iron protein, vitamin B12, vitamin D and folic acid) and the incidence of gallstones, no significant differences were found between two groups (all P>0.05). Conclusion: Both SADI-S and SG are safe and effective for the treatment of obesity and obesity-related metabolic diseases, but the former is more effective.