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SADI

SIPS/SADI/LDS Versus Sleeve–What’s the Difference

15/02/2023 by DrCurry

Gastric Sleeve

vertical sleeve gastrectomy

SIPS/SADI/LDS

loop duodenal switch

The field of bariatric surgery, or weight loss surgery, is always changing.  New options seem to come around frequently (and sometimes go away just as quickly).  One of the most recent options that has come to the forefront, however, is based on a time-tested procedure that has been around for decades and is likely to stick around.  The reason it is likely to stay is simple:  it offers great weight loss, similar to the older procedure on which it is based, but it has fewer complications overall.

Gastric sleeve has been around for a while now, so if you need to review the simple anatomy of this procedure just click here.  This article will focus on a newer procedure that can be thought of in some ways as a gastric sleeve/gastric bypass mash-up.

This new procedure, unfortunately, does not have a standard name.  In fact, at least three different labels have been assigned to it: SIPS, SADI-S, and LDS.

  • SIPS: Stomach-Intestinal Pylorus Sparing procedure
  • SADI-Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy
  • LDS: Loop Duodenal Switch

All of these acronyms refer to the same operation.  For the purposes of this article, we will use the name SADI-S.  In order to understand the SADI-S, first you need to understand the original procedure on which it’s based:  the duodenal switch, or DS. 

Duodenal Switch

SIPS procedure is based on duodenal switch

Five things are done in a traditional DS:

  1. A loose gastric sleeve is done
  2. The duodenum (first part of the small intestine) is divided just past the stomach
  3. The small intestine is divided way downstream
  4. The distal (far end) of this intestine is pulled up and re-connected to the duodenum up by the stomach
  5. The proximal (closer end) of this divided intestine is re-connected far downstream, resulting in a very short common channel

The “common channel” is the point where the food you eat gets mixed in with the digestive enzymes coming down from your liver and pancreas.  So the DS is very effective for weight loss because of this very short common channel–much shorter than in a gastric bypass, and of course much shorter than a regular gastric sleeve.  Of course, in a regular sleeve the common channel is the entire length of the intestine, because none gets bypassed at all.  Because of this short common channel, most studies show the DS to have better long-term weight loss results and diabetes remission than any other weight loss surgery around.

SADI-S/SIPS/LDS

Anatomy of a SADI-S procedure, also known as SIPS or LDS.

So what’s different about a SADI-S?  The SADI-S takes the original DS and simplifies it a bit.  In a SADI-S, the intestine is only divided one time, just past the stomach in the duodenum.  The short stump of duodenum is then re-connected to the side of the small intestine, far downstream.  So in a SADI-S pretty much the same thing is accomplished–separating the food from the digestive enzymes.  Because the procedure is simpler, though, there are less things that can go wrong with it.  Whenever a connection is made between intestine and intestine, or intestine and stomach, there is a risk that the connection could leak.  This can be a serious problem, and bariatric surgeons do everything they can to avoid this complication.  Since the SADI-S has only one connection that has to be made instead of two, this risk could be cut in half.  If we list the steps as before, only three things have to be done:

  1. A tighter gastric sleeve is done
  2. The duodenum is divided just past the stomach
  3. The duodenal stump is connected to the small intestine far downstream

Are there any disadvantages then to the SADI-S versus the old DS?  Except for a lower risk of leak in a SADI-S, most studies show pretty much the same results for the two procedures.  Some people worry about a problem called bile reflux after a SADI-S, but it doesn’t seem to be a huge problem.  Bile reflux could occur in SADI where the duodenum is plugged into the small intestine.  Bile from the liver is flowing past this connection, but in the original DS bile is kept completely away from that area.

 

Most bariatric surgeons are getting away from the DS and moving towards SADI-S.  So then, let’s look at the pro’s and con’s of SADI-S as compared to just a gastric sleeve.

SADI-S/SIPS/LDS

Pro’s

  • Better weight loss
  • Better diabetes remission
  • Less GERD issues

Con’s

  • More complex procedure
  • Longer operative time
  • Longer recovery time
  • Much higher chance of serious vitamin/nutrient deficiencies
  • No good options for revision down the road
  • Yearly lab work needed for life
  • If you don’t take your vitamins you will get a serious vitamin deficiency!

Gastric Sleeve/VSG

Pro’s

  • Simpler procedure
  • Can be done as outpatient
  • Shorter operative time
  • Can be converted to SADI-S or RNY

Con’s

  • Post-op GERD rate higher
  • Less weight loss
  • Lower diabetes remission rate
  • Vitamin/nutrient deficiencies rare

From a surgeon’s point of view, I think it makes sense for patients with higher BMI’s to go for the SADI-S.  For a patient with a BMI over 60 most surgeons would recommend SADI-S over gastric sleeve.  For a patient with a BMI under 50 many would recommend sleeve over SADI-S.  50-60 BMI is a gray zone as there are some patients who can be successful with a sleeve, and avoid all those long-term SADI-S risks.  In my opinion, sleeve would be my first choice but I would discuss with the patient that conversion to SADI-S down the road could be necessary.

Another issue to consider is insurance coverage.  Many policies will cover the older DS, but not the new SADI-S.  This will change with time, though, and more weight loss surgeons will become adept at performing this procedure.  So we can expect the SADI-S to not only stick around, but also to become more and more popular with time, given its excellent weight loss results and lower complication rates.

Trace Curry M.D.

Dr. Trace Curry is the medical director of JourneyLite Physicians and JourneyLite Surgery Center in Cincinnati, Ohio.  JourneyLite is a multi-specialty center that focuses on advanced outpatient laparoscopic weight loss surgery and incisionless weight loss procedures.  He has done over 7000 weight loss procedures in his career and is a key opinion leader in the field of surgical and incisionless weight loss.

JourneyLite For Life logo

Filed Under: Education Tagged With: DS, duodenal switch, LDS, SADI, SIPS, sleeve, vsg

New Study Finds Weight Loss Surgery Extends Lives

03/02/2023 by DrCurry

anatomy of gastric sleeve procedure

by Dr. Trace Curry, Cincinnati, Ohio

I remember when I did my first laparoscopic gastric bypass in 2003 at Wayne Hospital in Greenville, Ohio.  I was a general surgeon then, and I wanted to branch out and challenge myself with more advanced procedures.  Those were the very early days of laparoscopic weight loss surgery, and we were still fighting the bad rap of years of high complication rates from the same exact procedure being done with a huge 12 inch incision.  Originally, I had planned on weight loss surgery being just a small part of my general surgery practice, but when I saw how these procedures totally transformed my patients’ health with just a few tiny incisions, I quickly decided to dedicate my entire practice to this exciting field.  I could see a patient’s life expectancy improve right before my very eyes – in fact I once had a patient who was so obese and had such severe sleep apnea that he had to have a tracheostomy done (this was long before Thousand Pound Sisters).  When he came in for his 1 year post op check after his gastric bypass procedure, he proudly rode his bike right into my office, his trach tube long removed!

As a weight loss surgeon, the fact that weight loss surgery increases life expectancy is something that has been plainly obvious to me for the last 20 years.  Now, however, we have new data from a study spanning 40 years and including nearly 22,000 people that confirms this as fact!

These results were just published last Wednesday in the journal Obesity. It was a retrospective study out of Utah, meaning the researchers looked back at data from patients over past years. They looked at patients with and without weight loss surgery and matched patients for things such as age, sex, and BMI so they were comparing apples to apples. There were 21,837 matched surgery and non-surgery pairs and the follow up was up to a very impressive 40 years.  This study is important not only because of the large number of patients including such a large time span, but also because it involves data on American patients which may be more applicable to patients in my practice than if the data were taken from, say patients in Sweden or Africa.

Four procedures were examined (listed from most common to least common):

  • gastric bypass
  • gastric sleeve
  • gastric band
  • duodenal switch

The researchers found that patients who underwent one of these procedures were 16% less likely to die from any cause, 29% less likely to die from cardiovascular disease, 43% less likely to die from various cancers, and incredibly–72% less likely to die from diabetes!

There have been other large studies that support the data seen here, so I feel like it’s about time to shout it from the rooftops!  In the U.S., it’s estimated that only 2% of patients who qualify actually end up having weight loss surgery.  Some of this is related to lack of insurance coverage, and some to patients’ reluctance to seek out weight loss surgery.  Many patients are not even aware that, when they choose an insurance plan, it may exclude access to a surgical weight loss procedure which they qualify for medically.  Not because they don’t need it, but because language is written into their policy that says it’s not going to be covered, no matter how badly they need it.

Regardless of the reason, considering modern techniques, the complication rate for bariatric surgery procedures such as gastric bypass, gastric sleeve, Lap Band, and duodenal switch are miniscule compared to what they used to be 30 years ago.  This, given with the data we see from this study and others, should compel more insurance companies to provide coverage for these life-saving procedures and more patients to consider taking this step to be rid of the disease of obesity.

Trace Curry M.D.

 

Dr. Trace Curry is the medical director of JourneyLite Physicians and JourneyLite Surgery Center in Cincinnati, Ohio.  JourneyLite is a multi-specialty center that focuses on advanced outpatient laparoscopic weight loss surgery and incisionless weight loss procedures.  He has done over 7000 weight loss procedures in his career and is a key opinion leader in the field of surgical and incisionless weight loss.

Gastric Sleeve

vertical sleeve gastrectomy

Gastric Bypass

gastric bypass anatomy

SIPS

loop duodenal switch

Lap Band

lap band photo

Filed Under: Education Tagged With: duodenal switch, gastric band, gastric bypass, gastric sleeve, lap band, SADI, SIPS, weight loss surgery

SIPS Procedure More

SIPS procedure is based on duodenal switch
Standard Duodenal Switch

Thanks for your interest in the SIPS procedure!  SIPS is the newest weight loss surgery that is sanctioned by the ASMBS, and results in some of the best data on diabetes remission and weight loss.

Most long term studies on weight loss surgeries show that duodenal switch has the best long term weight loss and highest diabetes remission rates.  It has never gained wide acceptance though because of its higher short-and-long-term complication rates.  SIPS has the potential to provide equivalent long-term results with a much lower complication rate.  Our surgeons are the only in the region to offer this innovative procedure!

As a gastric sleeve is the first step in a SIPS procedure, it can be a great option for sleeve patients who need to lose more weight.

Watch this great Youtube video from our colleages at BMI Utah to learn more about the SIPS Procedure:

Other Surgical Options

Gastric Sleeve

vertical sleeve gastrectomy

Gastric Bypass

gastric bypass anatomy

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lap band photo

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