title: Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case-control study.
abstract: BACKGROUND
  The prevalence of superobesity (body mass index [BMI] ≥50 kg/m(2)) has increased steadily during the past decade, and the most suitable surgical strategy for these patients is still controversial. Our objective was to test the hypothesis that in selected superobese patients, laparoscopic sleeve gastrectomy (SG) followed by laparoscopic duodenal switch (DS) might reduce the rate of postoperative complications and the need for the second step duodenal switch. The setting was a university hospital in France.
  
  
  METHODS
  A retrospective analysis was performed of a prospective database of 110 consecutive patients with a BMI of ≥50 kg/m(2) undergoing the staged approach and matched for age, gender, and BMI with 110 consecutive patients undergoing single-stage DS. The excess weight loss (EWL), co-morbidity improvement, and incidence of postoperative complications were compared between the 2 groups.
  
  
  RESULTS
  One patient died in the staged strategy group (mortality rate .9%). The postoperative complication rate was 8.2% in the staged strategy group (110 patients) and 15.5% in the single-stage DS group (110 patients; P = 1). Multivariate analysis showed that single-stage DS surgery is the only variable significantly associated with the occurrence of postoperative complications (odds ratio 2.36; 95% confidence interval 1.001-5.61). In the staged strategy group, at a mean follow-up of 36.4 ± 13 months, 39 patients (35.5%) required the second-stage procedure. The mean %EWL was 50.8% ± 17.5% for SG alone (35% failed to maintain 50% EWL after SG), 61.5% ± 19.3% for the staged strategy, 72.7% ± 14.1% for 2-step DS (3.3% failed to maintain 50% EWL after 2-step DS), and 73.3% ± 17.6% for single-stage DS (7.3% failed to maintain 50% EWL after single-stage DS).
  
  
  CONCLUSIONS
  At 3 years of follow-up, staged DS surgery avoided biliopancreatic diversion in 72.7% of the patients. Single-stage DS increases the risk of postoperative complications but not of anastomotic leak.
authors.affiliation: Service de Chirurgie Digestive et Transplantation Hépatique, Pôle Digestif, Centre Hospitalier Universitaire de Nice, University of Nice Sophia-Antipolis, Nice, France. antonio_iannelli@hotmail.com
authors.forename: Antonio
authors.initials: A
authors.lastname: Iannelli
authors.forename: Anne-Sophie
authors.initials: AS
authors.lastname: Schneck
authors.forename: Philippe
authors.initials: P
authors.lastname: Topart
authors.forename: Michel
authors.initials: M
authors.lastname: Carles
authors.forename: Xavier
authors.initials: X
authors.lastname: Hébuterne
authors.forename: Jean
authors.initials: J
authors.lastname: Gugenheim
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D016022:Case-Control Studies; D003131:Combined Modality Therapy; D004386:Duodenum / Q000601:surgery*; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D011182:Postoperative Care; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation / Q000706:statistics & numerical data; D016896:Treatment Outcome; D015431:Weight Loss / Q000502:physiology; D055815:Young Adult