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Single-Anastomosis Duodeno-Ileal Bypass
Introduction
Worldwide, approximately 650 million adults and 340 million children are designated as obese. Environmental and genetic factors influence obesity, which is associated with comorbidities including diabetes, dyslipidemia, obstructive sleep apnea, nonalcoholic fatty liver disease, and coronary artery disease. Truncal obesity is associated with an increased risk of hypertension, heart disease, diabetes, and metabolic syndrome, which is defined by triglyceride levels greater than 150 mg/dL, fasting glucose levels of 100 to 125 mg/dL, or an elevated hemoglobin A1c level.[1] Recently, the World Health Organization noted that over 60% of people in Europe are overweight or obese, which represents a tripling of obesity in the last 50 years, mainly due to decreased activity and diet.[2] In the United States, obesity, morbid, and super morbid obesity continue to increase in both children and adults, predominantly impacting those with the highest genetic predisposition. Genetic influences include single genes associated with hyperphagia. Obesity has the most significant impact on Black women, Hispanic adults, and indigenous peoples.
Treating obesity, its physiological and psychological sequelae, and comorbidities is costly and requires a comprehensive interdisciplinary approach for the most effective management.[3] A recent surge in medications targeting energy expenditure and appetite-regulating mechanisms has occurred; these are most effective when implemented in conjunction with behavioral changes. National and global increases in obesity place a sizeable burden on health systems and economies and necessitate a multidisciplinary approach to management. Conventional weight management often fails in severe obesity, and surgery is the most effective intervention in such cases by offering persistent weight loss and improving obesity-related comorbidities.[3]
A body mass index (BMI) of 40 kg/m² or higher, or a BMI of 35 kg/m² or higher with severe comorbidities, is most effectively treated with surgical intervention to achieve a BMI between 18.5 and 24.9. The primary mechanism by which obesity surgery impacts weight loss is through restriction and malabsorption. Still, multiple complex hormonal and neuroregulatory factors influence the regulation of metabolism and food intake, which can aid in weight loss. Sustained weight loss following bariatric surgery also depends on patient compliance with diet and exercise. Bariatric surgery can resolve comorbid conditions such as hypertension, diabetes, and sleep apnea. The American Society of Metabolic and Bariatric Surgery in conjunction with the International Federation for the Surgery of Obesity and Metabolic Disorders has updated their indications for bariatric surgery to include persons with a BMI of 35 kg/m² or higher with or without comorbidities, and persons with a BMI between 30 to 34.9 kg/m² with related conditions. Additionally, the recent implementation of obesity surgery-specific quality improvement and enhanced recovery after surgery programs has standardized and improved the quality of care for these patients.[4]
According to the ASMBS, the most commonly performed bariatric surgery procedure in the United States is sleeve gastrectomy, followed by Roux-en-Y gastric bypass.[5] Additional bariatric surgery options include biliopancreatic diversion with or without duodenal switch, 1 anastomosis gastric bypass, and SADI, all of which are typically performed laparoscopically or robotically.[6][7] The SADI bypass, in conjunction with sleeve gastrectomy, is a relatively recent modification that exhibits physiology comparable to that of the duodenal switch and biliopancreatic diversion, with similar weight loss and improvements in comorbidities.[8][9] In early studies, patients who had undergone SADI experienced resolution of diabetes and hypertension within months of surgery.[10] The restrictive component of SADI with sleeve gastrectomy is created through resection of the stomach, and the malabsorptive aspect is generated through bypassing the small bowel. The distal small bowel becomes the common channel that receives ingested items from the esophagus and stomach, as well as secretions from the biliopancreatic limb, thereby reducing the absorption of nutrients.[10]
SADI has become more common due to its relative simplicity, with comparable efficacy compared to more complex surgeries like gastric bypass.[11] First described by Sánchez-Pernaute and colleagues, this intervention offers the combined benefits of restriction and malabsorption, aiming to optimize weight loss and metabolic outcomes with fewer complications. The metabolic outcomes of SADI eliminate diabetes, hypertension, dyslipidemia, and obstructive sleep apnea.[12] The single anastomosis technique reduces the number of potential failure points, thereby lowering the incidence of internal hernias and anastomotic leaks, which are more common in multianastomosis procedures.[13] Additionally, the incidence of dumping syndrome is reduced with SADI compared to gastric bypass through preservation of the pylorus, which maintains a more natural gastric emptying process.[12] However, SADI is not without potential complications. Nutritional deficiencies are common and require lifelong monitoring.[14] Furthermore, while fewer steps reduce operative time and immediate postoperative risks, long-term data are still emerging, necessitating ongoing research to understand durability and long-term safety.[15][16]
Anatomy and Physiology
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Anatomy and Physiology
Bariatric surgery employs both restrictive and malabsorptive mechanisms to promote weight loss, while also altering the hormonal environment that regulates appetite and metabolism. Enteric hormones influencing satiety and hunger act on the hypothalamus to regulate food intake. Cholecystokinin, polypeptide YY, glucagon-like peptide-1 (GLP-1), and leptin promote satiety while ghrelin stimulates appetite.[17] Hormones that circulate enterically are also present in saliva and have receptors on taste buds and olfactory neurons, such that taste and olfaction impact feeding behaviors. The gastrointestinal tract contains endocrine cells that secrete GLP-1 and peptide YY3-36 (PYY) in response to food intake, diminishing appetite, and regulating insulin secretion through signaling within enteric and brain pathways. Ghrelin, primarily produced in oxyntic glands in the fundus, increases in the fasting state and decreases in the fed state in proportion to the amount ingested. Ghrelin may also enhance pleasure eating. Additional hormones and proteins such as leptin, interleukin-6, tumor necrosis factor-alpha, and adiponectin act on the brainstem and hypothalamus to regulate hunger. Leptin, GLP-1, PYY, and ghrelin are found in saliva, taste buds, and olfactory neurons. Stimuli and the interaction between reward and satiety moderate these locations, and pathway dysregulation can lead to weight gain.[18]
The gut microbiome, influenced by diet and other factors, impacts insulin sensitivity and adipose storage, alters intestinal mucosal permeability, and intracellular thyroid hormone activation. The distribution of enteric bacteria affects the absorption of short-chain fatty acids and inflammation. Bile acids digest fat and fat-soluble vitamins, but also regulate glucose and energy homeostasis through upregulation of GLP-1 and insulin release. Bile acids may act on receptors within the small bowel that promote the secretion of fibroblast growth factor-19, which contributes to lipid homeostasis and peripheral glucose management, leading to increased metabolism and weight loss. Postprandial levels of biliary acids have been inversely correlated with body fat. Bile acids also bind to receptors in skeletal muscle and brown fat, contributing to weight loss with activation.[18]
SADI modifies the stomach and small intestine, significantly altering the exposure of ingested nutrients to the biliary and pancreatic metabolic milieu. SADI is most commonly performed with sleeve gastrectomy as the first step, the restrictive element, where approximately 80% of the stomach is removed, leaving a tubular gastric remnant, leading to rapid gastric emptying, early satiety, and reduced intake—the quicker transit of nutrients results in a metabolic profile that favors weight loss. Next, the duodenum is transected distal to the pylorus, and a single anastomosis is created between the proximal duodenum and a loop of the ileum approximately 250 cm from the ileocecal valve. In this configuration, bile acids are drained with pancreatic secretions and are exposed to ingested nutrients distally at the common channel, resulting in decreased nutrient absorption.[19][20][21]
In response to nonsurgical weight loss through behavior modifications, including dietary restriction, the body upregulates hunger and food drives with physiologic alterations such as reduced sympathetic activity and slower metabolism, declines in circulating leptin, vagal response, biliary acids, GLP-1, and PYY, and an increase in ghrelin. Bariatric surgery disrupts this homeostasis, leading to malabsorption, reduced nutrient intake, decreased hunger, and altered neural responses to food, as well as dampened reward feedback through mechanisms that involve increased vagal stimulation and changes in taste and smell, promoting healthier eating habits. Most ghrelin-producing cells are removed with sleeve gastrectomy, specifically by removing the fundus. Additionally, levels of GLP-1 and PYY increase proportionately with ingested nutrients.
The enterohepatic circulation of bile acids is rerouted, resulting in changes to bile composition and concentration, which in turn alter glucose metabolism and lipid regulation, promoting weight loss. The quantity of circulating biliary acids may continue to rise for several months following surgery, either due to more efficient recirculation in the enterohepatic system or increased hepatic synthesis. Following surgery, a microbiome is generated that favors weight loss by regulating the conjugation of biliary acids and the formation of secondary biliary acids.[18] Weight loss and improvements in glycemic control result in the remission of comorbidities such as type 2 diabetes.[22][23]
Indications
Per the American Society for Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity and Metabolic Disorders (2022), reflecting technological advancement in bariatric surgery and its impact on the resolution of metabolic disease, recommendations for consideration of bariatric intervention:
- BMI ≥35
- BMI ≥30 with type 2 diabetes or related metabolic disease, including selected adolescents and children; considered also for those who do not realize improvement using nonsurgical approaches
- Failure to achieve weight loss through nonsurgical methods
- No mental health issues
- No history of alcohol or substance abuse
- No medical contraindications to surgery [24]
The recommendation for metabolic surgery for those with type 2 diabetes and a BMI of 30.3 to 34.9 kg/m² with uncontrolled hyperglycemia is also supported by the American Diabetes Association (2022).[25] American Society for Gastrointestinal Endoscopy and European Society for Gastrointestinal Endoscopy published joint guidelines (2024) for bariatric endoscopic procedures, advocating for endoscopic therapies and behavioral modifications for persons with body mass index of 30 kg/m² or greater with or without associated comorbidities, or those with BMI between 27 and 29.9 kg/m² with 1 or more associated comorbidity.[26]
Contraindications
Contraindications for SADI include:
- Severe systemic disease contraindicating surgical intervention and general anesthesia
- Severe gastroesophageal reflux and/or Barrett esophagus, hiatal hernia
- Active cancer treatment
- Uncontrolled psychiatric illness
- Drug or alcohol dependency
- Inability to comply with lifelong dietary recommendations and follow-up
- Previous complex abdominal surgery may complicate the procedure [16][27][28][29]
Equipment
General surgical equipment for laparoscopic procedures includes surgical drapes, a CO2 gas insufflator, viewing monitors, laparoscopic graspers, scissors, electrocautery, retrieval bags, and trocars. Longer instruments are required to accommodate a thick abdominal wall.
For sleeve gastrectomy, the instruments required are the following:
- Three 5-mm trocars and 1 15-mm trocar
- Liver retractor
- 5-mm 30-degree angled laparoscope
- Endoscopic linear stapler
- 32 to 40 French bougie
- Flexible endoscope
- Laparoscopic energy device [7][20]
The equipment required for SADI includes:
- Harmonic scalpel or electrocautery devices
- Laparoscopic staplers
- Laparoscopic instruments for tissue handling and dissection
- Suturing materials for the anastomosis
Nasogastric tubes and drains are usually used during postoperative management.[30][31]
Personnel
An interdisciplinary team for the successful implementation of SADI includes:
- Bariatric surgeon with expertise in advanced laparoscopic procedures
- Anesthesiologist experienced in managing persons with obesity
- Scrub nurses and surgical technicians specialized in bariatric surgery
- Dietitian for preoperative and postoperative nutritional management
- Psychologist or psychiatrist for preoperative evaluation and postoperative support
- Radiologist for imaging studies
- Bariatric center of excellence to coordinate preoperative evaluation, counseling, and follow-up care
Preparation
Preparation for bariatric surgery requires a comprehensive evaluation, including comorbidities, nutritional assessment, psychological testing, and implementation of lifestyle modifications involving diet, exercise, and understanding of healthful living. Most persons must adhere to diet and exercise tenets, including achieving moderate weight loss before any procedure. Candidates with a tobacco history are also required to be strictly adherent to smoking cessation. Patients are enrolled in a detailed assessment and educational program investigating detailed eating patterns, weight management history, oral hygiene practices, and capacity to adapt lifestyle modifications. Most preoperative testing includes complete blood counts, comprehensive metabolic panel, lipid profile, and HbA1c, imaging studies that often assess the status of the gallbladder, and education about the procedure, potential risks, and the necessity for lifelong follow-up and supplementation.[32][33]
Technique or Treatment
The following describes the laparoscopic technique:
- General anesthesia is induced. A pneumoperitoneum is created using a Veress needle or a 12-mm optical trocar in the supra- or infraumbilical area. Two additional 12-mm ports are inserted under direct visualization in the midabdomen on the right and left sides. Two 5-mm ports are placed in the left subcostal and left lateral positions. A subxiphoid port may be placed for liver retraction. The patient is positioned in an anti-Trendelenburg tilt with the surgeon standing between the patient's legs.[34]
- The stomach is inspected, and the gastroepiploic arcade is ligated. A 32- to 40-French bougie is introduced endoscopically into the stomach. A laparoscopic stapler with a load selected for tissue thickness is introduced from the right midabdomen, and stapling is initiated approximately 4 to 6 cm from the pylorus, 1 cm from the angle of His. The greatest distance from the bougie is created at this starting point to avoid structuring. The stapler is then fired sequentially to divide the stomach more proximally along the bougie until approximately 70% to 80% of the stomach has been detached. The antrum is dissected 3 cm from the duodenum, starting from the duodenum to the left diaphragmatic crus. The duodenum is posteriorly mobilized to expose the gastroduodenal artery and the pancreas. The peritoneum is opened in the retroduodenal position, and the duodenum is encircled from behind over the hepatoduodenal ligament. Many surgeons seek to avoid damage to the right gastric artery, but ligation of this vessel has not been proven to induce duodenal ischemia.[10] At a distance of approximately 3 to 4 cm distal to the pylorus, the duodenum is transected using a 60-mm linear stapler. The patient is then positioned horizontally, and the surgeon moves to the patient's left. The laparoscope is then moved to the left subcostal port. An anastomosis site is measured approximately 250 to 300 cm from the ileocecal valve. An isoperistaltic, end-to-side duodenojejunal anastomosis is performed with a 30-mm linear stapler or hand-sewn with a 3-0 Polydioxanone suture. A bougie may be passed through the anastomosis to assess for patency.[35]
- A leak test is performed by instilling methylene blue or air through an orogastric tube while observing for bubbles or leaks at the anastomosis site in a saline-filled peritoneal cavity. An endoscope can also be used to test for a leak. The abdomen is inspected before deflation to ensure hemostasis has been achieved. Trocars are removed under direct visualization, and the trocar sites are closed, including fascia at the larger trocar sites to prevent incisional hernias. The subcutaneous tissue and skin are approximated according to the surgeon's preference, and a dressing or glue is applied.[30]
Complications
Short-Term Complications
- Hemorrhage/hematoma/anastomotic bleeding (1%-2%)
- Surgical site infection (1%-2%)
- Anastomotic leak (0.5%-2%)
- Stricture (1%-3%)
- Bile reflux (1%-2%)
- Bowel obstruction
- Blood clot (2%)
- Damage to organ or blood vessel (0.9%)
- Sepsis (0.3%)
- Abdominal abscess ± leak (6.4%)
- Perianastomotic inflammation/edema without abscess (3.7%) [36][37][38]
Long-Term Complications
- Nutritional deficiencies
- Protein-calorie malnutrition (2%-5%)
- Vitamin and mineral deficiencies (up to 30%)
- Anastomotic or gastric ulcer (0.1%)
- Bowel obstruction (0.3%-1.6%)
- Incisional hernia (2%-20%)
- Marginal ulcer (1%-4%)
- Internal hernia (1%-2%)
- Small intestinal bacterial overgrowth (5%-15%)
- Conversion to Roux-en-Y gastric bypass (1.2%)
- Kidney stones (3.7%-8.1%) [37][39][40][41][42]
Clinical Significance
SADI provides substantial weight loss and resolution of related comorbidities while having a shorter operative time and fewer postoperative complications than more extensive bariatric surgery. Five-year follow-up data showed similar weight loss percentages between SADI and duodenal switch, with fewer nutritional deficiencies and a lower reoperation rate.[22][43][44] SADI resolves diabetes, improves lipid profiles, and reduces hypertension.[9][45][46] SADI is often compared to a 1-anastomosis gastric bypass, especially as a revision procedure following sleeve gastrectomy to achieve a greater metabolic response.
Both procedures are effective in improving clinical response. However, the 1-anastomosis gastric bypass is associated with a higher rate of complications and a significant conversion rate to a RYGB.[47] Compared with other versions of bariatric surgery, SADI preserves easy endoscopic access to the duodenum and biliary system. As with all bariatric surgery patients, those who undergo SADI will require lifelong nutritional monitoring and supplementation.[48]
Enhancing Healthcare Team Outcomes
The successful care of patients undergoing SADI demands coordinated efforts across a multidisciplinary team. Surgeons and advanced clinicians must demonstrate technical precision in performing the anastomosis and perioperative decision-making, while anesthesiologists optimize intraoperative hemodynamics to reduce surgical risk. Nurses play a vital role in postoperative monitoring, early mobilization, and reinforcement of patient education, particularly around signs of leak, dehydration, and nutritional deficiencies. Pharmacists ensure safe prescribing, particularly in areas such as pain management, anticoagulation, and micronutrient supplementation, while dietitians provide tailored nutritional counseling to support long-term weight loss and prevent malabsorption-related complications. This team must center the care plan around the patient’s goals, cultural background, and readiness for behavior change, enhancing adherence and satisfaction.
Effective interprofessional communication is key to maintaining patient safety and optimizing outcomes in SADI. Structured handoffs, shared electronic health record documentation, and multidisciplinary rounds ensure that clinical priorities—such as leak surveillance, nutritional adequacy, and thromboembolism prevention—are not missed. Proactive care coordination, especially at transitions from hospital to home or outpatient follow-up, reduces readmission risk by aligning discharge instructions, ensuring continuity of vitamin supplementation, and clarifying postoperative dietary stages. Coordination minimizes errors, reduces delays, and enhances patient safety, ultimately leading to improved outcomes and patient-centered care that prioritizes the well-being and satisfaction of patients undergoing SADI.[49] Embedding the principles of team performance, such as clear role definition, mutual respect, and regular feedback, fosters a culture of safety and continuous quality improvement, ultimately enhancing the patient-centeredness of bariatric surgical care.
Nursing, Allied Health, and Interprofessional Team Interventions
Nursing and allied healthcare professionals play a crucial role in patient education during the preoperative, perioperative, and postoperative time frames. Professionals affiliated with bariatric programs provide invaluable monitoring and counseling about nutrition and education, and may readily identify complications and help promote adherence to follow-up protocols.[50]
Nursing, Allied Health, and Interprofessional Team Monitoring
Nursing and allied healthcare professionals also play a key role in ongoing monitoring, including regular follow-up visits to assess weight loss progress, nutritional status, and management of comorbidities. Interventions initiated by interdisciplinary teams improve outcomes for bariatric patients. Patient support and care coordination are imperative to patient satisfaction and long-term impact on metabolic and overall health. Care models focused on patient care render more sustained weight loss and improve overall outcomes. Laboratory tests are conducted periodically to detect and correct nutritional deficiencies. Continuous patient support and education are vital for long-term success and improvement in quality of life.[49]
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