Obesity Surgery Technique Uses Magnets in the Duodenum

BRUSSELS — In the face of ever-increasing demand, surgical techniques enabling significant weight loss are on the rise. It is simpler and less invasive to perform anastomosis by compression with two magnets, said Guy-Bernard Cadière, MD, professor of surgery at the Free University of Brussels, senior consultant in the Digestive Surgery Department at Saint-Pierre University Hospital, and founding director of the European School of Laparoscopic Surgery in Belgium, in an interview.

The virtues of bariatric surgery (from the Greek baros, meaning “heavy”), are well known. It is the only treatment for morbid obesity that has been proven effective in the long term. In broad terms, it induces either gastric restriction, which forces the patient to eat slowly, or malabsorption of the food ingested by the patient, thus drastically reducing the supply of nutrients and enabling rapid weight loss. Although there is large consensus for using this procedure for patients whose body mass index is over 40 (or over 35 with comorbidities), there is some disagreement as to the best technique to use. The range of options has recently been expanded to include a procedure whereby the surgeon places magnets in the patient’s duodenum. We asked Cadière, a pioneer in laparoscopic surgery in Belgium, what this procedure involves.

MediQuality: What is the idea behind placing magnets in a patient’s stomach?

Cadière: It would no doubt be useful here to quickly review the modus operandi of the various bariatric techniques available. Besides the adjustable gastric band, which is no longer recommended in Belgium, there is gastric bypass, which until now has been considered the gold standard in bariatric surgery. A small 25-cc pouch is created by stapling. Food passes from this pouch into the jejunum, bypassing the stomach and duodenum. In sleeve gastrectomy, which is currently the most popular procedure, the stomach is stapled, separating it into two parts, one of which is then removed. Duodenal switch (also called biliopancreatic diversion) consists of creating a sleeve, but then combining a section of the duodenum with it to anastomose (connect) it with the terminal ileum. This is a major malabsorption procedure that bypasses the largest portion of the intestine. It is the most effective procedure, in terms of weight loss, but also the riskiest. Over the past decade, new techniques have been presented at the Congress of Bariatric Surgery with a view to reducing risk and increasing effectiveness.

MediQuality: What are these techniques?

Cadière: First and foremost, there’s the single anastomosis duodenal switch. This is a variant of the duodenal switch. The proximal segment of the duodenum is anastomosed with the intestine 250 cm from where it joins the cecum. There is only one anastomosis, less malabsorption, and complications associated with the second anastomosis are eliminated. Late complications (nutritional deficiencies) seem to be less marked than after a classic duodenal switch, but more time is needed to be able to confirm this finding.

Then there’s gastro-ileal bipartition. This procedure has been performed for 7 years and was developed to reduce the technical complexity and complications of duodenal switch. After a sleeve gastrectomy is performed, a latero-lateral gastro-ileal anastomosis is created. A portion of food passes directly from the stomach into the 250-cm-long terminal ileum. This portion of food is therefore less digested or absorbed and immediately triggers satiety hormones, including GLP-1 and PYY-36. The other portion of food follows the physiological circuit through the duodenum and all of the jejunum and is digested normally. The goal is to preserve the anorexigenic neuroendocrine effects of malabsorptive procedures while minimizing the harmful effects of malabsorption. Weight loss is similar to that of duodenal switch, 80% to 90% of excess weight at 2 years. In subsequent years, weight loss seems to be maintained, but more time is needed to confirm these results. Complete remission of type 2 diabetes is observed in 85% of cases. The risk of immediate complications is lower than after a classic duodenal switch and includes bleeding along the staple line (0.8%) and gastrointestinal fistulas (1.2%). The risk of late complications also seems to be lower, but, once again, more time is needed to confirm this. Transit disorders (bloating, flatulence, diarrhea, stool odor) are not as marked as after a duodenal switch.

Finally, there is duodeno-ileal bipartition, which uses the intriguing magnet technique. This technique was invented by Michel Gagner. In theory, the advantage of performing bipartition at the duodenum is that it decreases the risk of biliary reflux; avoids dumping syndrome, ulcers, or gastrojejunal anastomotic stenosis; and avoids having the entirety of transit occur in the terminal ileum. However, manual suturing or staple suturing is riskier in the duodenum, and it is simpler and less invasive to perform this anastomosis by tissue compression and fusion using two magnets. Anastomosis is delayed 3 to 4 weeks and is performed by fusion of the tissue in the periphery of the magnets and necrosis of the central section. The magnet block is passed by natural means. This technique, which is theoretically very elegant, minimally invasive, and very easily reversible, is currently being studied. It constitutes a promising alternative to gastric bypass, which remains the procedure of choice but still needs to be evaluated.

MediQuality: Doesn’t inserting powerful magnets inside the body pose a safety problem?

Cadière: We have not observed any postoperative complications in our patients to date.

This article was translated from MediQuality.

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