The patient is placed in the supine position with both arms appropriately padded and tucked to the sides. The SG is performed first with a six-port approach (Fig. 21.2). The greater curvature of the stomach is dissected free with the harmonic scalpel starting 6 cm proximal to the pylorus up to the angle of His. Care is taken to dissect the whole gastric fundus posteriorly, where the left pillar is carefully identified and dissected free over its anterior aspect. In all cases, the vertical gastrectomy is done over a 40 Fr intraluminal boogie with green or gold staple cartridges. The gastric antrum is systematically spared, and the last stapling is fired 1 cm lateral to the esophagogastric junction. Seamguard (Gore-Tex, Flagstaff, AZ) to buttress the staple lines is selectively used.

Patient’s position and port placements are the same as those of the SG (Fig. 21.2). The duodenum is divided using a linear stapler with a blue cartridge 4 cm distal to the pylorus at the level of the gastroduodenal artery (Fig. 21.3). The small bowel is measured with a 50-cm-long tape along the unstretched antimesenteric border. It is then divided with the linear stapler 250 cm from the ileocecal valve, and the distal end is anastomosed to the proximal duodenum with an intracorporeal hand-sewn continuous absorbable suture (Fig. 21.4). The proximal end of the divided bowel is anastomosed to the ileum 100 cm from the ileocecal valve to create a 100-cm common channel and a 150-cm alimentary limb. The mesenteric and Petersen spaces are closed with nonabsorbable running sutures. A leak test (air bubbles and blue dye) is performed at the end of the procedure.

Buchwald et al. [15], in his meta-analysis of 361 studies including 85,048 patients reported an overall mortality of 0.28 % within 30 days of bariatric surgery. BPD/DS had the highest early mortality with a rate of 0.29–1.23 % for open and 0–2.7 % for laparoscopic procedures.

The operative mortality for large DS series by laparotomy is approximately 1 % with a range of 0.6–1.4 % (Table 21.1) [24–27]. Laparoscopic approach seems to be associated with a lower mortality, ranging from 0 to 0.5 %, although laparoscopic series report a smaller number of patients. Postoperative mortality is most commonly associated with pulmonary embolus, respiratory failure, and anastomotic leaks. In the aforementioned series [23–28] the leak rate varied between 1 and 3.6 %.

Biertho et al. [41] analyzed a series of 1,000 BPD/DS patients, comparing the laparoscopic (228 cases) and open (772 cases) groups. In this series they reported only 1 postoperative death (0.1 %) due to pulmonary embolus in the laparoscopy group. Major complications occurred in 7 % of the patients, with no significant differences between the two groups (7 % vs 7.4 %, P = 0.1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5 % vs 4 %, P = 0.1).

An important consideration is that BPD/DS is the procedure of choice for super-obese patients and it can be argued that surgical risk in this group is higher at baseline.

Flum et al. [42] in the Longitudinal Assessment of Bariatric Surgery, a prospective multicenter observational study, including 4,776 patients, analyzed 30-day outcomes after bariatric surgery and showed that extreme values of BMI were significantly associated with increased risk of major adverse outcomes (death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and length of stay greater than 30 days). Similar conclusion were found by Kim et al. [43], who carried out a retrospective study of 54 super-super-obese patients (BMI >60) operated on for DS with a laparoscopic approach in 26 cases and open in 28 cases. Major morbidity occurred in 23 % of patients in the laparoscopic group and in 17 % of patients in the open group (P = 0.63). There were two deaths in the laparoscopic group (7.6 % mortality) and one death (3.5 % mortality) in the open group (P = 0.51).

However, other investigators showed that the DS can be safely performed in patients with a BMI > 50 kg/m² as a single-stage procedure without significantly increasing the mortality [8]. Topart et al. showed that BMI becomes less predictive of complications once the learning curve for laparoscopic DS is overcome [22].

Iannelli et al. [23] conducted a case-control study in order to compare single-stage DS (110 patients) with a staged strategy (110 patients) consisting in a laparoscopic sleeve SG followed by laparoscopic DS in selected patients. The authors found a trend toward fewer postoperative complications in the staged strategy group that did not reach statistical significance on univariate analysis. However, single-stage DS was the only variable significantly associated with the risk of postoperative complications on multivariate analysis. Furthermore, six patients (5.5 %) in the single-stage DS group required conversion to open surgery and none did so in the staged group (P < .05) indicating that the staged approach simplifies the surgical procedure. The main advantage of the staged approach resides in the selection of patients who do not need the malabsorptive component of the complete DS procedure. In this series, 72.7 % of super-obese patients achieved 50.8 % EWL after SG at a mean follow-up of 3 years. These results are in accordance with those reported by Himpens et al. who recorded a 27 % rate of second-stage DS in a series of 41 morbidly obese patients undergoing SG at a follow-up of >6 years.