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Page 2 of 13 Pennestrì et al. Mini-invasive Surg. 2025;9:16 https://dx.doi.org/10.20517/2574-1225.2025.03

2
were 46 (40-53) years and 51.6 (46.7-56.7) kg/m , respectively. The median surgical duration was 120 min, with
an interquartile range of 100 to 160 min. Reoperation was required for two of the four patients (2.5%) who
experienced early postoperative complications. Furthermore, 5 (3.1%) patients developed late complications. At a
median follow-up of 23 (12-31) months, the median %TWL, %EWL, and BMI were 42 (29.3-52.4), 82 (59.1-99.4),
2
and 27.3 (21.2-33) kg/m , respectively. Seven years of follow-up were eligible in 13 out of 157 patients: median
2
%TWL, %EWL and BMI were 43 (40.1-52.7), 69 (66.4-85.6), and 31.1 (26.2-32.2) kg/m , respectively.
Conclusion: SADI-S is regarded as an effective primary and conversion operation, balancing bariatric and metabolic
outcomes with early and late complications.

Keywords: SADI-S, SADI, bariatric outcomes, long-term outcomes, learning curve, robotic SADI-S, complications

INTRODUCTION
Obesity remains one of the most challenging diseases to treat effectively . Bariatric surgeons can choose
[1]
[2]
from a variety of procedures, ranging from restrictive approaches to hypoabsorptive ones . Although
patients classified as obesity classes IV and V represent only a small fraction of those who undergo bariatric
[3]
surgery, they are the most difficult to manage . Indeed, some evidence suggests that hypoabsorptive
procedures, like biliopancreatic diversion with duodenal switch (BPD-DS), are associated with better
[4,5]
outcomes and comorbidity resolution rate compared to restrictive and mixed approaches . However, such
procedures are more technically demanding and are more appropriate in complex high-risk patients,
[3,6]
especially those in classes IV and V .
The “proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy”, also known as the “single
anastomosis duodeno-ileal bypass with sleeve gastrectomy” (SADI-S), was proposed by Sánchez-Pernaute
[7]
and Torres in 2007 as a simplified alternative to the BPD-DS . Unlike the BPD-DS, it involves only a single
anastomosis, as it utilizes an omega loop reconstruction technique . Compared to BPD-DS, the technical
[7]
requirements of SADI-S result in a shorter operating time, which in turn can reduce postoperative
complications and result in a shorter hospital stay . Moreover, despite Roux-en-Y gastric bypass being one
[8,9]
of the most commonly performed bariatric procedures worldwide, it is often associated with postoperative
issues, such as reactive hypoglycemia and dumping syndrome, conditions that are less likely when the
pylorus is preserved [9,10] . Nonetheless, since SADI-S does not require the stomach to be excluded, it can be
effectively performed in patients with gastric dysplasia, metaplasia, or chronic gastritis .
[11]

The study by Sánchez-Pernaute et al. reported the therapeutic advantages of a longer common channel in
reducing diarrhoea and malabsorption, following the initial description of the procedure [8,12] . Therefore, this
derivative approach might be suitable for a broader range of patients. It has been well documented that
SADI-S has comparable mid-term effectiveness to BPD-DS with respect to clinical response and
comorbidities resolution [13,14] .

Moreover, SADI-S can be performed as the second step of a two-stage procedure, one year after sleeve
gastrectomy (SG) [10,15] . Nevertheless, it may also be carried out as a conversion procedure following other
bariatric surgeries in cases of suboptimal clinical outcomes [16-18] .

The encouraging medium-term results have been referenced in the position statements endorsed by both
the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the American
[9]
Society for Metabolic & Bariatric Surgery (ASMBS) . As a result, SADI-S has gained international
[19]
recognition as a reliable and safe bariatric procedure.