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Pennestrì et al. Mini-invasive Surg. 2025;9:16 https://dx.doi.org/10.20517/2574-1225.2025.03 Page 5 of 13

eight patients following previous procedures: six after adjustable gastric banding and two after Roux-en-Y
gastric bypass. In the latter two cases, conversion was planned six months after surgical restoration of gastric
and small bowel anatomy.

Table 1 summarizes the key demographic and clinical characteristics of the study population.

We enrolled 53 (33.8%) males and 104 (66.2%) females, with a median age of 46 (IQR: 40-53) years and
2
preoperative BMI of 51.6 (IQR: 46.7-56.7) kg/m . For patients undergoing primary and conversion
procedures, the median preoperative BMIs were 53 (IQR: 50.6-57.8) and 44.6 (IQR: 38.6-50.4) kg/m ,
2
respectively. Except for three cases, all conversion procedures were indicated due to weight recurrences; in
these three patients, the indication for conversion surgery was a suboptimal response to the initial
procedure. Comorbid conditions were present in 101 out of 157 patients. The median BMI at the time of
initial bariatric surgery in patients who later underwent conversion to SADI-S/SADI was 51.4 (IQR: 44-
54.4) kg/m , with a median interval of 63 (IQR: 37.5-93) months between the primary and conversion
2
procedure to SADI-S/SADI.

A robotic approach was used in 35 cases (22.3%), while 122 (77.7%) procedures were laparoscopic. More in
detail, we performed 78 laparoscopic SADI-Ss (49.7%), 34 robot-assisted SADI-Ss (21.6%), 44 laparoscopic
SADIs (28%), and one robot-assisted SADI (0.7%).

The median OT was 120 min (IQR 100-160). When stratified by surgery procedure, median durations were:
102.5 min (IQR: 110-150) for laparoscopic SADI-S, 182.5 min (IQR: 167.5-207) for robot-assisted SADI-S,
93.5 min (IQR: 70.5-120) for laparoscopic SADI, and 120 min for robot-assisted SADI. No additional intra-
abdominal procedures were conducted, and no intraoperative complications were observed. There were no
conversions in our series and no 30-day mortality was reported. Early postoperative complications were
recorded in four patients, of which two (2.5%) required reintervention; whereas five (3.1%) patients
developed late complications. Postoperative complications of these procedures, although widely
reported [6,20,24] , are summarized in Table 2 and reported in extenso in the Supplementary Materials, as they
represent the endpoints of this study.

At a median follow-up of 23 months (IQR: 12-31), the median %TWL, %EWL, and BMI were 42 (IQR: 29.3-
2
52.4), 82 (IQR: 59.1-99.4), and 27.3 (IQR: 21.2-33) kg/m , respectively. Moreover, the median daily bowel
movements were 2 (IQR: 1-3).

Table 3 shows the BMI, %TWL, and %EWL distribution at 1, 2, 3, 5, and 7 years, respectively. We used the
CUSUM analysis to evaluate the experience of TOs, analyzing laparoscopic, robot-assisted SADI-Ss and
SADIs together. As for the learning curve, the first 61 cases (P = 0.029) led to the breakdown of the learning
curve [Figures 2 and 3].

DISCUSSION
This retrospective study supports the safety and effectiveness of SADI-S as a primary or conversion
procedure in terms of complications and bariatric outcomes. We have been performing this bariatric
procedure in our clinical practice since July 2016 [6,20] , beginning with a robotic SADI-S as our first case.
Since then, laparoscopic SADI-S or SADI and robot-assisted SADI were performed in February 2017,
February 2017, and March 2021, respectively [6,20] . In 2007, Sánchez-Pernaute et al. elaborated on a BDP-DS
[7]
variation, reporting the description of SADI-S’ surgical technique . BDP-DS has been one of the
[27]
[26]
cornerstones in the bariatric surgeons’ armamentarium since the 1990s when Hess and Marceau
[25]