Name: Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Model in Mice (Video) | JoVE Journal
Uploaded: 2023-02-10T14:05:00.000+00:00
Duration: 6 min 40 s
Description: Learn the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy procedure in mice. This model enables study of metabolic mechanisms and improves survival rates for bariatric surgery research.

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5 minutes

We thank Ethicon (Johnson and Johnson surgical technologies) for kindly providing the suture cord and surgical clips. This work was supported by grants from the NExT Talent Project, Universit&#233; de Nantes, CHU de Nantes.

This protocol has been approved by the local French ethical committee for animal experimentation (Comit&#233; d&#39;&#233;thique en exp&#233;rimentation animale; reference CEEA-PdL n 06).
1. Pre-operative preparation
<ol>
	<li>Add gel diet food to the normal diet 3 days before the surgery. Fast the mice 6 h before the surgery.</li>
	<li>Induce anesthesia with 5% isoflurane (1 L/min) in a dedicated chamber with oxygen (1 L/min). Inject the mice subcutaneously with buprenorphine (0.1 mg/kg), amoxicillin (15 mg/kg), metoclopramide (1 mg/kg), meloxicam (1 mg/kg)&#160;and iron (0.5 mg/kg).</li>
	<li>Shave the first 2/3 parts of the mouse&#39;s abdomen beginning from the xiphoid process using an electric razor. Disinfect the mouse&#39;s abdomen in two steps using an iodine polyvidone solution .</li>
	<li>Place the mouse supine on a dedicated heat pad covered with a clean underpad. Maintain anesthesia using a nose cone with 2%-2.5% isoflurane (0.4 L/min) with oxygen (0.4 L/min). Use a toe-pinch test to confirm the depth of anesthetization.</li>
	<li>Cover the mouse in a sterilized plastic wrap. In order to apply hyperextension on the mouse&#39;s abdomen, fix the lower paw and use a 1 mL syringe or equivalent placed behind the mouse&#39;s back. Cut an&#160;opening in a sterile compress with the size of the future incision,&#160;and use it as an operating field to cover the mouse. The general installation is shown in Figure 2A.</li>
	<li>Before the surgery, use a face mask, a scrub cap, and sterilized gloves. Use sterilized instruments for the surgery.</li>
</ol>
2. The SADI-S protocol
<ol>
	<li>Median laparotomy
	<ol>
		<li>Under a binocular microscope (8x magnification), perform a median laparotomy with scissors or a scalpel by opening the abdominal skin from the xiphoid process to the middle of the abdomen. Ensure that the xiphoid process and the musculoaponeurotic layer are visible (Figure 2B). 
		NOTE: Administer bupivacaine (3 mg/kg) subcutaneously at the surgical&#160;site 5 mins before making the skin incision.</li>
		<li>Open the abdominal wall along the linea alba with scissors between the abdominal muscles. Be careful not to enter the thoracic cavity (Figure 2C).</li>
	</ol>
	</li>
	<li>Duodenal exclusion
	<ol>
		<li>Gently mobilize the duodenum from the abdominal cavity using a moistened cotton swab to see its anterior and posterior sides. Localize the main bile duct, which is immediately visible under the binocular microscope on the posterior side of the lesser omentum and the duodenum (Figure 3A, black arrows).</li>
		<li>Proximally from the main bile duct, visualize an area between the duodenal arteries under the binocular microscope (Figure 3A,B, blue dotted circles). Penetrate this area using curved micro forceps from one side of the duodenum to the other, and perform a duodenal ligation between the arteries using a 6-0 non-absorbable suture (Figure 3C-E). Be careful not to ligate the branches of the duodenal arteries.</li>
	</ol>
	</li>
	<li>Sleeve gastrectomy
	<ol>
		<li>Mobilize the stomach from the abdominal cavity using a moistened cotton swab and a non-traumatic clamp. Separate the stomach from the surrounding organs using micro scissors: separate the greater omentum, cut the short gastric arteries (branch of the splenic artery) between the stomach and the spleen, and the lipoma linking the stomach to the lower part of the esophagus (Figure 4A,B).</li>
		<li>Using micro scissors, perform a 5 mm gastrotomy by opening the fundus and remove the residual food using a cotton swab (Figure 4C, arrow). Rinse the gastrotomy site with sterile saline solution (37 &#176;C) to avoid contamination from the removed gastric contents.&#160;</li>
		<li>Apply surgical clips (medium size, 5.6 mm) along the stomach&#39;s greater curvature to exclude approximately 80% of the stomach. Two clips are sufficient. Remove the excluded stomach by cutting it with micro scissors (Figure 4D-G).</li>
		<li>Anchor the surgical clips to ascertain impermeability by performing a running suture (8-0) from the beginning to the end of the stomach resection (Figure 4H).</li>
	</ol>
	</li>
	<li>Duodeno-ileal anastomosis
	<ol>
		<li>Under the binocular microscope, visualize the last ileal loop, which is situated just before the caecum (Figure 5A). Gently mobilize the small intestine outside the abdominal cavity from the last ileal loop. Lay out the small bowel, as displayed in Figure 5B, so that the last ileal loop is located on the left side. Using a previously sized suture cord, measure 10 cm (approximately 1/3 of the total length of the small bowel) from the last ileal loop; this will be the site of the future anastomosis.</li>
		<li>In order to ensure that the future biliary limb comes to the anastomosis site from its left side, make a large loop of the small intestine around the site of the future anastomosis. Using micro scissors, perform a 4 mm enterotomy by opening the small bowel at this point (Figure 5C-E).&#160;Rinse the enterotomy site with&#160;sterile saline solution (37 &#176;C) to avoid contamination.</li>
		<li>Perform a 4 mm enterotomy on the excluded part of the duodenum, immediately after the pylorus, between the stomach and the ligation performed in step 2.2.2 (Figure 5F). Place an absorbable 5 mm x 5 mm hemostatic collagen compress to favor homeostasis.</li>
		<li>Using a non-absorbable 8-0 suture, perform a side-to-side duodeno-ileal anastomosis. Begin with the posterior side anastomosis, followed by the anterior side anastomosis (Figure 5G-I).</li>
	</ol>
	</li>
	<li>Abdominal closure
	<ol>
		<li>Display the small bowel in the abdominal cavity so that the biliary limb comes to the anastomosis from the superior-left side of the abdomen and the common limb falls to the lower part of the abdomen. 
		NOTE: Lavage the abdomen three times with approximately 5 mL of sterile 0.9% saline solution (37 &#176;C). Then, suction the fluid from the abdomen to remove residual gastrointestinal fluid and digested food to avoid bacterial infection and subsequent abdominal inflammation.&#160;</li>
		<li>Rehydrate the mouse with 500 &#181;L of 37 &#176;C saline solution by applying it directly into the abdominal cavity using a 1 mL syringe.</li>
		<li>Close the musculoaponeurotic layer using a single 6-0 non-absorbable running suture. Close the abdominal skin using 6-0 non-absorbable separated sutures (Figure 5J,K).</li>
	</ol>
	</li>
</ol>
3. General postoperative care
<ol>
	<li>After stopping the isoflurane, let the mouse wake on the heat pad under 0.4 L/min O2 insufflated with the nose mask. When fully awakened, which can be ensured by complete motor recuperation, place the mouse alone in a cage in a 30 &#176;C incubator. Leave the mouse in the 30 &#176;C incubator for 5 days (no specific condition for gas or humidity). 
	NOTE: The cage should be warmed beforehand.</li>
	<li>Allow free access to water immediately after surgery. Add vitamin supplements, including vitamins B1, B9, B12, and liposoluble vitamins (A, D, E, K), to water (800 mg/180 mL of water) until the end of the protocol.</li>
	<li>Maintain analgesia by subcutaneous buprenorphine injections (0.1 mg/kg) twice a day from day 1 to day 3, once a day afterward until day 5. Continue amoxicillin (15 mg/kg), meloxicam (1 mg/kg) and metoclopramide (1 mg/kg) subcutaneous injections once a day until day 3. Provide subcutaneous injections of iron (0.5 mg/kg) once a day until the end of the protocol.</li>
</ol>
4. General measurements and euthanasia
<ol>
	<li>Weigh the mice every day until postoperative day 5. Then weigh on day 7, and then weekly.</li>
	<li>To measure daily food intake, place one mouse per cage. Place a known weight of a solid diet and measure the weight of the solid diet remaining after 24 h. Measure food intake on day 3, 4, 5, 7, and then weekly.</li>
	<li>Euthanize the mice by cervical dislocation under general anesthesia (5% isoflurane (1 L/min) with oxygen (1 L/min)) with subcutaneous injection of buprenorphine (0.1 mg/kg) after cardiac left atrium incision for blood sampling (500 to 600 &#181;L of blood).</li>
	<li>Measure the blood hemoglobin concentration using an automatic hematology analyzer requiring 20 &#956;L of blood.</li>
</ol>

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<li>Laura, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Establishing+a+reproducible+murine+animal+model+of+single+anastomosis+duodenoileal+bypass+with+sleeve+gastrectomy+%28SADl-S%29%5BTitle%5D)+AND+%22Obesity+Surgery%22%5BJournal%5D)">Establishing a reproducible murine animal model of single anastomosis duodenoileal bypass with sleeve gastrectomy (SADl-S).</a> Obesity Surgery. 28 (7), 2122-2125 (2018).</li>
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<li>Kumar, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Lipocalin-type+prostaglandin+D2+synthase+%28L-PGDS%29+modulates+beneficial+metabolic+effects+of+vertical+sleeve+gastrectomy%5BTitle%5D)+AND+%22Surgery+for+Obesity+and+Related+Diseases%22%5BJournal%5D)">Lipocalin-type prostaglandin D2 synthase (L-PGDS) modulates beneficial metabolic effects of vertical sleeve gastrectomy.</a> Surgery for Obesity and Related Diseases. 12 (8), 1523-1531 (2016).</li>
<li>Heffron, S. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Changes+in+lipid+profile+of+obese+patients+following+contemporary+bariatric+surgery%3A+A+meta-analysis%5BTitle%5D)+AND+%22The+American+Journal+of+Medicine%22%5BJournal%5D)">Changes in lipid profile of obese patients following contemporary bariatric surgery: A meta-analysis.</a> The American Journal of Medicine. 129 (9), 952-959 (2016).</li>
<li>Carswell, K. A., Belgaumkar, A. P., Amiel, S. A., Patel, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+systematic+review+and+meta-analysis+of+the+effect+of+gastric+bypass+surgery+on+plasma+lipid+levels%5BTitle%5D)+AND+%22Obesity+Surgery%22%5BJournal%5D)">A systematic review and meta-analysis of the effect of gastric bypass surgery on plasma lipid levels.</a> Obesity Surgery. 26 (4), 843-855 (2016).</li>
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<li>Sánchez-Pernaute, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Single-anastomosis+duodeno-ileal+bypass+with+sleeve+gastrectomy%3A+metabolic+improvement+and+weight+loss+in+first+100+patients%5BTitle%5D)+AND+%22Surgery+for+Obesity+and+Related+Diseases%22%5BJournal%5D)">Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients.</a> Surgery for Obesity and Related Diseases. 9 (5), 731-735 (2013).</li>
<li>Wei, J. H., Yeh, C. H., Lee, W. J., Lin, S. J., Huang, P. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Sleeve+gastrectomy+in+mice+using+surgical+clips%5BTitle%5D)+AND+%22Journal+of+Visualized+Experiments%22%5BJournal%5D)">Sleeve gastrectomy in mice using surgical clips.</a> Journal of Visualized Experiments. (165), e60719(2020).</li>
<li>Ying, L. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Technical+feasibility+of+a+murine+model+of+sleeve+gastrectomy+with+ileal+transposition%5BTitle%5D)+AND+%22Obesity+Surgery%22%5BJournal%5D)">Technical feasibility of a murine model of sleeve gastrectomy with ileal transposition.</a> Obesity Surgery. 29 (2), 593-600 (2019).</li>
<li>Bruinsma, B. G., Uygun, K., Yarmush, M. L., Saeidi, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+models+of+Roux-en-Y+gastric+bypass+surgery+and+sleeve+gastrectomy+in+rats+and+mice%5BTitle%5D)+AND+%22Nature+Protocols%22%5BJournal%5D)">Surgical models of Roux-en-Y gastric bypass surgery and sleeve gastrectomy in rats and mice.</a> Nature Protocols. 10 (3), 495-507 (2015).</li>
</ol>

Claire Blanchard has been paid by Medtronic to provide courses of clinical immersions.

Bariatric surgeries, whose techniques are constantly evolving, appear to be currently the most effective treatment for obesity and associated metabolic comorbidities3,19,20. The SADI-S procedure, firstly described in 20074, is a promising procedure associated with greater metabolic effects than other malabsorptive surgeries. Animal models, particularly mice that allow the rapid generation of genetically m...

Obesity is an emerging and endemic situation with increasing prevalence, affecting approximately 1 in 20 adults worldwide1. Bariatric surgery has become the most effective treatment option for the affected adults in recent years, improving both weight loss and metabolic disorders2,3, with variable results depending on the type of surgical procedure used.
There are two main mechanisms that are implicated in the effects of the bariatric procedures: restriction that aims to increase satiety (such as in the sleeve gastrectomy (SG) where 80% of the stomach is removed), and malabsorption. Among the procedures that imply both restriction and malabsorption, the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been proposed as an alternative to the Roux-en-Y gastric bypass (RYGB), in which a weight regain is observed in approximately 20% patients4,5. In this technique, a sleeve gastrectomy is associated with a small bowel rearrangment, dividing it into a biliary and a short common limb (one-third of the total small bowel length) (Figure 1A). Technically, the SADI-S has the advantage over the RYGB of requiring only a single anastomosis, reducing the operation time by approximately 30%. In addition, this method preserves the pylorus, which helps to reduce the risk of peptic ulcer disease and limits anastomotic leakage. The SADI-S is also associated with a high rate of metabolic improvement, strongly favoring its use during the last few years6,7.
Since metabolic effects have become increasingly foundational to bariatric procedures, elucidating their mechanisms seems crucial. Therefore, the use of animal models for bariatric procedures is of utmost importance to better understand their metabolic effects and the cellular and molecular pathways involved8. These models contributed, for example, to a better understanding of the change in food intake after SG or RYGB in a controlled environment9 and to the study of glucose or cholesterol fluxes through the intestinal barrier10,11; these informations are rarely available in clinical studies. This knowledge could help to define their optimal surgical indications. We previously described mouse models of SG and RYGB12. However, despite its promising results in clinical practice, the SADI-S has only been developed and described in rats13,14,15. However, given its genetic malleability, the mouse model has been useful in the past to study the various metabolic effects of such procedures16,17,18, and a SADI-S mouse model could be useful to evaluate effects of SADI-S despite the technical difficulty.
In this article, we describe the adaptation of the SADI-S procedure in mice (Figure 1B) in a reproducible manner. Special attention is given to the description of perioperative care.

<table><tbody><tr><td>Agagani needle 26 G</td><td>Terumo</td><td>050101B</td><td>26 G needle</td></tr><tr><td>Betadine dermique&amp;nbsp;</td><td>Pharma-gdd</td><td>3300931499787</td><td>Povidone solution</td></tr><tr><td>Betadine scrub</td><td>Pharma-gdd</td><td>&amp;nbsp;3400931499787</td><td>Povidone solution</td></tr><tr><td>Binocular microscope</td><td>Optika Microscopes Italy</td><td>SZN-9</td><td>Binocular stereomicroscope</td></tr><tr><td>Buprecare</td><td>Animalcare</td><td>3760087151244</td><td>Buprenorphin</td></tr><tr><td>Castroviejo, straight 9 cm</td><td>F.S.T</td><td>12060-02</td><td>Micro scissors</td></tr><tr><td>Castroviejo, straight 9 cm</td><td>F.S.T</td><td>12060-02</td><td>Needle holder</td></tr><tr><td>Chlorure de sodium Fresenius 0.9%</td><td>Fresenius Kabi&amp;nbsp;</td><td>BE182743</td><td>NaCl 0.9%</td></tr><tr><td>Clamoxyl</td><td>Med&#039;vet</td><td>5414736007496</td><td>Amoxicilline</td></tr><tr><td>Cotton buds</td><td>Comed</td><td>2510805</td><td>Cotton swabs</td></tr><tr><td>Element HT5</td><td>Scilvet</td><td>Element HT5</td><td>Automated hematology analyzer</td></tr><tr><td>Emeprid</td><td>CEVA</td><td>3411111914365</td><td>Metoclopramid</td></tr><tr><td>Extra Fine Graefe Forceps, curved (tip width: 0.5 mm)</td><td>F.S.T</td><td>11152-10</td><td>Surgical forceps</td></tr><tr><td>Extra Fine Graefe Forceps, straight (tip width: 0.5 mm)</td><td>F.S.T</td><td>11150-10</td><td>Surgical forceps</td></tr><tr><td>Fercobsang</td><td>Vetoprice</td><td>QB03AE04</td><td>Iron, multivitamins and minerals&amp;nbsp;</td></tr><tr><td>Forane</td><td>Baxter</td><td>1001936060</td><td>Isoflurane</td></tr><tr><td>Graefe forceps, straight (tip width: 0.8 mm)</td><td>F.S.T</td><td>11050-10</td><td>Forceps</td></tr><tr><td>Graphpad Prism version 8.0</td><td>GraphPad Software, Inc.</td><td>Version 8.0</td><td>Software for statistical analysis</td></tr><tr><td>Heat pad</td><td>Intellibio innovation</td><td>A-2101-00300</td><td>Heat pad</td></tr><tr><td>Incubator</td><td>Bioconcept Technologies</td><td>Manufactured on demand</td><td>Incubator&amp;nbsp;</td></tr><tr><td>Lighting</td><td>Optika Microscopes Italy</td><td>CL-30</td><td>Lighting for microscopy</td></tr><tr><td>Ocrygel</td><td>Med&#039;vet</td><td>3700454505621</td><td>Carboptol 980 NF</td></tr><tr><td>Pangen 2.5 cm x 3.5 cm</td><td>Urgovet</td><td>A02978</td><td>Haemostatic collagen compress</td></tr><tr><td>Prolene 6/0</td><td>B.Braun</td><td>3097915</td><td>Optilene 6/0 (0.7 metric) 75 cm 2XDR13 CV2 RCP, suture cord</td></tr><tr><td>Prolene 8/0</td><td>Ethicon</td><td>8732</td><td>2 x BV175-6 MP, 3/8 Circle, 8 mm,&amp;nbsp; suture cord</td></tr><tr><td>Scissors</td><td>F.S.T</td><td>146168-09</td><td>Surgical scissors</td></tr><tr><td>Sterile compresses&amp;nbsp;</td><td>Laboartoire Sylamed</td><td>211S05-50</td><td>Non-woven sterile compressed</td></tr><tr><td>Terumo Syringe</td><td>Terumo</td><td>50828</td><td>1 mL syringe</td></tr><tr><td>Titanium hemostatic clip</td><td>P&amp;eacute;ters Surgical</td><td>B2180-1</td><td>Surgical clip</td></tr><tr><td>Vannas Wolff</td><td>F.S.T</td><td>15009-08</td><td>Micro scissors</td></tr><tr><td>Vita Rongeur</td><td>Virbac</td><td>3597133087611</td><td>Vitamin supplementation</td></tr><tr><td>Vitaltec stainless</td><td>P&amp;eacute;ters Surgical</td><td>PB 220-EB Medium</td><td>Surgical clip applier</td></tr></tbody></table>

single-anastomosis duodeno-ileal bypass with sleeve gastrectomy model in mice

Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Model in Mice

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes mellitus, dyslipidemia, non-alcoholic steatohepatitis, cardiovascular events, and cancers) through restrictive and malabsorptive mechanisms. Understanding the mechanisms by which these procedures allow such improvements often require their transposition into animals, especially in mice, because of the ease of generating genetically modified animals. Recently, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has emerged as a procedure that uses both restrictive and malabsorptive effects, which is being used as an alternative to gastric bypass in case of major obesity. Thus far, this procedure has been associated with strong metabolic improvements, which has led to a marked increase in its use in daily clinical practice. However, the mechanisms underlying these metabolic effects have been poorly studied as a result of a lack of animal models. In this article, we present a reliable and reproducible model of SADI-S in mice, with a special focus on perioperative management. The description and use of this new rodent model will be helpful for the scientific community to better understand the molecular, metabolic, and structural changes induced by the SADI-S and to better define the surgical indications for clinical practice.

Learning curve 
The learning curve for this model is displayed in Figure 6. A progressive decrease in the operating time is observed, reaching approximately 60 min of surgery after 4 weeks of intensive training (Figure 6A). The 5-day postoperative survival also improved with time, reaching 77% during regular practice (Figure 6B). The most frequent causes of mortality were anastomotic leaks and an afferent loop sy...

Single-anastomosis duodeno-ileal bypass (SADI-S) is an emerging bariatric procedure with important metabolic effects. In this article, we present a reliable and reproducible model of SADI-S in mice.

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes ...

single-anastomosis-duodeno-ileal-bypass-with-sleeve-gastrectomy-model

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In this video, a vertical sleeve gastrectomy procedure is performed on an experimental mouse model. This procedure helps remove a significant portion of the stomach along its greater curvature.

Murine Vertical Sleeve Gastrectomy: A Surgical Procedure to Downsize Stomach in Experimental Mouse Models

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Roux-en-Y Gastric Bypass Procedure: A Bariatric Surgical Procedure for Gastric Resectioning in Murine Model

Bariatric surgery is the most efficient way to reduce body weight and the deadly metabolic complications (diabetes, obesity, and dyslipidemia) frequently associated with morbid obesity. Mouse models of bariatric surgery represent a unique asset for deciphering molecular mechanisms behind the beneficial effects of these surgeries on diabetes, hypertension, and dyslipidemia.

Techniques of Sleeve Gastrectomy and Modified Roux-en-Y Gastric Bypass in Mice

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A Murine Model of Vertical Sleeve Gastrectomy

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One-anastomosis Gastric Bypass (OAGB) in Rats

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Sleeve Gastrectomy in Mice using Surgical Clips

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Duodenal-Jejunal Bypass Surgery in Diet-Induced Obese Diabetic Mice

Filamentous occlusion of  the Middle cerebral artery is a common model for studying ischemic stroke in mice.

Modeling Stroke in Mice - Middle Cerebral Artery Occlusion with the Filament Model

Numerous studies using gastric bypass rat models have been recently conducted to uncover the underlying physiological mechanisms of Roux-en-Y gastric bypass operations. This article aims to demonstrate and discuss the technical and experimental details of our published gastric bypass rat model to understand advantages and limitations of this experimental tool.

Roux-en-Y Gastric Bypass Operation in Rats

This paper describes a novel nonocclusive coronary anastomotic connector in a porcine off-pump coronary artery bypass (OPCAB) model. This easy-to-use coronary connector has intrinsic potential to facilitate minimally invasive OPCAB surgery.

Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model

Learn the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy procedure in mice. This model enables study of metabolic mechanisms and improves survival rates for bariatric surgery research.

Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Model in Mice

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