Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures



Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss.

Materials and Methods

Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1 years earlier.


Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids—leucine, isoleucine, and valine—were higher after SADI-S as compared with BPD-DS.


Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Collaborators GBDO, Afshin A, Forouzanfar MH, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017;377(1):13–27.

    Article  Google Scholar 

  2. 2.

    Apovian CM. Obesity: definition, comorbidities, causes, and burden. Am J Manag Care. 2016;22(7 Suppl):s176–85.

    PubMed  Google Scholar 

  3. 3.

    Glandt M, Raz I. Present and future: pharmacologic treatment of obesity. J Obes. 2011;2011:636181.

    Article  Google Scholar 

  4. 4.

    Adams TD, Davidson LE, Litwin SE, et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017;377(12):1143–55.

    Article  Google Scholar 

  5. 5.

    Skogar ML, Sundbom M. Duodenal switch is superior to gastric bypass in patients with super obesity when evaluated with the bariatric analysis and reporting outcome system (BAROS). Obes Surg. 2017;27(9):2308–16.

    Article  Google Scholar 

  6. 6.

    Strain GW, Torghabeh MH, Gagner M, et al. The impact of biliopancreatic diversion with duodenal switch (BPD/DS) over 9 years. Obes Surg. 2017;27(3):787–94.

    Article  Google Scholar 

  7. 7.

    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    CAS  Article  Google Scholar 

  8. 8.

    Sethi M, Chau E, Youn A, et al. Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data. Surg Obes Relat Dis. 2016 Nov;12(9):1697–705.

    Article  Google Scholar 

  9. 9.

    Sanchez-Pernaute A, Rubio Herrera MA, Perez-Aguirre E, et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8.

    Article  Google Scholar 

  10. 10.

    Surve A, Zaveri H, Cottam D, et al. A retrospective comparison of biliopancreatic diversion with duodenal switch with single anastomosis duodenal switch (SIPS-stomach intestinal pylorus sparing surgery) at a single institution with two year follow-up. Surg Obes Relat Dis. 2017;13(3):415–22.

    Article  Google Scholar 

  11. 11.

    Cottam A, Cottam D, Portenier D, et al. A matched cohort analysis of stomach intestinal pylorus saving (SIPS) surgery versus biliopancreatic diversion with duodenal switch with two-year follow-up. Obes Surg. 2017;27(2):454–61.

    Article  Google Scholar 

  12. 12.

    Surve A, Cottam D, Sanchez-Pernaute A, et al. The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience. Surg Obes Relat Dis. 2018;14(5):594–601.

    Article  Google Scholar 

  13. 13.

    Torres A, Rubio MA, Ramos-Levi AM, et al. Cardiovascular risk factors after single anastomosis duodeno-Ileal bypass with sleeve gastrectomy (SADI-S): a new effective therapeutic approach? Curr Atheroscler Rep. 2017;19(12):58.

    Article  Google Scholar 

  14. 14.

    Pereira SS, Guimaraes M, Almeida R, et al. Biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) result in distinct post-prandial hormone profiles. Int J Obes (Lond). 2019;43(12):2518–2527.

  15. 15.

    Billeter AT, Fischer L, Wekerle A-L, et al. Malabsorption as a therapeutic approach in bariatric surgery. Viszeralmedizin. 2014;30(3):198–204.

    Article  Google Scholar 

  16. 16.

    Atiyeh B Body contouring following bariatric surgery and massive weight loss: post-bariatric body contouring: Bentham science publishers; 2012.

  17. 17.

    Moon RC, Kirkpatrick V, Gaskins L, et al. Safety and effectiveness of single- versus double-anastomosis duodenal switch at a single institution. Surg Obes Relat Dis. 2019;15(2):245–52.

    Article  Google Scholar 

  18. 18.

    Wewer Albrechtsen NJ, Junker AE, Christensen M, et al. Hyperglucagonemia correlates with plasma levels of non-branched-chain amino acids in patients with liver disease independent of type 2 diabetes. Am J Physiol Gastrointest Liver Physiol. 2018;314(1):G91–g6.

    Article  Google Scholar 

  19. 19.

    Emwas A-H, Roy R, McKay RT, et al. NMR spectroscopy for metabolomics research. Metabolites. 2019;9(7):123.

    CAS  Article  Google Scholar 

  20. 20.

    Jarak I, Pereira SS, Carvalho RA, et al. Gastric Bypass with different biliopancreatic limb lengths results in similar post-absorptive metabolomics profiles. Obes Surg. 2020;30(3):1068–1078.

  21. 21.

    Handzlik-Orlik G, Holecki M, Orlik B, et al. Nutrition management of the post-bariatric surgery patient. Nutr Clin Pract. 2015;30(3):383–92.

    Article  Google Scholar 

  22. 22.

    Kiela PR, Ghishan FK. Physiology of intestinal absorption and secretion. Best Pract Res Clin Gastroenterol. 2016;30(2):145–59.

    CAS  Article  Google Scholar 

  23. 23.

    Brosnan JT, Brosnan ME. Branched-chain amino acids: enzyme and substrate regulation. J Nutr. 2006;136(1):207S–11S.

    CAS  Article  Google Scholar 

  24. 24.

    Wu G. Amino acids: metabolism, functions, and nutrition. Amino Acids. 2009;37(1):1–17.

    Article  Google Scholar 

  25. 25.

    Adibi SA, Gray SJ. Intestinal absorption of essential amino acids in man. Gastroenterology. 1967;52(5):837–45.

    CAS  Article  Google Scholar 

  26. 26.

    Sener A, Malaisse WJ. The stimulus-secretion coupling of amino acid-induced insulin release: insulinotropic action of branched-chain amino acids at physiological concentrations of glucose and glutamine. Eur J Clin Investig. 1981;11(6):455–60.

    CAS  Article  Google Scholar 

  27. 27.

    Yoon M-S. The emerging role of branched-chain amino acids in insulin resistance and metabolism. Nutrients. 2016;8(7):405.

    Article  Google Scholar 

  28. 28.

    Yang J, Chi Y, Burkhardt BR, et al. Leucine metabolism in regulation of insulin secretion from pancreatic beta cells. Nutr Rev. 2010;68(5):270–9.

    Article  Google Scholar 

  29. 29.

    Müller WA, Faloona GR, Unger RH. The effect of alanine on glucagon secretion. J Clin Invest. 1971;50(10):2215–8.

    Article  Google Scholar 

  30. 30.

    Zaveri H, Surve A, Cottam D, et al. Mid-term 4-year outcomes with single anastomosis duodenal-Ileal bypass with sleeve gastrectomy surgery at a single US Center. Obes Surg. 2018;28(10):3062–72.

    Article  Google Scholar 

  31. 31.

    Cottam A, Cottam D, Zaveri H, et al. An analysis of mid-term complications, weight loss, and type 2 diabetes resolution of stomach intestinal pylorus-sparing surgery (SIPS) versus roux-en-Y gastric bypass (RYGB) with three-year follow-up. Obes Surg. 2018;28(9):2894–2902.

  32. 32.

    Cottam A, Cottam D, Roslin M, et al. A matched cohort analysis of sleeve Gastrectomy with and without 300 cm loop duodenal switch with 18-month follow-up. Obes Surg. 2016;26(10):2363–9.

    Article  Google Scholar 

  33. 33.

    Topart P, Becouarn G. The single anastomosis duodenal switch modifications: a review of the current literature on outcomes. Surg Obes Relat Dis. 2017;13(8):1306–12.

    Article  Google Scholar 

  34. 34.

    Sanchez-Pernaute A, Rubio MA, Cabrerizo L, et al. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015;11(5):1092–8.

    Article  Google Scholar 

  35. 35.

    Enochs P, Bull J, Surve A, et al. Comparative analysis of the single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) to established bariatric procedures: an assessment of 2-year postoperative data illustrating weight loss, type 2 diabetes, and nutritional status in a single US center. Surg Obes Relat Dis. 2020;16(1):24–33.

  36. 36.

    Shoar S, Poliakin L, Rubenstein R, et al. Single anastomosis duodeno-Ileal switch (SADIS): a systematic review of efficacy and safety. Obes Surg. 2018;28(1):104–13.

    Article  Google Scholar 

  37. 37.

    King N. Amino acids and the mitochondria. In: Schaffer SW, Suleiman MS, editors. Mitochondria: the dynamic organelle. New York: Springer New York; 2007. p. 151–66.

    Google Scholar 

Download references


Authors would like to thank the Senior Nurse Sandra Tavares (Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal) for her technical assistance during the MMTT.


Unit for Multidisciplinary Research in Biomedicine (UMIB) is funded by Foundation for Science and Technology (FCT) Portugal (UID/Multi/00215/2019). JJH holds an unrestricted grant from the NNF Center for Basic Metabolic Research, Copenhagen, Denmark. The NNF foundation Center for Basic Metabolic Research is an independent research institution at the University of Copenhagen, Denmark.

Author information



Corresponding author

Correspondence to Mariana P. Monteiro.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Pereira, S.S., Jarak, I., Carvalho, R.A. et al. Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures. OBES SURG 30, 4019–4028 (2020). https://doi.org/10.1007/s11695-020-04774-z

Download citation


  • Malabsorptive bariatric surgeries
  • BPD-DS
  • SADI-S
  • Metabolomics
  • Amino acid absorption