SLEEVE GASTRECTOMY WITH LOOP DUODENOJEJUNAL BYPASS
(SG LDJB)
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Dr. AMAR VENNAPUSA

ROBOTIC, LAPAROSCOPIC
SLEEVE GASTRECTOMY WITH LOOP DUODENOJEJUNAL BYPASS (SG LDJB)
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Dr. AMAR VENNAPUSA

– It is a type of sleeve plus bypass combination surgery (Sleeve plus procedure) for the treatment of severe obesity and severe diabetes.

– It is a loop modification of biliopancreatic diversion with duodenal switch (BPD DS).

– It is similar to Single anastomosis duodenoileal bypass with sleeve (SADI S) but with a more proximal anastomosis (duodenojejunal anastomosis in place of duodenoileal anastomosis).

– Procedure:

  1. Performed by robotic or laparoscopic method (By putting small holes over the tummy) using advanced high quality imported laparoscopic equipment and instruments.
  2. Up to 80% of the stomach is removed using high quality staplers and stapler guns to form a vertical sleeve.
  3. When the stomach is divided using staplers, it is stapled in three rows, sealed and cut simultaneously.
  4. The percentage of the removed stomach is relative but the capacity of the remaining gastric sleeve is 60 to 100 ml.
  5. Duodenum (First part of the small intestine) is divided and attached to the mid jejunum (Second part of the small intestine) in a loop fashion 200 to 250 cm distal to duodenojejunal junction (loop duodenojejunal bypass).

As per IFSO Guidelines 2022

– In India and Asia,

1. Individuals suffering from mild obesity with the body mass index is ≥ 27.5 kg/m2 with co-morbid medical conditions such as uncontrolled type 2 diabetes.

2. Individuals suffering from severe obesity with the body mass index is ≥ 32.5 kg/m2 even without any co-morbid medical conditions.

– In Western countries

1. Individuals suffering from mild obesity with the body mass index is ≥ 30 kg/m2 with co-morbid medical conditions such as type 2 diabetes.

2. Individuals suffering from severe obesity with the body mass index is ≥ 35 kg/m2 even without any co-morbid medical conditions.

– Weight loss is mainly due to physiological changes altering body energy balance.

– Because of these changes

  1. Appetite (Hunger) is reduced.
  2. Metabolic rate is increased.
  3. Energy expenditure is increased.
  4. ‘Fat mass’ is reset to a lower level.
  5. Fat starts melting as body doesn’t want to store large quantity of fat.
  6. You don’t eat large quantity of food as you start hating unhealthy foods.

– Physiological changes are significantly high as undigested food directly enters from 1st part of the duodenum into mid jejunum and rapidly reaches distal ileum.

– Diversion of the biliopancreatic juices contribute further to these physiological changes.

– Role of food restriction and malabsorption is secondary.

– Same physiological changes are responsible for type 2 diabetes remission.

  1. Insulin resistance is reduced.
  2. Insulin production is optimised to control blood sugars.

– Average excess weight loss is ~ 70 to 80%.

– Some may lose above average, even 100% of the excess weight loss but that number is less.

– For Example – If you are 50 kg excess weight, you lose approximately 35 to 40 kg on average. Some may lose all the extra 50 kg but that number is less.

– Generally if your weight burden is less, you lose more percentage of excess weight and if your weight burden is more you lose less percentage of excess weight.

– Total weight loss percentage is ~ 30 to 35%.

– Average diabetes remission ~ 70 to 80%.

– It is necessary to follow lifestyle modifications to improve weight loss and diabetes remission and to prevent weight regain and diabetes recurrence.

– Results in long lasting weight loss.

– Results in long lasting diabetes remission.

– Physiological changes are relatively high in Sleeve with loop duodenojejunal bypass as longer small intestine is bypassed compared to the standard Gastric sleeve (SG), or Roux en y gastric bypass (RYGB).

– Weight loss is more effective & long lasting after SG LDJB compared to the standard SG, or RYGB.

– Diabetes remission is relatively high & durable after Sleeve with Loop duodenojejunal bypass compared to the standard SG, or RYGB.

– Weight regain  after SG LDJB is low.

– Diabetes recurrence after SG LDJB is low.

– SG LDJB has several advantages compared to RYGB and MGB – OAGB.

  1. There is no ‘at risk’ stomach remnant.
  2. Calcium and iron deficiency risk is low since first part of the duodenum is not bypassed
  3. Risk of dumping syndrome is less because of intact pylorus controlling food out put
  4. There is no risk of marginal ulcers
  5. Risk of internal hernias is low.

– Compared to BPD DS, protein energy malnutrition and malabsorption risk is low because common channel (intestine available for digestion and absorption) is relatively long.

– SG LDJB is technically more advanced, complex and time taking compared to SG, RYGB and MGB – OAGB.

– It needs advanced laparoscopic surgical skills and training.

– There is loss of endoscopic access to biliary tract (Pathway connecting liver and small intestine).

– SG LDJB is less effective compared to Sleeve gastrectomy with loop gastroileal bypass (SG LGIB), SADI S and BPD DS because bypassed small intestine (biliopancreatic limb) is relatively shorter.

– Some may lose below average. Inadequate weight loss ~ 10%. They may lose only 5 to 10 kg and stop losing further.

– Average weight regain ~ 20 to 30%.

– Diabetes recurrence after SG LDJB is ~ 30 to 40%.

– If anyone regains weight or if diabetes recurs after Sleeve with Loop duodenojejunal bypass, revision to Loop duodenal switch or Duodenal switch re-induce significant weight loss and diabetes remission.

– It is very very safe procedure.

– It is a life saving surgery.

– Severe obesity and severe diabetes are dangerous.

– Bariatric and Metabolic surgeries are very safe.

– Complications are very rare. Even if they occur, they can be rectified.

Publication in the Journal of Minimally Invasive Surgery (JMIS) –

Amar Vennapusa, Ramakanth Bhargav Panchangam, Charita Kesara, Nazneen Mallick. Safety and feasibility of laparoscopic sleeve gastrectomy with loop duodenojejunal bypass for obesity. Journal of Minimally Invasive Surgery 2021; 24(1): 10-17. https://doi.org/10.7602/jmis.2021.24.1.10

http://www.e-jmis.org/journal/download_pdf.php?doi=10.7602/jmis.2021.24.1.10

Please download the full text of the article from the above link

 

Publication in Journal of Obesity and Metabolic Syndrome (JOMES) –

Amar Vennapusa, Ramakanth Bhargav Panchangam, Charita Kesara, Tejaswi Chivukula.  Factors Predicting Weight Loss after “Sleeve Gastrectomy with Loop Duodenojejunal Bypass” Surgery for Obesity.  JOMES 2020;29:208-214.  https://doi.org/10.7570/jomes20044

http://www.jomes.org/journal/download_pdf.php?doi=10.7570/jomes20044

Please download the full text article from the above link

 

Publication in the Journal of Metabolic and Bariatric Surgery (JMBS) –

Amar Vennapusa, Ramakanth Bhargav Panchangam, Charita Kesara, Mukharjee Syam Sundar Madivada.  Metabolic Efficacy and Diabetes Remission Predictors Following Sleeve Gastrectomy with Loop Duodenojejunal Bypass Surgery.  J Metab Bariatr Surg 2020;9:33-41.  https://doi.org/10.17476/jmbs.2020.9.2.33

http://www.jmbs.or.kr/journal/download_pdf.php?doi=10.17476/jmbs.2020.9.2.33

Please download the full text of the article from the above link

 

Publication in Journal of Obesity and Metabolic Syndrome (JOMES) –

Amar Vennapusa, Ramakanth Bhargav Panchangam, Charita Kesara, Tejaswi Chivukula.  Response: Factors Predicting Weight Loss after “Sleeve Gastrectomy with Loop Duodenojejunal Bypass” Surgery for Obesity (J Obes Metab Syndr 2020;29:208-14).  JOMES 2020;29:327-329.  https://doi.org/10.7570/jomes20132

https://www.jomes.org/journal/download_pdf.php?doi=10.7570/jomes20132

Please download the full text of the article from the above link

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