Laparoscopic Sleeve Gastrectomy with Duodenal Transit Bipartition is a modification of Single Anastomosis Duodenoileal Bypass with Sleeve (SADI S, Sleeve with Loop Duodenal Switch) without exclusion of proximal small intestine. It is one of the most effective Sleeve with Diversion Surgery.

• 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 Single anastomosis duodenoileal bypass with sleeve (SADI S) without duodenal division.

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. 1st part of the Duodenum (First part of the small intestine) is opened and anastomosed (joined) to the distal ileum (Last part of the small intestine) in a loop fashion (loop duodenoileal anastomosis). Anastomosis can be performed by hand sewn (sutured) method or stapled method. 6. Small intestine before anastomosis (From ‘Duodenojejunal Flexure [Junction of Duodenum and Jejunum] to the Anastomosis) is known as ‘Afferent Limb’ and after anastomosis (From the anastomosis to the Ileocecal Junction [Junction of Small and Large Intestine]) is known as ‘Efferent Limb’ (From the anastomosis to Ileocecal Junction – Junction of Small and Large Intestine)

7. Efferent Limb length is generally kept at 250 to 350 cm. But I perform fixed percentage bipartition (50% in majority) and keep longer efferent limb in order to minimise malabsorption without compromising on the efficacy. Anastomosis is midway between duodenojejunal flexure and ileocecal junction – 50:50 bipartition.

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.

It is a type of transit bipartition bariatric & metabolic surgery, where hormonal and physiological changes required for long lasting significant weight loss and long term diabetes remission are achieved without the need to exclude any part of small intestine.

– 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 the distal ileum. Undigested food enters ileum through loop duodenoileal anastomosis, reaching distal ileum rapidly, leading to maximal incretin response. In addition to this, bile juice can reach distal ileum directly across anastomosis leading to maximum incretin response.

• Partial 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 > 90%.

– Some may lose above average, even 100% of the excess weight loss.

– For Example – If you are 50 kg excess weight, you lose approximately > 45 kg on average. Some may lose all the extra 50 kg.

– 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.

– Average Total weight loss percentage  > 40%.

– Average diabetes remission is > 90%.

– 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 and significant weight loss.

– Results in long lasting and effective diabetes remission.

– Physiological changes are very high in Sleeve with duodenal bipartition compared to the standard Gastric sleeve (SG), Roux en y gastric bypass (RYGB) or mini gastric bypass – one anastomosis gastric bypass (MGB – OAGB), and Sleeve with bypass combination procedures such as Sleeve with loop duodenojejunal bypass (SG LDJB) or Sleeve with proximal jejunal bypass (SG PJB), Sleeve with jejunoileal bipartition (SG JIB), Single Anastomosis Sleeve Jejunal Bypass (SASJ Bypass) or Single Anastomosis Sleeve Ileal Bypass (SASI Bypass).

– Weight loss is more effective & long lasting after Duodenal Bipartition compared to the standard SG, RYGB or MGB, and Sleeve with bypass combination procedures such as SG LDJB, SG PJB, SG JIB, SASJ or SASI Bypass. Results are similar to those after SADI S.

– Diabetes remission is significantly high & durable after Sleeve with duodenal bipartition compared to the standard SG, RYGB or MGB – OAGB, and Sleeve with bypass combination procedures such as SG LDJB, SG PJB, SG JIB, SASJ Bypass or SASI Bypass. Results are similar to those after SADI S.

– Average weight regain  after Sleeve with duodenal bipartition is very low (< 5%).

– Average diabetes recurrence after Sleeve with duodenal bipartition is very low (< 5%).

– Duodenal bipartition 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 duodenum is not completely bypassed

3. Risk of dumping syndrome is less because of intact pylorus controlling food out put

4. Risk of internal hernias is low.

5. Access to biliary tract is maintained.

6. Maintaining natural pathway allows endoscopic access to biliary system and reduces risk of malnutrition.

7. Anastomosis is post pyloric, so risk of marginal ulcers and bile pooling in the stomach is significantly less.

– Compared to BPD DS, and SADI S, risk of protein energy malnutrition, malabsorption and vitamin & mineral deficiencies is low because, it is partial bypass and part of the food enters natural duodenojejunal pathway leading to sufficient absorption of essential nutrients, vitamins and minerals. This surgery reduces malnutrition significantly while maintaining efficacy.

– Duodenal bipartition is technically more advanced, compleex and time taking compared to SG, RYGB and MGB – OAGB.

– It needs advanced laparoscopic surgical skills and training.

– Protein energy malnutrition, malabsorption, foul smelling oily stools, diarrhea and incontinence are high if the efferent limb length is 250 cm or less. These problems are significantly reduced but efficacy remains same when efferent limb is kept minimum of 300 cm and afferent limb of small intestine of not more than 50 – 55%.

– Some may lose below average. Inadequate weight loss < 1%. They may lose only 5 to 10 kg and stop losing further.

– 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.