Technically it is a modification of biliopancreatic diversion with duodenal switch (BPD DS), with an additional anastomosis between ileum and jejunum. Gastric sleeve is formed using staplers. First part of small intestine (duodenum) is transected. 170 cm segment of distal ileum (last part of small intestine) is isolated and interposed between the divided first part of duodenum and proximal jejunum.
Weight loss and diabetes remission after SG DII are mainly because of hormonal and genetic changes. Role of food restriction or mal-absorption is secondary. After this operation Ghrelin hormone levels come down as fundus of the stomach is removed. GLP 1, Peptide YY hormone levels increase as food directly enters from 1st part of duodenum into interposed distal ileal segment. Food doesn’t enter the remaining duodenum and proximal jejunum. So levels of anti incretin hormones come down. There will be more than 200 hormone changes after surgery. Removal of body of stomach alters several genes involved in energy balance. These hormonal and genetic changes reduce appetite, increase energy expenditure and reset the ‘fat mass’ to a lower level, resulting in weight loss. Same hormonal changes are responsible for type 2 diabetes remission. Ghrelin and anti incretins act against insulin. As levels of these hormones come down, insulin resistance comes down. Since GLP 1 hormone is increased, insulin production increases and insulin resistance comes down. Diversion of biliopancreatic juices also contributes to the metabolic effects of this surgery.
Hormonal and genetic changes responsible for weight loss and diabetes remission are high in SG DII compared to Sleeve gastrectomy (SG) and Roux en y gastric bypass (RYGB). So weight loss and diabetes remission are relatively high. SG DII have several advantages compared to RYGB and Mini gastric bypass – One anastomosis gastric bypass (MGB – OAGB). There is no ‘at risk’ stomach remnant, calcium and iron deficiency risk is low since first 4 cm of duodenum is not bypassed and risk of dumping syndrome is less because of intact pylorus controlling food out put into first part of duodenum and there is no risk of marginal ulcers.
Compared to BPD DS, risk of protein energy malnutrition, malabsorption and vitamin & mineral deficiencies is very low because common channel (intestine available for digestion and absorption) is very long.
It is a very good procedure in individuals suffering from uncontrolled type 2 diabetes but BMI is < 30 kg/m2
SG DII is less effective compared to Sleeve gastrectomy with loop gastroileal bypass (SG LGIB), Single anastomosis duodenoileal bypass with sleeve (SADI S) and BPD DS because bypassed small intestine (biliopancreatic limb) is relatively shorter. It is technically complex and time taking compared to SG, RYGB and MGB – OAGB. It needs advanced laparoscopic surgical skills and training. Another disadvantage is loss of endoscopic access to biliary tract (Pathway connecting liver and small intestine). There will be a risk of internal herniation and intestinal obstruction, but this is very rare as all the gaps in the mesenteric layers are closed carefully.
LAPAROSCOPIC SLEEVE GASTRECTOMY WITH DUODENOILEAL INTERPOSITION – LAP SG DII
(LAPAROSCOPIC DIVERTED SLEEVE GASTRECTOMY WITH ILEAL INTERPOSITION – LAP DSG II) (DRAWN BY Dr. V. AMAR)
PLEASE WATCH LAPAROSCOPIC SLEEVE GASTRECTOMY WITH DUODENOILEAL INTERPOSITION
BY Dr. AMAR (SG DII, HD 1080P, AUDIO)