Technically it is a modification of biliopancreatic diversion with duodenal switch (BPD DS), with a more proximal anastomosis (duodenojejunal anastomosis in place of duodenoileal anastomosis). Gastric sleeve is formed using staplers. First part of small intestine (duodenum) is disconnected and attached to mid jejunum (Middle part of small intestine) in a Roux en y fashion.
Weight loss and diabetes remission after SG DJB 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 mid jejunum and rapidly reaches distal ileum (last part of small intestine). 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 DJB compared to Sleeve gastrectomy (SG) or Roux en y gastric bypass (RYGB). So weight loss and diabetes remission are relatively high. SG DJB 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.
SG DJB is less effective compared to Sleeve gastrectomy with loop duodenojejunal bypass (SG LDJB), 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)
LAPAROSCOPIC SLEEVE GASTRECTOMY WITH DUODENOJEJUNAL BYPASS
(LAPAROSCOPIC SG DJB)
(DRAWN BY Dr. V. AMAR)