Technically it is a modification of Sleeve gastrectomy with duodenoileal interposition (SG DII), the difference being duodenum is not transected and ileal segment is interposed into proximal jejunum rather than between duodenum and jejunum. Gastric sleeve is formed using staplers. Proximal jejunum is divided. 170 cm segment of distal ileum is isolated and interposed at the site of jejunal division.
Weight loss and diabetes remission after SG JII are mainly because of hormonal and genetic changes. Role of food restriction or malabsorption 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 rapidly reaches interposed distal ileal segment (last part of small intestine). 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 acts against insulin. As levels of this hormone come down, insulin resistance comes down. Since GLP 1 hormone is increased, insulin production increases and insulin resistance comes down. Unlike in SG DII, anti incretins production is not reduced in this operation as food is not diverted from duodenum.
Hormonal and genetic changes responsible for weight loss and diabetes remission are high in SG JII compared to Sleeve gastrectomy (SG) or Roux en y gastric bypass (RYGB). So weight loss and diabetes remission are relatively high. SG JII have several advantages compared to RYGB and Mini gastric bypass – One anastomosis gastric bypass (OAGB). There is no ‘at risk’ stomach remnant, calcium and iron deficiency risk is low since duodenum is not bypassed and risk of dumping syndrome is less because of intact pylorus controlling food out put into duodenum and there is no risk of marginal ulcers.
Compared to Biliopancreatic diversion with duodenal switch (BPD DS), risk of protein energy malnutrition, malabsorption risk and vitamin & mineral deficiencies is very low because there is no diversion of food. Access to biliary tract is maintained.
It is a good procedure in individuals suffering from uncontrolled type 2 diabetes but BMI is < 30 kg/m2.
SG JII is less effective compared to Sleeve gastrectomy with duodenoileal interposition (SG DII), Sleeve gastrectomy with loop gastroileal bypass (SG LGIB), Single anastomosis duodenoileal bypass with sleeve (SADI S) and BPD DS because there is no intestinal bypass. It is technically complex and time taking compared to SG, RYGB and MGB – OAGB. It needs advanced laparoscopic surgical skills and training. 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 JEJUNOILEAL INTERPOSITION
(Laparoscopic SG JII)
LAPAROSCOPIC SLEEVE GASTRECTOMY WITH ILEAL INTERPOSITION
(Laparoscopic SG II)
(DRAWN BY Dr. V. AMAR)