(SG LGIB) (SASI BYPASS) (SG LB)
SLEEVE GASTRECTOMY WITH LOOP GASTROILEAL BYPASS
SINGLE ANASTOMOSIS SLEEVE ILEAL BYPASS
SLEEVE GASTRECTOMY WITH LOOP BIPARTITION
– 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).
– Difference being duodenum is not divided and anastomosis is gastroileal anastomosis in place of duodenoileal anastomosis.
- Performed by robotic or laparoscopic method (By putting small holes over the tummy) using advanced high quality imported laparoscopic equipment and instruments.
- Up to 80% of the stomach is removed using high quality staplers and stapler guns to form a vertical sleeve.
- When the stomach is divided using staplers, it is stapled in three rows, sealed and cut simultaneously.
- The percentage of the removed stomach is relative but the capacity of the remaining gastric sleeve is 60 to 100 ml.
- Pyloric antrum of gastric sleeve (Last part of the stomach) is opened and attached to the distal ileum (Last part of the small intestine) in a loop fashion (loop gastroileal bypass). 6. Approximately half of the small intestine is bypassed.
– In India and Asia,
- Individuals suffering from severe obesity with the body mass index is ≥ 32.5 kg/m2 with co-morbid medical conditions such as type 2 diabetes.
- Individuals suffering from severe obesity with the body mass index is ≥ 37.5 kg/m2 even without any co-morbid medical conditions.
– In Western countries
- Individuals suffering from severe obesity with the body mass index is ≥ 35 kg/m2 with co-morbid medical conditions such as type 2 diabetes.
- Individuals suffering from severe obesity with the body mass index is ≥ 40 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
- Appetite (Hunger) is reduced.
- Metabolic rate is increased.
- Energy expenditure is increased.
- ‘Fat mass’ is reset to a lower level.
- Fat starts melting as body doesn’t want to store large quantity of fat.
- 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.
– 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.
- Insulin resistance is reduced.
- Insulin production is optimised to control blood sugars.
– Average excess weight loss is ~ 80 to 90%.
– 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 40 to 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.
– Total weight loss percentage is ~ 35 to 40%.
– Average diabetes remission ~ 80 to 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.
– It is technically very simple surgery.
– Access to biliary tract is maintained.
– Physiological changes are relatively high in Sleeve with loop gastroileal bypass as longer small intestine is bypassed 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 duodenojejunal bypass (SG DJB), Sleeve with loop duodenojejunal bypass (SG LDJB), Sleeve with proximal jejunal bypass (SG PJB) or Sleeve with jejunoileal anastomosis (SG JIA).
– Weight loss is more effective & long lasting after SASI Bypass compared to the standard SG, RYGB or MGB, and Sleeve with bypass combination procedures such as SG DJB, SG LDJB, SG PJB or SG JIA.
– Diabetes remission is relatively high & durable after Sleeve with loop bipartition compared to the standard SG, RYGB or MGB – OAGB, and Sleeve with bypass combination procedures such as SG DJB, SG LDJB, SG PJB or SG JIA.
– Weight regain after Sleeve with loop gastroileal bypass is low.
– Diabetes recurrence after SASI Bypass is low.
– SG LGIB has several advantages compared to RYGB and MGB – OAGB.
- There is no ‘at risk’ stomach remnant.
- Calcium and iron deficiency risk is low since duodenum is not bypassed.
- Risk of dumping syndrome is less because natural food pathway is intact.
- Risk of internal hernias is low.
– Compared to BPD DS, 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.
– Protein energy malnutrition, malabsorption, foul smelling oily stools, diarrhea and incontinence are high if the common channel length is 250 cm or less. These problems are significantly reduced but efficacy remains same when common channel is kept minimum of 300 cm and bypassed small intestine of not more than 55%.
– Risk of reflux of ileal contents into gastric sleeve. Long term consequences of this reflux is not known.
– Some may lose below average. Inadequate weight loss ~ 05%. They may lose only 5 to 10 kg and stop losing further.
– Average weight regain ~ 15 to 25%.
– Diabetes recurrence after SASI Bypass is ~ 25 to 35%.
– If anyone regains weight or if diabetes recurs after Sleeve with loop gastroileal 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.