Gastric sleeve is formed using staplers. Proximal jejunum (First part of small intestine) is anastomosed to distal ileum (Last part of small intestine) 250 – 300 cm proximal to ileocecal junction (Junction of small and large intestine). Practically a short cut is created between proximal jejunum and distal ileum.
Weight loss and diabetes remission after SG JIA 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 distal ileum from proximal jejunum. 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. Anti incretin hormones 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 JIA compared to Sleeve gastrectomy (SG) or Roux en y gastric bypass (RYGB). So weight loss and diabetes remission are relatively high. SG JIA 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 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 and vitamin & mineral deficiencies is very low because duodenum and proximal jejunum are not diverted. It is technically simple operation. Access to biliary tract is maintained.
SG JIA 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 duodenum and proximal jejunum are not bypassed. 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 ANASTOMOSIS
(LAPAROSCOPIC SG JIA)
(DRAWN BY Dr. V. AMAR)