SLEEVE GASTRECTOMY WITH LOOP DUODENOJEJUNAL BYPASS (SG LDJB)

SG LDJB
Technically 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) but 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 anastomosed (attached) to mid jejunum (Middle part of small intestine) in a loop fashion 200 to 250 cm distal to duodenojejunal junction (loop duodenojejunal anastomosis). 

Weight loss after SG LDJB is 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 directly enters from 1st part of duodenum into mid jejunum and rapidly reaches distal ileum. Food doesn’t enter the remaining duodenum and proximal 200 – 250 cm of 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 long lasting and effective weight loss. Same hormonal changes are responsible for long lasting 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. Significant diversion of biliopancreatic juices also contributes to the metabolic effects of this surgery.
Hormonal and genetic changes responsible for long lasting weight loss and durable diabetes remission are very high in SG LDJB compared to Sleeve gastrectomy (SG), Roux en y gastric bypass (RYGB) or Mini gastric bypass – One anastomosis gastric bypass (MGB – OAGB) because bypassed bowel is relatively longer compared to these procedures. So weight loss is more effective & long lasting and diabetes remission is more & durable. Chances of weight regain and diabetes recurrence are low. SG LDJB have several advantages compared to RYGB and 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, there is no risk of marginal ulcers and risk of internal hernias is low.

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 LDJB is less effective compared to SADI S, Sleeve gastrectomy with loop gastroileal bypass (SG LGIB) 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 LOOP DUODENOJEJUNAL BYPASS

 (LAPAROSCOPIC SG LDJB)  

(DRAWN BY Dr. V. AMAR)


SURGERY VIDEO:

PLEASE WATCH LAPAROSCOPIC SLEEVE GASTRECTOMY WITH LOOP DUODENOJEJUNAL BYPASS 

BY Dr. AMAR (SG LDJB, HD 1080P, AUDIO)

https://youtu.be/XshvMjD3R-E

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