Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India

Laparoscopic Sleeve Gastrectomy plus Duodenojejunal Bypass: Learning Curve Analysis and Technical Feasibility of Duodenojejunostomy Using Linear Stapler

INTRODUCTION

Laparoscopic sleeve gastrectomy plus duodenojejunal bypass (LSG-DJB) has emerged as an alternative bypass surgery. Despite its potential benefits, the technical challenges of the procedure have limited its adoption. This study aims to present the learning curve for LSG-DJB and explore potentially beneficial technical modifications for the standardization of the procedure.

METHODS

The study retrospectively analyzed 100 patients who underwent LSG-DJB as a primary procedure from July 2014 through September 2021. Baseline characteristics, weight loss outcomes, remission of metabolic diseases, and perioperative complications were assessed. The operative time was analyzed across both time trends and anastomosis type subgroups.

RESULTS

At 1-year follow-up after LSG-DJB, the mean %total weight loss and the mean BMI loss were 25.38 ± 8.58% and 9.38 ± 4.25 kg/m2, respectively. Remission rates for type 2 diabetes, hypertension, and dyslipidemia were 72.0% (67/93), 84.1% (37/44), and 70.3% (52/74), respectively. In the analysis of operative time, the learning curve exhibited a plateau after 25 cases. The mean operative time was 136.00 ± 21.64 min in the stapled anastomosis group, and 150.62 ± 25.42 min in the hand-sewn anastomosis group.

CONCLUSION

The learning curve for LSG-DJB plateaued after 25 cases. In the LSG-DJB procedure, stapled duodenojejunal anastomosis is feasible and achieves similar outcomes to the hand-sewn method.

Treatment Options for Poor Responders to Bariatric Surgery

PURPOSE OF REVIEW

This review aims to evaluate the latest evidence on the treatment options for perceived poor responders to bariatric surgery and provide practitioners with a guide on when to consider revisional surgery and when to consider alternatives.

RECENT FINDINGS

The use of adjuvant pharmacotherapy has been increasingly described in the literature as an adjunct to primary bariatric surgery, in order to attain more weight loss or better control of obesity-related complications. The newer anti-obesity and anti-diabetes drugs also have cardiorenal benefits, which are shown in recent cardiovascular outcome trials. Revisional bariatric surgery has emerged as a distinctive entity and can be broadly organized into three categories: corrective, conversion, and reversal surgeries. Careful patient selection and preoperative optimization are needed to ensure long-term favorable outcomes. Newer treatment modalities involving the use of anti-obesity medications and endoscopic bariatric interventions provide patients and healthcare providers with more options, when faced with the challenge of poor response after bariatric surgery.

Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients

BACKGROUND

Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising.

OBJECTIVES

The aim of this study was to look at our intermediate outcomes after LDJB-SG.

SETTING

An academic medical center.

METHODS

A prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications.

RESULTS

A total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m², respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m² at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period.

CONCLUSION

At 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.

[Efficacy of two bariatric surgeries in type 2 diabetic patients with a body mass index of 25-27.5]

OBJECTIVE

To evaluate the therapeutic effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG) in patients with type 2 diabetes mellitus and a low body mass index (BMI) of 25-27.5.

METHODS

Thirty-one type 2 diabetic patients with a BMI of 25-27.5 underwent bariatric surgeries in the General Hospital of Guangzhou Military Command between August, 2013 and August, 2015. The patients receiving LRYGB (17 cases) and SADJB-SG (14 cases) were compared for physical indexes, glucose metabolism and of pancreatic islet function at 1 year after the surgeries.

RESULTS

No mortality occurred in the patients after the operations. At 1 year after the operation, the patients in LRYGB group showed significant improvements in body weight, BMI, glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), oral glucose tolerance test 2 h (OGTT2h), C-peptide, fasting insulin (FINS), and postprandial 2 hour insulin (2 hPINS) (P<0.05); in SADJB-SG group, significant improvements were observed in the body weigh, BMI, HbA1c, FPG, OGTT2h, and FINS after the operation (P<0.05). The postoperative improvements in body weigh, BMI, HbA1c, FPG, OGTT2h, C-peptide, and 2hPINS were comparable between SADJB-SG group and LRYGB group (P>0.05), but the incidence of postoperative anastomotic ulcer was lower in SADJB-SG group.

CONCLUSION

SADJB-SG and LRYGB produce similar therapeutic effects in type 2 diabetic patients with a low BMI, but SADJB-SG is associated with a low incidence of postoperative complications and is therefore more suitable in such patients.

Roux-en-Y Gastric Bypass

Background:

Roux-en-Y gastric bypass (RYGB) is considered the gold standard for gastric bypass, displaying better results for metabolic disorders than other surgical procedures over the long term. The aim of this study was to determine the effects of bariatric surgery, in particular the RYGB technique, on metabolic syndrome (MS) and other biochemical parameters implicit in the comorbid conditions associated with obesity, as well as to explore the influence of this surgical procedure on psychiatric comorbidity in the study population.

Method:

An observational retrospective cohort study based on 146 clinical records of patients having undergone RYGB between January 1, 2011, and January 1, 2014, was performed. Data related to metabolic and psychiatric comorbidity were gathered at three stages: prior to surgery and at 3 and 9 months following surgery.

Results:

There was a progressive and statistically significant reduction of all biochemical parameters analyzed at 3 and 9 months following surgery except high-density lipoprotein cholesterol, which significantly increased (beneficial) in value. These changes imply a remission of >90% for all metabolic disorders and the consequent tendency toward a reduction in prescribed pharmacological treatments, with MS found in only one subject at 9 months. There was, however, no significant reduction in pharmacological treatments for psychiatric comorbidities.

Conclusion:

Findings suggest that RYGB is an effective treatment for MS and other metabolic disorders but not for psychiatric comorbidities accompanying MS.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in the stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to loss of appetite or dietary restriction.

Effect of Sleeve Gastrectomy Plus Side-to-Side Jejunoileal Anastomosis for Type 2 Diabetes Control in an Obese Rat Model

BACKGROUND

Sleeve gastrectomy plus side-to-side jejunoileal anastomosis (JI-SG), a relatively new approach to bariatric surgeries, has shown promising results for treating obesity and metabolic comorbidities. This study investigated the feasibility and safety of JI-SG in weight loss and diabetes remission compared with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

METHODS

Forty 10-week-old male Zucker diabetic fatty rats were randomly assigned to four groups: control, SG, JI-SG, and RYGB. Their body weights, food intake, and levels of gut hormones (ghrelin, insulin, and glucagon-like peptide-1 (GLP-1)) and lipids were measured.

RESULTS

Rats in the SG, JI-SG, and RYGB groups demonstrated lower food intake and more weight loss 2 weeks postoperatively compared with control rats. Furthermore, rats in the JI-SG group achieved more weight loss (mean 242.7 ± 11.2 g) compared with those in the SG and RYGB groups (SG, 401.4 ± 15.1 g and RYGB, 298 ± 12 g, both P < 0.01). All surgery groups demonstrated a decreased fasting insulin, serum glucose, lipid levels, and increased GLP-1 postoperatively. The JI-SG group had lower fasting ghrelin levels than the RYGB group (168 ± 19.8 ng/L vs. 182 ± 16.7 ng/L, P < 0.01) and higher fasting GLP-1 levels than the SG group (1.99 ± 0.11 pmol/L vs. 1.71 ± 0.12 pmol/L, P < 0.01) at 12 weeks postoperatively. Over the experimental period, the ghrelin levels slowly increased in all surgical groups but remained lower than the preoperative and control levels.

CONCLUSIONS

JI-SG induced higher ghrelin and GLP-1 levels and improved glycemic control in Zucker diabetic fatty rats. Compared with SG and RYGB, JI-SG appeared to be a simple, relatively safe, and more effective procedure for treating type 2 diabetes and obesity in this animal model.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to the loss of appetite or dietary restriction.

Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review

BACKGROUND

Bariatric surgery results in remission of type 2 diabetes mellitus in a significant proportion of patients. Animal research has proposed the foregut and hindgut hypotheses as possible mechanisms of remission of T2DM independent of weight loss. These hypotheses have formed the basis of investigational procedures designed to treat T2DM in non-obese (in addition to obese) patients. The aim of this study was to review the procedures that utilise the foregut and hindgut hypotheses to treat T2DM in humans.

METHODS

A systematic review was conducted to identify the investigational procedures performed in humans that are based on the foregut and hindgut hypotheses and then to assess their outcomes.

RESULTS

Twenty-four studies reported novel procedures to treat T2DM in humans; only ten utilised glycated haemoglobin A1c (HbA1c) in their definition of remission. Reported remission rates were 20-40 % for duodenal-jejunal bypass (DJB), 73-93 % for duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG), 62.5-100 % for duodenal-jejunal bypass sleeve (DJBS) and 47-95.7 % for ileal interposition with sleeve gastrectomy (II-SG). When using a predetermined level of HbA1c to define remission, the remission rates were lower (27, 63, 0 and 65 %) for DJB, DJB-SG, DJBS and II-SG.

CONCLUSIONS

The outcomes of the foregut- and hindgut-based procedures are not better than the outcomes of just one of their components, namely sleeve gastrectomy. The complexity of these procedures in addition to their comparable outcomes to a simpler operation questions their utility.

Bariatric Surgery in Women: A Boon Needs Special Care During Pregnancy

Obesity is one of the leading causes of health related disorder and has reached epidemic proportions not only in developed nations but also in developing countries like India. Bariatric surgery has become a popular alternative for obese women planning pregnancy. A multidisciplinary approach involving the obstetrician, the bariatric surgeon and the nutritionist is required to manage pregnancy following bariatric surgery. Early consultation should be done to determine baseline nutritional status and the importance of regular check-ups must be explained. Nutritional supplementation should be tailored to the patient's status and the type of bariatric surgery performed.

Effect of Modified Roux-en-Y Gastric Bypass Surgery on GLP-1, GIP in Patients with Type 2 Diabetes Mellitus

The type 2 diabetes mellitus (T2DM) is one of the most serious diseases that threaten public health. Modified gastric bypass surgery has been applied to the treatment of T2DM patients in the 1990s, but the therapeutic mechanism to this function is still unclear. The aim of this study was to further clarify the effect and the mechanism of modified gastric bypass surgery on glucose metabolism in patients with T2DM. In the study, the incretin indexes and blood glucose indexes were analyzed before surgery and 1 week and 1, 3, and 6 months after surgery. The results suggested that modified Roux-en-Y gastric bypass can promote GLP-1 secretion in patients with T2DM, while reducing the secretion of GIP. Thus it could effectively control blood glucose of patients with T2DM.

Recent advances in bariatric/metabolic surgery: appraisal of clinical evidence

Obesity and associated type 2 diabetes mellitus (T2DM) are becoming a serious medical issue worldwide. Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients. Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2DM patients. The review of recent developments in bariatric/metabolic surgery covers 4 major fields. 1) Improvement of safety: recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago. The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now. 2) New bariatric/metabolic surgery: laparoscopic sleeve gastrectomy (LSG) is becoming the leading bariatric surgery because of its simplicity and efficacy. Other new procedures, such as gastric plication, banded plication, single anastomosis (mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery. 3) Mechanism of bariatric/metabolic surgery: Restriction is the most important mechanism for bariatric surgery. Weight regain after bariatric surgery is usually associated with loss of restriction. Recent studies demonstrated that gut hormone, microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2DM remission. However, weight loss is still the cornerstone of T2DM remission after metabolic surgery. 4) PATIENT SELECTION: patients who may benefit most from bariatric surgery was found to be patients with insulin resistance. For Asian T2DM patients, the indication of metabolic surgery has been set to those with not well controlled (HbA1c > 7.5%) disease and with their BMI > 27.5 Kg/m(2). A novel diabetes surgical score, ABCD score, is a simple system for predicting the success of surgical therapy for T2DM.

Comparison of different gastric bypass procedures in gastric carcinoma patients with type 2 diabetes mellitus

AIM: To determine the effect of different Roux-en-Y gastric bypass procedures in gastric carcinoma patients with type 2 diabetes mellitus.

METHODS: A retrospective analysis of the clinical data of 54 patients with gastric cancer and type 2 diabetes mellitus treated in the Department of General Surgery from January 2006 to June 2013 was conducted. The patients underwent gastrectomy using different Roux-en-Y gastric bypass procedures (traditional, n = 26; modified, n = 28). Fasting plasma glucose (FPG), two hour postprandial blood glucose (2 h PBG) and hemoglobin A1c (HbA1c) were analyzed before surgery (0 mo) and 1, 3 and 6 mo after surgery.

RESULTS: FPG and 2 h PBG levels were significantly decreased 1 mo after surgery in the traditional Roux-en-Y gastric bypass group (FPG 7.5 ± 1.3 vs 10.7 ± 1.2, P < 0.05) (2 h PBG 10.2 ± 1.8 vs 13.8 ± 3.2, P < 0.05). FPG and 2 h PBG levels were significantly decreased after surgery in the modified Roux-en-Y gastric bypass group (FPG 6.9 ± 1.2 vs 10.5 ± 1.1, 6.5 ± 1.3 vs 10.5 ± 1.1, 6.4 ± 1.2 vs 10.5 ± 1.1, P < 0.05) (2 h PBG 9.9 ± 2.2 vs 14.1 ± 2.9, 9.2 ± 2.4 vs 14.1 ± 2.9, 8.9 ± 2.6 vs 14.1 ± 2.9, P < 0.05). Compared with the levels before surgery, HbA1c levels were significantly decreased 3 and 6 mo after surgery (7.2 ± 1.1 vs 10.5 ± 1.1, 5.5 ± 1.1 vs 10.5 ± 1.1, P < 0.05). Significant differences between the two groups regarding FPG, 2 h PBG and HbA1c concentration were observed 3 and 6 mo after surgery (FPG 10.1 ± 1.5 vs 6.5 ± 1.3, 10.3 ± 1.4 vs 6.4 ± 1.2, P < 0.05) (2 h PBG 13.1 ± 2.8 vs 9.2 ± 2.4, 13.6 ± 3.1 vs 8.9 ± 2.6, P < 0.05) (HbA1c 10.1 ± 1.4 vs 7.2 ± 1.1, 10.5 ± 1.3 vs 5.5 ± 1.1, P < 0.05).

CONCLUSION: Modified Roux-en-Y gastric bypass can improve glucose metabolism in type 2 diabetic patients with gastric cancer.

Duodenal-jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG).

OBJECTIVES

The aim of this study was to compare one-year results between DJB-SG and SG.

SETTING

University hospital.

METHODS

A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months.

RESULTS

The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups.

CONCLUSIONS

In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Efficacy of metabolic surgery on HbA1c decrease in type 2 diabetes mellitus patients with BMI <35 kg/m2--a review

High glycated hemoglobin A1c (HbA1c) is strongly correlated with developing type 2 diabetes mellitus (T2DM) complications; this study reviews the efficacy of various types of metabolic surgeries in reducing HbA1c levels in type 2 diabetics with BMI <35 kg/m(2). An electronic search of MEDLINE databases using terms 'metabolic surgery', type 2 diabetes mellitus, BMI <35 kg/m(2), and related keywords for studies published between 1987 and 2013. Data from 53 articles with 2,258 patients were selected for this review. The weighted mean change in HbA1c was -2.8 % (95 % CI -2.8 to -2.7, p < 0.01) and weighted mean BMI change was -5.5 kg/m(2) (95 % CI -5.6 to -5.4, p < 0.01). There was a strong correlation between weighted percentage mean change in HbA1c and BMI. Adjustable gastric banding and duodenal jejunal bypass were inferior to other surgeries in reducing BMI and HbA1c in BMI <35 kg/m(2). Metabolic surgery significantly decreases HbA1c in T2DM patients with BMI <35 kg/m(2) and that the magnitude of HbA1c change may be a useful surrogate of DM control.

Laparoscopic sleeve gastrectomy with loop bipartition: A novel metabolic operation in treating obese type II diabetes mellitus

INTRODUCTION

We report the first case of laparoscopic sleeve gastrectomy with loop bipartition (a modified form of Santoro's operation) in the treatment of type II diabetes mellitus associated with obesity.

PRESENTATION OF CASE

A 46-year-old gentleman (baseline BMI 32.9; BW 98.5kg) with 7-year history of type II diabetes mellitus (DM) underwent the procedure in Hong Kong. The control of DM was poor even with intensive medical therapy before the operation. Standard laparoscopic sleeve gastrectomy (SG) was performed and a loop gastroileostomy was fashioned at the antrum 250cm from the ilececal valve without division of the 1st part of duodenum after SG. The resultant gastric tube has two outlets, one to the first part of duodenum and the other to the ileum with preferential passage of food through the gastroileostomy as shown on subsequent contrast study. The patient's recovery was uneventful. The excess BMI loss was 97% with complete normalization of all metabolic parameters at 1-year follow-up.

DISCUSSION

This new surgical procedure (sleeve gastrectomy with loop bipartition: SG+LB) was evolved and derived from the combined concepts of sleeve gastrectomy with transit bipartition (SG+TB), single anastomosis duodenal-ileostomy (SADI), mini-gastric bypass (MGB) and duodenal-jejunal bypass (DJB) with less nutritional and surgical complications.

CONCLUSION

Sleeve gastrectomy with loop bipartition may be a very effective and simple operation to treat uncontrolled DM associated with obesity with a lot of apparent advantages over most current metabolic procedures available at the moment.

Bariatric procedures: an update on techniques, outcomes and complications

PURPOSE OF REVIEW

Obesity is a rising epidemic, and it is projected that over 700 million people will be obese by 2015. As the number of people with morbid obesity rises, so will the number of bariatric procedures performed. The goal of this article is to review current surgical and endoscopic options for weight loss in morbidly obese patients including their efficacy and complications.

RECENT FINDINGS

New bariatric surgical techniques have been developed with the goals of maximizing weight loss and metabolic outcomes, while minimizing complications. In addition, there is a role for therapeutic endoscopy in treating obesity as well as managing bariatric surgical complications. As the metabolic effects of bariatric surgery are better elucidated, bariatric surgeries may provide a role in treatment of metabolic syndrome in mildly obese individuals. For those with insufficient weight loss, revisional bariatric surgeries have been performed with varying success.

SUMMARY

Bariatric surgery is an effective treatment for obesity and its comorbidities. Several bariatric surgeries are available, and a multidisciplinary approach is recommended for choosing the best procedure for the appropriate candidate, along with providing long-term follow-up care to maximize outcome.