Dr. Jaydeep Palep
For Appointments: +91-90223 59776, +91-22- 35685303
Sleeve Gastrectomy with DuodenoJejunal Bypass, also popularly known as the Sleeve + D-J bypass, is very successful (70-80% excess weight loss) as a primary weight loss surgery, especially in Type II Diabetes Mellitus. It can be used on patients who have failed previous weight loss surgeries, sweet eaters, and patients with heartburn.
The Sleeve Gastrectomy with DuodenoJejunal Bypass is also a restrictive and malabsorptive procedure (like the Roux-en-Y Gastric Bypass and Mini Gastric Bypass) that not only reduces food intake, but also reduces the absorption of nutrients from the food. Absorption of nutrients is limited because a part of the upper small intestine is bypassed and not used for digestion.
Sleeve Gastrectomy with DuodenoJejunal Bypass is a surgical procedure that can be performed by a minimally invasive surgical method. Usually 4-5 small cuts of 0.5 – 1 cm are made on the abdomen. The Sleeve + D-J Bypass is then performed Laparoscopically or Robotically, using highly advanced technology to make it safe. In the first step of a Sleeve + D-J Bypass, a Sleeve Gastrectomy is performed. The volume of the stomach sleeve is between 80-100 ml. The first part of the small intestine is then disconnected just below the stomach and the small intestine is then joint in continuity to this cut portion without disconnecting it (unlike in Roux-en-Y Gastric Bypass). Unlike the Roux-en-Y Gastric Bypass, only 1 joint is made in the body. Technically, Sleeve + D-J Bypass is a more complex procedure to perform when compared with the Roux-en-Y Gastric Bypass or Mini Bypass.
In a Sleeve + D-J Bypass, the amount of food you can eat in one sitting is reduced because of the small stomach capacity. Because of this, the brain utilises the fat stored in your body for its energy needs. This burns the excess fat in your body, thus helping you lose weight. The malabsorptive effect because of the bypass of the small intestine in this weight loss surgery is very strong. It leads to markedly reduced absorption of fats from your intestine. This contributes greatly to the weight loss effect. Also, in a Sleeve + D-J Bypass, the production of the hunger hormone Ghrelin is reduced, since the fundus of the stomach is excluded. Because of this, you do not feel hungry all the time, and are satisfied with the small amount of food you eat without feeling tired or weak.
Of all weight loss surgeries, Sleeve + D-J Bypass is the one associated most strongly with complete reversal of Type II Diabetes Mellitus in 90-95% of patients for 10-15 years (along with the Mini Bypass). This means, that almost 95% of patients who were diabetic can STOP all medications (including insulin) for Diabetes after undergoing a Sleeve + D-J Bypass just like the Mini bypass. This occurs due to beneficial effect of the bypass of the small intestine that causes major changes in the hormonal axis of the body for better control of blood sugar levels. In addition, after a Sleeve + D-J Bypass, marked improvement is seen in many other medical problems which are caused due to obesity, such as hypertension, sleep apnea, Hypothyroidism, Osteoarthritis, PCOS, etc. (similar to those seen in other weight loss surgeries). A reduction in body weight is the key mechanism behind this improvement.
Anybody with a BMI of > 37.5 kg/m2 (Asian population) or >32 kg/m2 with medical diseases can undergo a Sleeve + D-J Bypass. It is very beneficial in: • Super obese (BMI > 50 kg/m2) • Patients with Diabetes Mellitus, Hypertension and other obesity – related diseases • Vegetarians • Previously failed weight loss surgery. In certain low BMI (27.5 – 32 kg/m2) patients with uncontrolled Type II Diabetes Mellitus, this surgery can be very benficial in reversal of Type II Diabetes Mellitus. However, these patients need to be carefully selected.
The amount of weight loss you achieve differs with every weight loss procedure. Typically, in medical literature, it has been reported that patients lose upto 80% of their excess body weight after a Sleeve + D-J Bypass just like a Mini Bypass. This is adequate to maintain a healthy lifestyle without any medical diseases. However, patients who stick to a regular exercise pattern post weight loss surgery may achieve even greater amounts of weight loss.
Weight loss after any weight loss procedure is a gradual process. It starts within the first week of surgery, and continues for upto 10-12 months post weight loss surgery. By this point, most of your excess weight is lost, and you become fitter and healthier.
This is a rare possibility after Sleeve + D-J Bypass, since the malabsorptive effect of the surgery is very strong and persists for a long time after the surgery. In these rare cases, if the malabsorptive effect is too strong, excessive weight may be lost and partial surgical reversal of the procedure is required.
Rarely we may get a patient with nutritional deficiencies post Sleeve + D-J Bypass unlike the Roux-en-Y Gastric Bypass or Mini Bypass. All our patients are given regular multivitamin and multi mineral supplements soon after surgery. These supplements may have to be taken life long, since the malabsorptive effect of the weight loss surgery persists for life.
No, a Sleeve + D-J Bypass is not a fully reversible procedure. The small intestinal joint has to be disconnected and a new joint created between the small intestine and stomach without the bypass effect. This second surgery can again be performed by minimally invasive techniques (laparoscopically or robotically) to create a near normal architecture. It is a very complex surgery requiring a high degree of surgical skill and intensive post-operative care.
The chances of you regaining weight after a Sleeve + D-J Bypass are much lower than with a Sleeve Gastrectomy or a Roux-en-Y Gastric Bypass. However, maintenance of a healthy lifestyle is of the utmost importance after any type of weight loss surgery. Having good control over your diet, i.e. eating protein rich food, and exercising regularly will help ensure that you do not regain weight after the surgery. Outcome depends on long-term adherence to diet and lifestyle changes and requires frequent monitoring and adjustments to achieve ultimate weight loss.
The chances of you regaining weight after a Sleeve + D-J Bypass are much lower than with a Sleeve Gastrectomy or a Roux-en-Y Gastric Bypass. However, maintenance of a healthy lifestyle is of the utmost importance after any type of weight loss surgery. Having good control over your diet, i.e. eating protein rich food, and exercising regularly will help ensure that you do not regain weight after the surgery. Outcome depends on long-term adherence to diet and lifestyle changes and requires frequent monitoring and adjustments to achieve ultimate weight loss.
very successful (upto 80% of excess weight loss) as a primary weight loss procedure especially in type II DM
excellent reversal of Type II Diabetes Mellitus
operation for patients who failed restrictive procedures like balloon, banding and sleeve gastrectomies
Conventional upper gastroscopy of duodenum is not possible
Life long supplementation of vitamins and minerals may usually be required
Any surgery performed on the stomach or intestines has certain risks. Some of the possible dreaded complications of Sleeve + D-J Bypass are:
1. Staple line leak/ Anastomotic leak – this usually occurs along the staple line or at the joint between the duodenum and jejunum (both parts of the small intestine) in Sleeve + D-J Bypass. It may occur due to poor blood supply to the new joint. In most cases, this leads to a localized area of fluid collection, which can be managed with antibiotics. In certain cases, a second surgery maybe needed to drain the fluid leaking from the joint. In either case, it prolongs the hospital stay. Fortunately, the incidence of a leak is 1 in a 1000 patients, making it rare. We ALWAYS test for a mechanical fault in the staple line by doing a Methylene Blue dye test on the operating table, so that a defect, if any, can be repaired immediately.
2. Deep Vein Thrombosis – This is a complication that can occur in any morbidly obese patient irrespective of whether they undergo a surgery or not. In this condition, blood in the deep veins of your calves can form clots. These clots may then dislodge from the veins, reaching the lungs and leading to Pulmonary embolism, which if not treated quickly may be fatal. It is treated by giving injectable anticoagulant medications (blood thinners) to the patient. The incidence of DVT is also rare, being seen in 1 patient out of a 1000. We ALWAYS give preventive injectable anticoagulants to the patient for 28 days after a Sleeve + D-J Bypass. In addition, if the patient is well mobilized and is walking daily as advised after the surgery, the chances of DVT are very remote.
3. Bleeding – This is again a complication that can occur with any surgery in any patient. All possible sites of bleeding are checked at the end of surgery, and it is ensured that bleeding does not occur in the post-operative period.
4. Dumping syndrome – Dumping is very rare and if at all occurs a few weeks after Sleeve + D-J Bypass, due to poor food choices. It is related to the ingestion of refined sugars, high glycemic carbohydrates, dairy products, some fats, and fried foods. These foods rapidly empty from the gastric pouch into the small intestine, which triggers a cascade of gastrointestinal changes. This should be discussed in detail with your surgeon. It can usually be managed with good dietary habits.
DR JAYDEEP H. PALEP
MS, FIAGES, FALS
Fellow Robotic & Laparoscopic GI Surgeon (Italy)
Consultant Bariatric & GI Surgeon
(Robotic & Laparoscopic)
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