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Single-Anastomosis Sleeve Jejunal Bypass, a Novel Bariatric Surgery, Versus Other Familiar Methods: Results of a 6-Month Follow-up—a Comparative Study

DOI:10.1007/s11695-019-04266-9
Authors:
Masoud Sayadishahraki at Isfahan University of Medical Sciences
Masoud Sayadishahraki
Mohammad Taghi Rezaei
Mohammad Taghi Rezaei
Mohammad Taghi Rezaei
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Mohsen Mahmoudieh at Isfahan University of Medical Sciences
Mohsen Mahmoudieh
Behrouz Keleydari
Behrouz Keleydari
Behrouz Keleydari
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Abstract and Figures

Background: Obesity and its associated morbidities have become a significant concern all over the world. Bariatric surgery, regardless of its type, is the most effective approach for treating morbid obesity. Single-anastomosis sleeve jejunal (SASJ) bypass is a novel bariatric surgery technique and can be considered for patients with former background of severe gastroesophageal symptoms. The purpose of this research was to compare SASJ bypass outcomes with other techniques during a 6-month follow-up. Methods: This is a non-randomized clinical trial conducted on 100 patients, who underwent four types of bariatric surgery (classic Roux-en-Y bypass, SASJ bypass, omega gastric bypass, and sleeve gastrectomy), and each one of these types contained 25 cases, during the time period of 2 years from 2016 to 2018. Patients' information including age, gender, height, basal weight, body mass index (BMI), serum albumin, and hemoglobin A1C were recorded, within 1, 3, and 6 months after their surgery, and also were compared with each other. Results: Members of the four groups were similar due to their age, gender distribution, height, baseline BMI, hemoglobin A1C, albumin, and also excess weight (P value > 0.05); however, the sleeve gastrectomy group baseline weight was significantly higher compared with the other three groups (P value = 0.013). All of the groups significantly lost weight during this 6-month period, but the comparison between them indicated no statistical difference regarding excess weight loss, BMI, hemoglobin A1C, and albumin (P value > 0.05). The excess weight loss mean during 6 months in SASJ bypass was 34.2 ± 5.4%, which was comparable with other groups. Conclusions: The weight loss trend after the SASJ bypass was similar to that of older techniques; consequently this technique can be considered for cases with particular indications due to the reversibility and also more accessible gastric follow-up studies in the SASJ approach. Further researches with longer follow-ups are strongly recommended.
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NEW CONCEPT
Single-Anastomosis Sleeve Jejunal Bypass, a Novel Bariatric Surgery,
Versus Other Familiar Methods: Results of a 6-Month Follow-up—a
Comparative Study
Masoud Sayadishahraki
1
&Mohammad Taghi Rezaei
1
&Mohsen Mahmoudieh
1
&Behrouz Keleydari
1
&
Shahab Shahabi
1
&Mostafa Allami
1
Published online: 25 November 2019
#Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Background Obesity and its associated morbidities have become a significant concern all over the world. Bariatric surgery,
regardless of its type, is the most effective approach for treating morbid obesity. Single-anastomosis sleeve jejunal (SASJ) bypass
is a novel bariatric surgery technique and can be considered for patients with former background of severe gastroesophageal
symptoms. The purpose of this research was to compare SASJ bypass outcomes with other techniques during a 6-month follow-
up.
Methods This is a non-randomized clinical trial conducted on 100 patients, who underwent four types of bariatric surgery (classic
Roux-en-Y bypass, SASJbypass, omega gastric bypass, and sleeve gastrectomy), and each one of these types contained 25 cases,
during the time period of 2 years from 2016 to 2018. Patients’information including age, gender, height, basal weight, body mass
index (BMI), serum albumin, and hemoglobin A1C were recorded, within 1, 3, and 6 months after their surgery, and also were
compared with each other.
Results Members of the four groups were similar due to their age, gender distribution, height, baseline BMI, hemoglobin A1C,
albumin, and also excess weight (Pvalue > 0.05); however, the sleeve gastrectomy group baseline weight was significantly
higher compared with the other three groups (Pvalue = 0.013). All of the groups significantly lost weight during this 6-month
period, but the comparison between them indicated no statistical difference regarding excess weight loss, BMI, hemoglobin A1C,
and albumin (Pvalue > 0.05). The excess weight loss mean during 6 months in SASJ bypass was 34.2 ± 5.4%, which was
comparable with other groups.
Conclusions The weight loss trend after the SASJ bypass was similar to that of older techniques; consequently this technique can
be considered for cases with particular indications due to the reversibility and also more accessible gastric follow-up studies in the
SASJ approach. Further researches with longer follow-ups are strongly recommended.
Keywords Bariatric surgery .Metabolic surgery .Jejunal bypass .Body mass index
Introduction
Nowadays, obesity and metabolic disorders have been turned
to a major concern all over the world. Technology progres-
sion, urbanization, and lifestyle change have resulted in peo-
ple’s tendency for fast food consumption, less physical activ-
ity, and also a sedentary lifestyle; therefore, obesity frequency
is progressing dramatically, and age of metabolic disorder
onset has decreased in both developing and developed coun-
tries [1]. Obesity leads to metabolic disorders like hyperlipid-
emia, type 2 diabetes mellitus, hypertension, cardiovascular
disease–increased risk, musculoskeletal disorders, and various
types of malignancies [2].
Nowadays, bariatric surgery is the best approach in order to
treat morbid obesity. Bariatric surgery, regardless of its type,
leads to dramatic weight loss and metabolic improvement in
comparison with those medical treatments used for weight
loss management [3,4].
Bariatric surgery techniques are developing, and factors
like surgeons’expectancy, surgical technique complications,
*Mohammad Taghi Rezaei
Rezaei.mohammadtaghi@gmail.com
1
Isfahan University of Medical Sciences, Isfahan 8174675731, Iran
Obesity Surgery (2020) 30:769–776
https://doi.org/10.1007/s11695-019-04266-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... An example of anastomosis between two parts of the intestine besides SG is between the duodenum and ileum, which is called the single anastomosis duodenal-Ileal approach (SADI) [6]. Recently, surgeons used more developed techniques with single anastomosis between the sleeve and ileum, which is called SASI [7], or between the sleeve and jejunum, which is called SASJ [8]. ...
... SASI bypass has several superiorities based on the previous study by Mahdi et al. [7]; in addition, SASJ and SASI unlike SADI are easily reversible techniques [6,8]. However, SASJ is a kind of modification to SASI with a shorter biliopancreatic limb length; therefore, it seems SASJ has a lower risk of nutrient deficiency [8,9]. ...
... SASI bypass has several superiorities based on the previous study by Mahdi et al. [7]; in addition, SASJ and SASI unlike SADI are easily reversible techniques [6,8]. However, SASJ is a kind of modification to SASI with a shorter biliopancreatic limb length; therefore, it seems SASJ has a lower risk of nutrient deficiency [8,9]. The longer common limb length compared to SASI may avoid long-term nutritional complications; therefore, SASJ is safer theoretically than SASI in patients with extreme weight loss and baseline nutritional deficiencies and simpler due to its surgical steps. ...
Single-anastomosis Sleeve Jejunal: a Mid-term Follow-up Report of a New Surgical Technique
Article
Full-text available
Introduction Single anastomosis sleeve ileal bypass (SASI) is a combined bariatric metabolic technique, in which few studies have shown its outcomes efficacy. However, this technique has a high risk of malnutrition due to long biliopancreatic limb. Single anastomosis sleeve jejunal bypass (SASJ) has a shorter limb. Therefore, it seems to have a lower risk of nutrient deficiency. Furthermore, this technique is relatively new, and little is known about the efficacy and safety of SASJ. We aim to report our mid-term follow-up of SASJ from a high-volume center for bariatric metabolic surgery in the Middle East region. Methods For the current study, the 18-month follow-up data of 43 patients with severe obesity who underwent SASJ was collected. The primary outcome measures were demographic data, weight change variables according to ideal body mass index (BMI) of 25 kg/m² at 6, 12, and 18 months, laboratory assessments, remission of obesity-associated medical problems, and other potential bariatric metabolic complications after the surgery. Results No patient was lost due to follow-up. After 18 months, patients lost 43.4 ± 11 kg of their weight and 68 ± 14% of their excess weight, and their BMI decreased from 44.9 ± 4.7 to 28.6 ± 3.8 kg/m² (p < 0.001). The percentage of total weight loss till 18 months was 36.3%. The T2D remission rate at 18 months was 100%. Patients neither faced deficiency in significant markers for nutrition state nor represented major bariatric metabolic surgery complications. Conclusion SASJ bypass achieved satisfactory weight loss and remissions in obesity-associated medical problems within 18 months after surgery without major complications and malnutrition. Graphical Abstract
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... Single anastomosis sleeve jejunal (SASJ) bypass is a modification of SASI using a shorter biliopancreatic limb length compared to SASI to prevent long-term nutritional complications. Primary investigations presented acceptable excess weight loss and also associated medical problems rehabilitation [7,8]. The SASJ bypass appears to be safer than the SASI procedure in patients with excessive weight loss and nutritional deficiencies and is simpler due to its improved surgical ergonomics [9]. ...
... In this study, the %EWL of SASJ patients was approximately 76%, which was lower than the %EWL after SASI (87%) at 1-year follow-up. Currently, Sayadishahraki et al. [7] have reported %EWL of 64% for SASJ, which was not significantly different from Roux-en-Y gastric bypass (RYGB), SG, and omega procedure. In other words, patients under SASJ bypass bariatric surgery showed significant excess weight loss during the 12 months after their surgical procedure, which means SASJ was as successful as other procedures that were more common. ...
... The previous studies reported an 84-100% rate of diabetic remission or improvement after 1-year post-surgery for SASI bypass [11][12][13]16] and 100% for SASJ bypass [8]. Moreover, Sayadishahraki et al. reported that in SASJ bypass, the HbA1C as the glycemic metabolic status presentation in 6 months was reduced by 0.25%, which was comparable with other groups, including RYGB, omega gastric bypass, and SG [7]. Indeed, previous studies have demonstrated that T2DM remission and improvement in 1-year follow-ups are high after both SASI and SASJ procedures. ...
Optimal Length of Biliopancreatic Limb in Single Anastomosis Sleeve Gastrointestinal Bypass for Treatment of Severe Obesity: Efficacy and Concerns
Article
Full-text available
Purpose The present study aimed to compare two newly introduced procedures, single anastomosis sleeve jejunal (SASJ) with ileal (SASI) bypass in terms of weight loss, remission of obesity-associated medical problems, complications, and nutritional status. Materials and Methods This retrospective study was carried out with 162 patients who underwent single anastomosis sleeve gastrointestinal bypass from October 2017 to September 2021, either single anastomosis sleeve jejunal bypass (SASJ) or single anastomosis sleeve ileal bypass (SASI). The main outcome measures were weight loss and improvement in obesity-associated medical problems, nutritional status, and complications at 12 months post-surgery. Results At 12 months, both groups showed significant weight loss and remission in obesity-associated medical problems. There were significant differences in body mass index (BMI), total weight loss (TWL), and excess weight loss (EWL) between SASI and SASJ bypass (P < 0.05). Improvements in associated medical problems after the two procedures were similar except for hypertension. The reversal surgery rate of the SASI group was significantly higher than that of the SASJ group (5.5% vs. 0.0%, p = 0.03). Conclusions SASJ and SASI bypass achieved satisfactory weight loss and improvement in obesity-associated medical problems that were comparable between the two groups. SASI bypass was followed by a significant difference in the rate of reversal surgery at 1 year due to a short common channel, which was not observed after SASJ bypass. Graphical abstract
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... This was consistent with Sayadishahraki et al. (14) who revealed rapid improvement of diabetes and reported that all of the patients who underwent Single-Anastomosis Sleeve Jejunal Bypass, showed improved diabetes mellitus during the 6 months follow up and stop medication as well as insulin therapy. ...
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... She was mentioned an initial weight of 113 kg, BMI 41 kg/m 2 . The patient was a candidate for SASJ Bypass surgery due to her tendency to squint, high volume of food consumption, and affinity for sweets [10]. Three weeks after the surgery, the patient felt dyspepsia, nausea, and vomiting. ...
Case report of multidisciplinary approach to post single anastomosis sleeve jejunal bypass (SASJ) surgery refusal to eat
Article
Full-text available
  • Sep 2022
Introduction and importance Bariatric surgeries are introduced as novel procedures in the whole world. Among the most important side effects after these surgeries is malnutrition. One of the reasons for suffocation can be the patient's psychological problems (such as depression). Paying attention to these symptoms can be effective in managing post-surgical complications. Case presentation A 36-year-old female patient who was operated with SASJ BYPASS surgery method presented three weeks after the surgery with symptoms of weakness, lethargy, nausea, vomiting, and PO (Per OS) intolerance, which did not respond to outpatient treatment. Barium swallow imaging and abdominopelvic CT scan was done for the patient and findings were normal. During conservative treatment and total parenteral nutrition (TPN) the patient underwent psychiatric consultation and took psychiatry medications. Gradually after these consultation sessions the patient had a good PO tolerance, no edema and no weakness and was discharged in a good condition. She was advised to continue psychologic consultation sessions besides other post-surgical follow ups. Clinical discussion After complete assessment of malnutrion etiologies after bariatric surgeries it was advised to ensure that the patients demonstrate an understanding of the bariatric surgical procedure, necessity of changes in eating habits. Any existing psychological issues should be identified and treated the patient should be educated to make a commitment to multidisciplinary care after these surgeries. Conclusion With continued communication, support, and multidisciplinary monitoring, nutritional complications can be minimized among patients undergoing bariatric surgeries. Level of evidence: V.
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... Otherwise, innovation of bariatric surgeries regardless of their methods has become the best treatment method of morbid obesity. Singleanastomosis sleeve jejunal (SASJ) bypass that has been developed since 2004 is a bariatric technique with advantage of presenting stomach and intestine anatomy with more similarity to normal anatomy compared with other bariatric techniques [2]. Another surgical treatment modality of morbid obesity is vertical banded gastroplasty (VBG). ...
Severe malnutrition after single anastomosis sleeve jejunal bypass (SASJ) surgery due to a rare surgical complication: Report of the case
Article
Full-text available
  • Feb 2022
Introduction Bariatric procedures rates are increased due to the epidemic in obesity. Up to 50% of patients operated with vertical banded gastroplasty (VBG) procedures experience failure or complications in the mid- and long-term and present for revision bariatric surgery. Despite the increase in revisions, their safety and efficacy remain controversial. Case presentation A 44-year-old female patient with severe malnutrition after single anastomosis sleeve jejunal bypass (SASJ) surgery was referred to this center. SASJ was the chosen bariatric procedure for her after the first failed VBG. She was unable to swallow anything. Upper GI endoscopy was done and the laparoscopic prolene mesh used in the first bariatric surgery (VBG) was seen inside the gastric lumen. Total parental nutrition was initiated and continued for 12 days in this medical center and then she was candidate for exploratory laparoscopy. Clinical discussion Using prophylactic preperitoneal Prolene mesh during wound closure in bariatric surgery is safe and effective in preventing incisional hernia development. During the revision bariatric surgeries, surgeons should be careful about the used mesh in the first bariatric surgery. Conclusion Surgeons should be aware of the management of rare surgical complications that might lead to malnutrition which is insidious. Level of evidence V
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... Out of the remaining records (n=369), the full article version of 23 articles were thoroughly assessed for eligibility. However, 10 articles were excluded due to lack of primary outcomes [24][25][26][27][28], article retraction [29], short follow-up periods (six months) [30,31], lack of access to a full article [32], and an article published in a non-English language [33]. Therefore, 13 studies were formally included in our systematic review and meta-analysis ( Figure 1). ...
Nutritional Complications After Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: A Comparative Systematic Review and Meta-Analysis
Article
Full-text available
  • Jan 2022
A systematic review and meta-analysis were carried out involving studies that compared the nutritional complications of Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB); these included the incidence of malnutrition as well as deficiencies of other nutritional elements, such as total protein, albumin, calcium and iron. A comprehensive search strategy was implemented in PubMed, Embase, and the Cochrane Library. Effect sizes included the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs), as well as mean differences (MDs) and 95% CIs of the percentage total weight loss (%TWL) and excess weight loss percentage (%EWL). Thirteen studies were included (12,964 patients, 66.27% females, 53.82% underwent OAGB). At the longest follow-up period (≥3 years), OAGB was associated with significantly higher %TWL (MD=5.41%, 95%CI, 1.52 to 9.29) and %EWL (MD=13.81%, 95%CI, 9.60 to 18.02) compared to RYGB. However, OAGB procedures were associated with malnutrition (OR=3.00, 95%CI, 1.68 to 5.36, p<0.0001), hypoalbuminemia (OR=2.38, 95%CI, 1.65 to 3.43, p<0.0001), hypoproteinemia (OR=1.85, 95%CI, 1.09 to 3.14, p=0.022), anemia (OR=1.38, 95%CI, 1.08 to 1.77, p=0.011), and hypocalcemia (OR=1.78, 95%CI, 1.01 to 3.12, p=0.046). On subgroup analyses, the proportions of anemia and hypoalbuminemia remained significantly higher at longer follow-up periods and in studies published in Asia. Despite the favorable weight loss profile, the unfavorable nutritional consequences of OAGB merits further investigations to explore the malabsorptive element, ethnic variation, and the role of biliopancreatic limb length.
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... Otherwise, innovation of bariatric surgeries regardless of their methods has become the best treatment method of morbid obesity. Singleanastomosis sleeve jejunal (SASJ) bypass that has been developed since 2004 is a bariatric technique with advantage of presenting stomach and intestine anatomy with more similarity to normal anatomy compared with other bariatric techniques [2]. Another surgical treatment modality of morbid obesity is vertical banded gastroplasty (VBG). ...
Effects of aquatic therapy on balance in older adults: a systematic review and meta-analysis
Article
PurposeBalance is a key component of movement for daily activities, especially in older adults. Previous studies examining aquatic therapy as an effective way for improving balance have yielded inconsistent findings. The current systematic review and meta-analysis investigated the effectiveness of aquatic therapy on balance among older adults.Methods Sources include Cochrane Central Register of Controlled Trials, Medline, ISI Web of Science, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Randomized controlled or cross-over trials published by Feb 2020 were included following pre-determined search and selection criteria. Data extraction was performed by two researchers independently using a pre-determined data extraction form. Methodological quality was assessed by two reviewers using the PEDro scale which was used to rate trials according to criteria such as concealed allocation, blinding, and intention-to-treat analysis. Furthermore, meta-analysis was conducted where possible. This review was registered at PROSPERO CRD42018118382.ResultsFifteen trials with 385 healthy participants aged 50 or over were included. Results showed that aquatic therapy had a significant effect on dynamic balance (SMD, − 1.13; 95% CI, [− 1.45 to (− 0.82)]; I2 = 77%). The analysis indicated that aquatic therapy improved balance ability compared to controls.Conclusions Aquatic therapy has a positive impact on dynamic balance in older adults. However, further high-quality and appropriately powered studies are required to confirm this assertion.
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BRAZILIAN MULTI-SOCIETY POSITION STATEMENT ON EMERGING BARIATRIC AND METABOLIC SURGICAL PROCEDURES
Preprint
Full-text available
  • Jul 2023
This Brazilian multi-society position statement on emerging bariatric and metabolic surgical procedures was issued by the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM), the Brazilian College of Digestive Surgery (CBCD), and the Brazilian College of Surgeons (CBC). This document is the result of a Brazilian Emerging Surgeries Forum aimed at evaluating the results of surgeries that are not yet listed in the Federal Council of Medicine (CFM), the regulatory agency that oversees and regulates medical practice in Brazil. The Forum integrated more than 400 specialists and academics with extensive knowledge about bariatric and metabolic surgery, representing the three surgical societies: SBCBM, CBC, and CBC. International speakers participated online and presented their experiences with the techniques under discussion, emphasizing the regulatory policies in their countries. The indications for surgery and the subsequent procedures were carefully reviewed, including One Anastomosis Gastric Bypass (OAGB), Single Anastomosis Duodeno-Ileal with Sleeve Gastrectomy (OADS or SADI-S), Sleeve Gastrectomy with Transit Bipartition (SGTB), and Sleeve Gastrectomy with Ileal Interposition (SGII). The recommendations of this document are based on an extensive literature review and discussions among bariatric surgery specialists from the three surgical societies. We concluded that patients with a body mass index (BMI) over 30 kg/m2 may be candidates for metabolic surgery in the presence of comorbidities (arterial hypertension and type 2 diabetes) with no response to clinical treatment of obesity or in the control of other associated diseases. Regarding the surgical procedures, we concluded that OAGB, OADS, and SGTB are associated with low morbidity rates and with satisfactory weight loss and resolution of obesity-related comorbidities such as diabetes and arterial hypertension. SGII was considered a good and viable promising surgical alternative technique. The recommendations of this statement aim to synchronize our societies with the sentiments and understandings of most of our members and also serve as a guide for future decisions regarding bariatric surgical procedures in our country and worldwide.
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Sleeve gastrectomy with transit bipartition: a review of the literature
Article
Introduction: Obesity has been identified by the World Health Organization (WHO) as a significant global medical, social, and public health issue. Surgery is the most important therapeutic option for severe morbid obesity and metabolic diseases linked to obesity. Sleeve gastrectomy-transit bipartition (SG-TB) and the single anastomosis sleeve ileal (SASI) bypass, a more simplified variation of SG-TB, have recently become popular methods for treating these conditions. The clinical investigations of SG-TB and SASI bypass are included in this review. In order to find papers published up until December 2022, the Pubmed database was searched. Areas covered: We comprehensively review the most recent research on the use of SG-TB and SASI bypass in clinical practice, including the surgical technique, weight loss, comorbidity remission, post-operative complications, post-operative nutritional status, and the mechanism of operation. Expert opinion: Studies on the SG-TB and SASI bypass have shown positive short-term outcomes. The weight loss and improvement of comorbid conditions with SG-TB and SASI bypass have shown promising results. In comparison to other operations, it has also been demonstrated that there is a relatively low incidence of adverse effects. However, more research is necessary to determine its long-term effectiveness and to address several intriguing issues.
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Comparative Study between Single Anastomosis Sleeve Jejunal Bypass, Sleeve Gastrectomy and One Anastomosis Gastric Bypass: A Prospective Randomized trial
Preprint
Full-text available
  • May 2022
Background: A variety of bariatric procedures are being practiced nowadays. Laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB) are two commonly practiced bariatric procedures. Recently, single anastomosis sleeve jejunal bypass (SASJ) has emerged as a novel effective procedure with a decreased risk of malnutrition due to the presence of two pathways for food. Herein, we compared outcomes of these three procedures regarding short-term weight loss, complications, comorbidity resolution and quality of life. Patients and methods: We included a total of 60 cases in this prospective randomized study, and they were divided into three equal groups; SASJ, LSG and OAGB groups. The three procedures were performed by the same surgical team adapting standardized techniques. Weight loss parameters were our primary objectives, while secondary outcomes included post-operative complications, nutritional status, improvement/resolution of comorbidities and quality of life. Results: Operative time was significantly prolonged in the SASJ group, compared to the other two groups. Nevertheless, the incidence of post-operative complications did not significantly differ between the three groups, apart from GERD, that was more encountered in LSG group (20% of cases). Percentage of total weight loss (%TWL) were comparable among the 3 procedures; (SASJ 39.4 and 56.85%), (LSG 46.05 and 65.6%) and (OAGB 43 and 61.4%) at 6 and 12 months respectively. Comorbidity improvement, quality of life and nutritional status didn’t differ among the three study groups. Conclusion: SASJ bypass is an effective bariatric procedure regarding weight loss and comorbidity resolution, with a safe perioperative outcome comparable to OAGB and LSG.
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Bariatric surgery for obesity and metabolic disorders: state of the art
Article
Full-text available
  • Nov 2016
Obesity is one of the most important public health conditions worldwide. Bariatric surgery for severe obesity is an effective treatment that results in the improvement and remission of many obesity-related comorbidities, as well as providing sustained weight loss and improvement in quality of life. Contemporary bariatric operations include Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric band and the duodenal switch. The vast majority of these procedures are now performed using laparoscopic technique, the main advantages of which include rapid recovery, the reduction of postoperative pain and the reduction of wound-related complications, compared with open surgery. Contemporary bariatric surgery is now safe, with a mortality of three in 1,000 patients; however, all bariatric operations are associated with their own unique short-term and long-term nutritional and procedural-related complications. Type 2 diabetes mellitus (T2DM) is the most studied metabolic disorder associated with obesity, with data demonstrating that improvement and remission of T2DM in patients with obesity is superior after bariatric surgery compared with conventional medical therapy. Bariatric surgery is now a part of some treatment algorithms for the medical management of patients with T2DM and severe obesity. New, minimally invasive and endoscopic devices for the treatment of obesity have now been approved in the USA, which will expand the treatment options for individuals with obesity.
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Compared to Sleeve Gastrectomy, Duodenal–Jejunal Bypass with Sleeve Gastrectomy Gives Better Glycemic Control in T2DM Patients, with a Lower β-Cell Response and Similar Appetite Sensations: Mixed-Meal Study
Article
Full-text available
Background: Functional studies of how duodenal-jejunal exclusion (DJE) brings a superior glycemic control when added to sleeve gastrectomy in duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG) patients, are lacking. To study this, we compared the appetite sensations and the β-cell response following a standard mixed meal in patients with DJB-SG, versus those with sleeve gastrectomy (SG) alone. Methods: Twenty one patients who underwent DJB-SG and 25 with SG, who participated in mixed-meal tests (MMTT) preoperatively and at 1 year, with complete data were included and compared. Blood glucose, C-peptide, and insulin levels were estimated, along with the visual analogue scale (VAS) scoring of the six appetite sensations, as a part of the MMTT. Results: At 1 year following surgery, compared to SG group, DJB-SG group had greater complete remission rates (HbA1C <6.0 %) of 62 versus 32 % (p < 0.05), with similar total body weight loss (25.7 vs. 22 %). There were significantly lower post-prandial blood glucose and lower C-peptide levels during the MMTT in the patients with DJB-SG compared to SG group. There were no significant differences in the appetite sensations (mean VAS) scores between the groups. Conclusion: The addition of DJE component to SG, as in DJB-SG, was associated with higher diabetes remission rates, lower glycemic fluctuations, and lower C-peptide levels. This may point to a β-cell preserving glucose control which could result in longer remission of type 2 diabetes mellitus (T2DM). This effect also may be unrelated to food intake as there were no significant differences in the appetite sensations.
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Bariatric Surgery Worldwide 2013
Article
Full-text available
The first global survey of bariatric/metabolic surgery based on data from the nations or national groupings of the International Federation for the Surgery of Obesity and Metabolic Diseases (IFSO) was published in 1998, followed by reports in 2003, 2009, 2011, and 2012. In this survey, we report a global overview of worldwide bariatric surgery in 2013. A questionnaire evaluating the number and the type of bariatric procedure performed in 2013 was emailed to all members of bariatric societies belonging to IFSO. Trend analyses from 2003 to 2013 were also performed. There were 49/54 (90.7 %) responders; 37 of the 49 with national registries. The total number of bariatric procedures performed worldwide in 2013 was 468,609, 95.7 % carried out laparoscopically. The highest number (n = 154,276) was from the USA/Canada region. The most commonly performed procedure in the world was Roux-en-Y gastric bypass (RYGB), 45 %; followed by sleeve gastrectomy (SG), 37 %; and adjustable gastric banding (AGB), 10 %. Most significant were the rise in prevalence of SG from 0 to 37 % of the world total from 2003 to 2013, and the fall in AGB of 68 % from its peak in 2008 to 2013. SG is currently the most frequently performed procedure in the USA/Canada and in the Asia/Pacific regions, and second to RYGB in the Europe and Latin/South America regions. The accuracy of the IFSO-based world survey of procedures would be enhanced if each nation or national group would create a national registry.
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Single Anastomosis Sleeve-Jejunal Bypass: a New Method of Bariatric/Metabolic Surgery
Article
  • Jun 2019
Bariatric surgery plays a key role in treating morbid obesity and its associated comorbidities whose incidence is increasing. The single anastomosis sleeve ileal (SASI) bypass is an investigatory procedure that is performed parallel with standard and established operations. The present research introduces the SASJ bypass with less concerns about malnutrition and excessive weight loss.
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Novel metabolic surgery: first Asia series and short-term results of laparoscopic proximal jejunal bypass with sleeve gastrectomy
Article
  • Dec 2016
Background: There has been a rapid rise in incidence of obesity and its associated metabolic consequences in Asia where 60% of the world population resides and who are already at an elevated risk of developing diabetes. Though laparoscopic Roux-en-Y gastric bypass (LRYGB) has established itself as a standard, considering its technical difficulty and long term morbidity, there are possible alternatives being developed for equally effective but less morbid. Laparoscopic proximal jejunal bypass with sleeve gastrectomy (LPJB-SG) was first described by de Menezes in 2004 and further studies had shown it to be effective in weight loss and in remission of type 2 diabetes mellitus. Methods: Sixty five patients with obesity/uncontrolled type 2 diabetes underwent LPJB-SG between October 30th, 2014 and April 15th, 2016. This is an ongoing prospective study on Asian patients. All surgeries were performed by a single surgeon and consisted of a sleeve gastrectomy and bypassing proximal jejunum about 250–300 cm in length. Intra and post-surgical data were collected and operation time, length of hospital stay (LOS) and early complications were documented. BMI, percentage of excess weight loss (%EWL), fasting sugar and HbA1c, were assessed at 1 month and 3 monthly follow-up visits thence for a year. Surgical complications were recorded. Results: All surgeries were completed laparoscopically. The operation time was 93.13 minutes on average with a mean hospital stay of 2.2 days. The average EWL was 26.49, 44.77 and 65.87 percentages at 1, 3 and 6 months respectively. The percentage of diabetic patients achieving an HBA1c of <6.0 without medicines was 11.5, 60.56 and 66.66 at 1, 3 and 6 months respectively. There were 3 (6.5%) complications developed (1 bleeding, 1 dehydration and 1 gastric stenosis).The gastric stenosis required a conversion to a Roux-en-Y bypass and the patients with bleeding and dehydration were successfully managed conservatively. Conclusions: LPJB-SG is a feasible, safe and effective surgery for treatment of obesity and diabetes in this first Asia short-term result. It is technically simpler to perform and is easily reproducible. Long term and randomized controlled studies comparing with other surgical procedures would be required to assess it further.
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Efficacy of single anastomosis sleeve ileal (SASI) bypass for type-2 diabetic morbid obese patients: gastric bipartition, a novel metabolic surgery procedure: A Retrospective Cohort Study
Article
Introduction: The single anastomosis sleeve ileal (SASI) bypass is a Novel Metabolic/Bariatric Surgery operation based on mini gastric bypass operation and Santoro's operation in which a sleeve gastrectomy is followed by a side to side gastro-ileal anastomosis. The purpose of this Study is to report the clinical results of the outcomes of SASI bypass as a therapeutic option for obese T2DM patients. Methods: We conducted a retrospective cohort study of type 2 diabetic obese patients who underwent SASI bypass at one hospital from March 1, 2013 to December 31, 2014. Patients with previous bariatric surgery, history of upper laparotomy, and with less than one year follow up, were excluded. Sleeve gastrectomy was performed over a 36-Fr bougie, 6 cm from the pylorus, and 250 cm from the ileocecal valve the ileum brought to be anastomosis side to side with the antrum. Data collected included comorbidity resolution, percent excess weight loss (% EWL), and one-year morbidity and mortality. Results: During the study period, 61 underwent laparoscopic SASI bypass. Ultimately, 50 patients with a mean BMI of 48.7 ± 7.6 kg/m2 met inclusion criteria and were evaluated. %EWL reached 90% at one year and all patients have normal glucose level in the first 3 months after surgery. Hypertension remitted in 86%, hypercholesterolemia in 100% and hypertriglyceridemia in 97% of patients. There were 6 postoperative complications. One pulmonary embolism, one postoperative bleeding, one leak from biliary limb and one complete obstruction at the gastro-ileal anastomosis. Six months postoperative, one patient was diagnosed with marginal ulcer, 12 months after surgery, another patient was re-operated for fear of more excessive weight loss. Conclusion: SASI bypass is a promising operation that offers excellent weight loss and diabetic resolution.
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1 The Global Burden of Obesity and Diabetes
Article
  • Nov 2015
The global pandemic of obesity and diabetes continues relentlessly in developed and developing nations. On a population basis, current preventative strategies for obesity and diabetes appear ineffective. The increase in obesity prevalence only partly explains the increase in diabetes prevalence. The increased prevalence and burden of diabetes in developed nations is generally occurring in an older population and is related to aging, reduced mortality associated with diabetes, an increase in the proportion in the population with high-diabetes-risk ethnicities, and increasing levels of obesity. In contrast in developing countries, the increased in diabetes prevalence and burden is in a younger working demographic and related to aging and rapid increase in those at risk related to obesity. Effective strategies for obesity-diabetes prevention and management at a population level are desperately needed globally.
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The clinical effectiveness and cost-effectiveness bariatric (weight loss) surgery for obesity: A systematic review and economic evaluation
Article
  • Sep 2009
OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. DATA SOURCES Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references. REVIEW METHODS Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and or = 30 and or = 30 and 40, ICERs were 18,930 pounds at two years and 1397 pounds at 20 years, and for BMI > or = 30 and < 35, ICERs were 60,754 pounds at two years and 12,763 pounds at 20 years. Deterministic and probabilistic sensitivity analyses produced ICERs which were generally within the range considered cost-effective, particularly at the long twenty year time horizons, although for the BMI 30-35 group some ICERs were above the acceptable range. CONCLUSIONS Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.
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A 7-Year Clinical Audit of 1107 Cases Comparing Sleeve Gastrectomy, Roux-En-Y Gastric Bypass, and Mini-Gastric Bypass, to Determine an Effective and Safe Bariatric and Metabolic Procedure
Article
The epidemic of obesity is engulfing developed as well as developing countries like India. We present our 7-year experience with laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and mini-gastric bypass (MGB) to determine an effective and safe bariatric and metabolic procedure. The study is an analysis of a prospectively collected bariatric database of 473 MGBs, 339 LSGs, and 295 RYGBs. Mortality rate was 2.1 % in LSG, 0.3 % in RYGB, and 0 % in MGB. Leaks were highest in LSG (1.5 %), followed by RYGB (0.3 %), and zero in MGB. Bile reflux was seen in <1 % in the MGB series. Persistent vomiting was seen only in LSG. Weight regain was 14.2 % in LSG, 8.5 % in RYGB, but 0 % in MGB. Hypoalbuminemia was minimal in LSG, 2.0 % in RYGB, and 13.1 % in MGB (in earlier patients where bypass was >250 cm). The following resolution of comorbidities: dyslipidemia, type 2 diabetes (T2D), hypertension, and percent excess weight loss (%EWL) was maximum in MGB. GERD was maximum in LSG (9.8 %), followed by RYGB (1.7 %), and minimal in MGB (0.6 %). RYGB and MGB act on the principle of restriction and malabsorption, but MGB superseded RYGB in its technical ease, efficacy, revisibility, and reversibility. Mortality was zero in MGB. %EWL and resolution of comorbidities were highly significant in MGB. Based on this audit, we suggest that MGB is the effective and safe procedure for patients who are compliant in taking their supplements. LSG may be done in non-compliant patients and those ready to accept weight regain.
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