Diabetic - Establised Procedure

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Establised Procedure

Roux-en-Y Gastric Bypass

A Surgical stapler to create a small and vertically oriented gastric pouch and its volume is usually<30 cc. The upper pouch is completely divided from the gastric remnant and is anastomosed to the jejunum (30–75 cm from the ligament of Treitz) through a narrow gastro-jejunal anastomosis. Bowel continuity is restored by an entero-entero anastomosis between the excluded bil-iopancreatic limb and the alimentary limb. This anastomosis is usually performed 75–100 cm distal to the gastro-jejunostomy. although it has also been performed at 100–250 cm in patients with BMI>50 kg/m2. As this is a restrictive as well as malabsorpative procedure, diabetes control is moderate and acepatable and easily manageable mal-absorption related deficiencies.

Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) is a restrictive procedure that involves encircling the upper part of the stom-ach with a band-like, saline-filled tube. The band is wrapped around the superior portion of the stomach, just distal to the gastroesophageal junction. The amount of restriction can be adjusted by injecting or withdrawing saline solution from the hollow core of the band through a subcutaneous port. Being a purely restrictive procedure, diabetes control correlates with corresponding weight loss. As it does not affect gastro-intestinal hormonal milieu, diabetes control is mild.

Roux-en-Y Gastric Bypass

Roux-en-Y Gastric Bypass

Laparoscopic Adjustable Gastric Banding

Laparoscopic Adjustable Gastric Banding

Biliopancreatic Diversion

The operation consists of a distal, horizontal gastrectomy that leaves behind upper stomach 200–500 ml in size. This remnant stomach is anastomosed to the distal 250 cm of small intestine (alimen-tary limb). The excluded small intestine (including the duodenum, the jejunum, and part of the proximal ileum) carries bile and pancreatic secretions (biliopancreatic limb), and it is connected to the alimentary channel 50 cm proximal to the ileocecal valve. The 50-cm “common limb” is the only segment of small bowel where digestive secretions and nutrients mix.

Biliopancreatic Diversion with Duodenal Switch

The biliopancreatic diversion with duodenal switch (BPD-DS) includes a “sleeve” vertical gastrectomy (rather than a horizontal version, as in Scopinaro’s original procedure), which leaves a 150–200-ml gastric reservoir. The duodenum is closed∼2 cm distal to the pylorus, and a duodeno-ileal anastomosis is performed. Bowel continuity is restored, as in BPD; however, the entero-entero anastomosis is performed more proximally on the alimentary limb, leaving a longer common channel of ∼100 cm, as opposed to 50 cm in Scopinaro’s original procedure. As this is also restrictive as well as mal-absorptive procedure, but it induced greatest mal-absorption. Thus diabetes control is greatest with this procedure and also associated with maximum deficiency of nutrients. That led some researchers to raise concern in the long term safety of this procedure.

Biliopancreatic Diversion

Biliopancreatic Diversion

Biliopancreatic Diversion with Duodenal Switch

Biliopancreatic Diversion with Duodenal Switch

Noval Procedure:

Sleeve gastrectomy (SG)

To shorten the duration of the laparoscopic BPD-DS in high-risk patients, the originator of this operation, proposed a two-stage approach in which SG is performed first, with the duodeno-ileostomy and ileo-ileostomy as a second stage a few months later. This approach resulted in reduced surgical morbidity and mortality compared to the traditional one-stage approach in super-superobese patients (BMI>60 kg/m2). Unexpectedly, patients achieved re-markable weight loss after the first stage of this approach, and SG is now being proposed as an independent anti-obesity operation by some authors. In addition to reducing the functional capacity of the stomach, this procedure eliminates the ghrelin-rich gastric fundus, which may play a role in its mechanism of action. SG has also been shown to improve diabetes in severely obese patients. The short term results are encouraging. The long-term efficacy of the procedure is pending.

DJB:duodenal-jejunal bypass

DJB is a stomach-sparing bypass of a short portion of proximal intestine, comparable to the segment excluded in a standard RYGB (Figure 2a). Variants of this experimental procedure include techniques that preserve the pylorus (duodeno-jejunal anastomosis) or do not (gastro-jejunal anasto-mosis). DJB has now been performed in several centers worldwide to treat T2DM in non-obese patients, and short term results are encouraging and long-term follow-up clinical data are pending.

Sleeve gastrectomy

Sleeve gastrectomy

duodenal-jejunal bypass

duodenal-jejunal bypass

Ileal Interposition (IT)

Ileal Interposition

This operation involves the surgical insertion of a small segment of ileum, with its neurovascular supply intact, into the proximal intestine, increasing its exposure to ingested nutrients that leads to increased level of glucagon-like peptide-1 (GLP-1) and peptide-YY. These hormonal changes, in the absence of gastric restriction or malabsorption, are associated with reductions in food intake and body weight & improvement in glucose levels. This procedure, alone or in combination with SG, has been used in lean diabetic patients. The short term results are encouraging. The late metabolic sequalae are therefore unknown, and long-term safety is still to be evaluated.


Endoluminal duodenal-jejunal sleeve (ELS)

The ELS is a flexible plastic sleeve, placed in stomach using endoscope. This sleeve extends for distal stomach to duodenum and proximal jejunum, thus disrupting absorption of nutrients. Studies to determine the safety and efficacy of long-term ELS placement in humans are under way.

Endoluminal duodenal-jejunal sleeve (ELS).

Endoluminal duodenal-jejunal sleeve (ELS).

Most appropriate Diabetes Surgery for you

The choice of operation for diabetes is multiple & requires a careful risk–benefit analysis before opting for any procedure. You are encouraged to discuss with surgical multidisciplinary team.