Evidence from several studies (Haber et al.1977; Jenkins et al.1980; Wise´n and Johansson1992; Ranganath et al.1996; Lugari et al.2002; Lam and Kieffer2002;
Bojanowska2005) suggested that an excessive proximal absorption due to dietary interventions could be the cause for enterohormonal disorders. In 1997, Naslund et al. showed that the jejunoileal bypass (JIB), an old bariatric procedure that sends nutrients through a shortcut to the ileum (maintaining the duodenum inflow but excluding most of the jejunum and ileum), caused a long-lasting enhancement in GLP-1 secretion (Naslund et al. 1997). Consequently, it was demonstrated that GLP-1 deficient patients were indeed capable of secreting GLP-1 if distal nutritive stimuli were sufficient. Additionally, it became clear that JIB worked by promoting intentional malabsorption and through unpredicted metabolic ways. Looking back to 1980, this discovery could be explained by the observation documented by Organ et al. (1980), that JIB induced a fast remission of diabetes, before the occurrence of significant weight loss.
In 1998, the world was intrigued by an article (Hickey et al. 1998), that investigated whether type 2 diabetes mellitus (T2DM) could be a disease of the foregut. The nonrestrictive and non-malabsorptive effects of bariatric surgery became a topic of interest.
Fig. 5.5 Sleeve gastrectomy and transit bipartition (Santoro et al.2012)
Based on these elements, we supposed that the mentioned dietetic modifications that intensify proximal absorption indeed diminish distal absorptive work, causing signaling disorders (Santoro 2003, 2008a). A surgical strategy (Santoro 2006, 2008b) was proposed to counterbalance the digestive tract signaling aiming at enterohormonal correction. It was the first strategy originally developed to maxi-mally avoid restriction and malabsorption, instead of inducing them for therapeutic purposes.
This strategy included different procedures capable to cause metabolic interven-tions. Among them, we observed that sleeve gastrectomy and transit bipartition (SG + TB) were highly effective.
Patients with classic indication for bariatric surgery, that understand and accept that their surgery will basically rely on its metabolic components and not on malabsorption, are offered SG + TB. From June, 2004, until January, 2011, 1020 patients underwent SG + TB (Santoro et al.2012).
At the time of surgery, patients had body mass indexes (BMIs) ranging from 33 to 72 kg/m2(average 42.2 kg/m2). Diagnosed comorbidities included orthopedic problems, including joint pain, essential hypertension, diabetes, dyslipidemia, and respiratory problems including sleep apnea. Other frequently occurring preopera-tive conditions included a high prevalence of abnormally high levels of hepatic enzymes and hepatic steatosis, cholelithiasis, hyperparathyroidism, low blood thiamine, insufficient levels of 25 hydroxyvitamin D, menorrhagia in association with anemia, polycystic ovary syndrome, depression, and anxiety disorders.
5.4.1 Operative Technique
The procedure combines a typical SG with a TB; this creates a shortcut to the ileum while maintaining access to the duodenum (Fig. 5.5). The procedure may be performed in a conventional open method, laparoscopically, or, alternatively, with mixed access, where the SG is performed through laparoscopy, and a mini-laparotomy is formed by the union of two trocar incisions. This approach provides adequate access for the retrieval of the gastric specimen and composes the enteric part of the surgery. Here, we describe the laparoscopic method.
Pneumoperitoneum is obtained using a Veress needle. Six trocars are positioned, including three 12-mm trocars (one in the midline 3–5 cm above the umbilicus and two others in the upper left and right quadrant) and three 5-mm trocars (one in the epigastrium for the liver retractor and two at each lateral flank).
The omental bursa is opened, and the greater omentum is sectioned with a sealer and divider device (Ultracision®or Ligasure®). The greater curvature is freed from 2 cm proximal to the pylorus up to the angle of His, including the left arm of the hiatal crura. If a hiatal hernia is present, then a hiatoplasty is performed.
A typical sleeve gastrectomy (Baltasar et al.2005) is performed with a laparo-scopic linear cutting stapler starting at the gastric greater curvature, at a point located 4–5 cm from the pylorus, up to 0.5 cm from the angle of His. A 36 French
bougie is passed to the stomach, to guarantee that the remnant gastric tube, which is positioned by the lesser curvature, has an internal lumen 3 cm wide. A seromuscular running suture is sometimes used to cover the stapling line to reduce bleeding.
After the SG, the ileocecal transition is located. A single stitch is used to mark the point at the ileum 80 cm from the ileocecal valve. The point at 260 cm is then located, and a perforation is made with the cautery to allow the insertion of one arm of the linear stapler into the ileal lumen. Another hole is created in the stomach antrum at the end of the stapling line, by applying the cautery against the bougie’s protuberance. The other arm of the stapler is inserted in the stomach from the patient’s left to the right, toward the pylorus, to create a 3- to 4-cm wide latero-lateral gastroileal anastomosis in an antecolic position. A 3-0 absorbable extra mucosal running suture closes the residual defect.
In the following sequence, the small bowel cranial to the gastroileal anastomosis is laterally widely anastomosed to the ileum, at 80 to 120 cm from ileocecal valve (previously marked), in a lateral–lateral mode. A laparoscopic linear stapler with a 45-mm white cartridge is used for the anastomosis. A nonabsorbable running suture closes the mesenteric borders to prevent internal hernias. Today we use a 120 cm
“common channel” to avoid worsening the odor of stools. At the end of the procedure, the segment between both anastomoses is interrupted with stapling and cutting. A closed suction drain, lying along the sleeve gastrectomy staple line, is exteriorized through the lower left port incision. The other laparoscopic incisions are closed.
Patients fast in the first postoperative day (POD), and liquid fractioned meals are offered for the subsequent 12 days. Then, soft solid meals are allowed, in a slow progression toward normal food. Patients are instructed to begin meals with a portion of varied salad, enriched with protein (tuna, salmon, or chicken). Avoidance of refined sugar is advised. The patients are also advised to enroll in a physical activity program, with increasing intensity as weight loss occur. Multivitamins and pantoprazol are prescribed in the first 2 months and maintained for longer if necessary.
5.4.2 Follow-up
Patients are instructed to return after 10 days, 1 month, 3 months, 6 months, one year after the procedure and then annually, bringing blood tests, and at least one abdominal sonography performed around 1 year of surgery. Detected gallstones are surgically treated, frequently simultaneously to plastic surgery. Weight is actually measured and not self-reported. Unfortunately, around 40 % of patients return just in the early postoperative period, and not any more.
Data are collected online using an especially developed software; means, graphics, and standard deviations are immediately updated. Remission of T2DM is defined by HbA1c <6.5 % without oral hypoglycemic drugs or insulin, while improvement is defined as a reduction of at least 25 % in the fasting plasma glucose
level, and of at least 1 % in the HbA1c level, with hypoglycemic drug treatment.
Systemic arterial hypertension and dyslipidemia are considered resolved when the patients do not need medication anymore, to maintain normal values for these conditions, while respiratory and orthopedic problems are considered resolved or improved based on patients perception of symptoms.
5.4.3 Early Surgical Results
The length of operative laparoscopic procedures ranged from 110 to 280 min (average 170 min). Mainly due to coverage restrictions, only 361 were laparoscopic procedures, and 659 procedures were performed with open or mixed access. In general, patients were discharged in the third POD. Early significant 30-day post-operative complications occurred in 60 patients (6 % Table5.1). Nineteen patients required reoperation (1.9 %). There were 2 deaths (0.2 %).
5.4.4 Late Surgical Results
Late complications included 132 patients with cholelithiasis (21.9 %), 19 (3.1 %) with incisional hernias, and 15 (2.4 %) with internal hernias or intestinal subocclusion related to adherences. Most of these patients did not present the typical signs of obstruction, vomiting, or interruption of evacuation because of the TB. Pain was the predominant presenting symptom, along with some mostly left-sided abdominal distension. Postoperatively, three cases (0.5 %) had a hiatal
Table 5.1 Significant 30-day postoperative complications (Santoro et al.2012) Fistula—9acases (0.9 %)
Bleeding (requiring reoperation or blood transfusion)—8 (0.8 %) Intestinal subocclusion—8 cases (0.8 %)
Non-obstructive prolonged ileus—7 cases (0.7 %) Symptomatic atelectasis or pneumonia—5acases (0.5 %) Symptomatic partial portal thrombosis—5 cases (0.5 %) Acute crises of urolithiasis—5 cases (0.5 %)
Early incisional dehiscence, in open cases—4 cases (0.4 %; 0.6 % of open cases) Intraperitoneal infection or abscess of unknown origin—3 cases (0.3 %) Cardiac complications—2 cases (0.2 %)
Compression neuroplegia—2 cases (0.2 %)
Clinically significant rhabdomyolysis—1 case (0.1 %) Pulmonary thromboembolism—1 case (0.1 %)
aRefers to one case of fatality
hernia, corrected by a hiatoplasty due to gastroesophageal reflux. Approximately 35 % of patients were taking a daily or occasional proton-pump inhibitor (PPI) for heartburn. In relation to the frequency of bowel movements, mild constipation was rarely observed; most patients presented more frequent bowel movements, or maintained the same frequency observed before surgery. Typically, patients reported softened stools, and many reported a worsened odor in flatus and feces.
However, the severity of these symptoms was rarely reported to be a problem, especially if the 120 cm common channel were used.
Radiographic gastrointestinal (GI) series routinely showed preferential flow through the wide gastroileal anastomosis (Fig. 5.6). GI ulcers were very rare (only one case, a patient with a prior history of a duodenal ulcer, who was easily cured with PPI treatment). Stenosis at the gastroileal anastomosis was rare, but this occurred in three patients, all of whom were successfully treated with endoscopic dilation. Typical dumping was not observed, but in rare circumstances, some hypoglycemia caused mild symptoms. No patients required treatment for this reason. Changes in food preferences were frequently reported, including an aver-sion to fatty foods.
Fig. 5.6 Late radiographic aspect of a SG + TB. Observe that part of the contrast media empties through the duodenum. The gastroileal anastomosis is very well shown (Personal file)
5.4.5 Clinical Outcome: Weight Loss and Nutritional Status
Weight was monitored in the form of BMI and percentage of excess of BMI loss (EBMIL%¼ preoperative BMI—current BMI 100/preoperative BMI—25). SG + TB presented an average EBMIL% of 74 22.5 % in the fifth year (Fig.5.7).
From a nutritional perspective, SG + TB has excellent results. Protein malnutri-tion, a severe adverse effect of BPDs, did not occur. Some patients temporarily presented low albumin levels, during some complication. Fortunately, there are no cases of chronic hypoalbuminemia. High levels of parathyroid hormone (PTH) and low levels of vitamin D and B1(thiamine) were frequently observed preoperatively (around 60 % and 40 %, respectively). Nutritional supplementation was started prior to surgery for many patients. These conditions frequently required continued supplementation of calcium, cholecalciferol, and thiamine postoperatively (the latter, in common multivitamin tablets). Anemia was rarely a problem and usually temporary. Around 7 % maintain hemoglobin below 12 g/dL, and this occurs especially when menstrual losses are excessive. No one developed chronic anemia below 10 g/dL (including the rare minor thalassemic patients of the group). Low plasmatic zinc was also eventually observed, but no supplementation was needed beyond the multivitamin tables. In general, the nutritional status was excellent.
Fig. 5.7 (a, b) Graph on the left (a) shows the evolution in BMI (kg/m2) standard deviation (SD) (black bars over the columns). Graph on the right (b) shows EBMIL% SD over time in months (mo) and years (y) after the procedure. Note that these columns refer to 603 patients at the initial column and at 3 months; then the numbers of patients related to columns are 450 at 6 mo, 366 at 1 y, 289 at 2 y, 183 at 3 y, 80 at 4 y, and 36 at 5 y (Santoro et al.2012)
5.4.5.1 Clinical Outcome: Resolution of Comorbidities Diabetes Type 2
From 333 diabetic patients, 281 had adequate follow-up (84.3 %, better than the nondiabetic group). From this group, 86 % went into complete remission; 14 % were much improved but still required some oral diabetes medication. Among these 14 % without full remission, 4 % had to restart medication very soon (usually with reduced dosages, and mostly in the worse cases) and 10 % had to do it just later, usually between 18 and 36 months, after some weight regain. Those who had to restart medication temporarily, but rapidly went into remission without medication, are counted among the 86 % of complete remission.
Diabetic patients are discharged without any medication for diabetes, but they are kept under rigid glycemic control, using their portable devices. If necessary, some of the previous medication could be restarted temporarily, until endogenous control improved. Usually, good glycemic control was already observed when solid food was reintroduced. It is worth mentioning that two patients did not present the expected rapid improvement, and a stenosis of the gastroileal anastomosis was observed. A notable fall in glycemic levels occurred immediately after endoscopic dilation. After a period of rapid improvement, a period of slow further improvement was continuously observed, for the first 6–12 months.
Other Comorbidities
Respiratory problems, including sleep apnea, were also very much improved within a few weeks. Respiratory problems were resolved in 91 % of patients, and improve-ments were noted in the others. The pain associated with orthopedic problems was resolved in 83 % of the patients, and was improved in the remaining patients.
Hypertriglyceridemia was improved by the surgery (85 %) to a greater extent than hypercholesterolemia (70 %). Essential hypertension no longer required medication in 72 % of patients (Table5.2).
Resolution was defined as the disappearance of the problem or withdrawal of medication. Improvement was defined as a reduction in medication required, or an improvement in objective laboratorial results or symptoms.
Table 5.2 Clinical resolution and improvement of comorbidities after SG + TB (Santoro et al.2012)
Condition Resolved Improved
Orthopedic problems 83 % 17 %
Arterial hypertension 72 % 28 %
Type 2 diabetes 86 % 14 %
Hypertriglyceridemia 85 % 15 %
Hypercholesterolemia 70 % 30 %
Respiratory problems 91 % 9 %