Laparoscopic Sleeve Gastrectomy with Duodeno-Jejunostomy (DJB)

“The groundwork of all happiness is health!”

Laparoscopic sleeve gastrectomy with duodenojejunal bypass is a novel bariatric procedure. It has good weight loss results and it also leads to a significant improvement in all obesity related co-morbidities like type 2 diabetes, high blood pressure, high cholesterol etc.

Laparoscopic sleeve gastrectomy with duodenojejunal bypass is a procedure in which a sleeve of the stomach is created and a loop of the part of intestine called jejunum is attached to the first part of duodenum. First part of duodenum and jejunum are bypassed in this surgery. This surgery was first popularised in Japan and one of the advantages of this surgery is that no part of the stomach is bypassed. Countries like Japan and Korea have a very high prevalence of stomach cancer and it is important that even after bariatric surgery, stomach must remain accessible for upper GI endoscopy.

Laparoscopic sleeve gastrectomy with duodenojejunal bypass leads to about 70 to 75% excess weight loss over 12 to 18 months. Ofcourse this can be made better if the patient puts in more effort in the form of diet and exercise. Laparoscopic sleeve gastrectomy with duodenojejunal bypass also leads to a significant improvement in associated co-morbidities like type 2 diabetes, high blood pressure, high cholesterol, gout, obstructive sleep apnoea, joint diseases etc.

Laparoscopic sleeve gastrectomy with duodenojejunal bypass has comparable results to all other bariatric operations.

Eligibility for laparoscopic duodenojejunal bypass surgery

The IFSO- APC (International Federation for Surgery for Obesity and Metabolic Disorders – Asia Pacific Chapter) guidelines for weight loss surgery are as under:

• Bariatric surgery/obesity surgery/weight loss surgery must be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 Kg/m² with or without any associated diseases.
• Bariatric surgery/metabolic surgery must be considered for the treatment of type 2 diabetes or metabolic syndrome for patients who are inadequately controlled by lifestyle alterations and medical treatment for acceptable Asian candidates with BMI ≥ 30 Kg/m².
• Bariatric surgery/metabolic surgery may also be considered as a non-primary alternative to treat inadequately controlled type 2 diabetes or metabolic syndrome for suitable Asian candidates with BMI ≥ 27.5 Kg/m².

Duodenojejunal bypass surgery has shown good weight loss outcomes and co-morbidity remission. This surgery can be safely performed in most patients. Duodenojejunal bypass surgery has shown good results in obese diabetics and a lot of times patients do not need to take any anti-diabetic medications after this surgery. Remission of type 2 diabetes and other co-morbidities varies from patient to patient and depends on a lot of factors, which the doctor and the team will explain to you during consultation. Duodenojejunal bypass surgery must be avoided for patients who suffer from hiatus hernia and acid reflux disease as it can increase the symptoms of acid reflux.

Preparation before the procedure

• First step is a consultation with the doctor and the team to decide on your eligibility for Duodenojejunal bypass weight loss surgery. A detailed medical history, diet recall and a complete physical and psychological assessment will be performed at this time.
• Once we have decided to go ahead with loop duodenojejunal bypass surgery, you will need to undergo a battery of tests. You may also need to see a diabetologist, endocrinologist, nephrologist, chest physician etc based on your clinical profile and associated co-morbidities.
• A pre-operative upper GI endoscopy is a must before all bariatric procedures.
• You will also need to be on a high protein liquid diet for a period of 5 to 7 days prior to the procedure. Most obese patients have fatty and enlarged livers. Swelling on the liver makes the surgery difficult for the surgeon. Pre-operative high protein liquid diet helps to shrink the liver and makes the surgery easier for the surgeon and safer for the patient. It has been seen that patients who sincerely follow the pre-operative liquid diet, tend to achieve better weight loss results post bariatric surgery.

In the hospital

• Once all the tests have been done and you are medically fit to undergo loop duodenojejunal bypass surgery, you will need to get admitted to the hospital one evening before your scheduled surgery.
• All pre-operative medications including prophylaxis for venous thrombo-embolism will be taken care off at the hospital.
• You will be fasting for 6 to 8 hours prior to the surgery.
• Loop duodenojejunal bypass surgery typically takes about 90 to 120 minutes to perform and is done under general anaesthesia.
• You will be encouraged to walk around on the same day and can go to the washroom yourself.
• You will be started on liquids on the next day after the surgery. If all is well, you will be discharged to go home on the day after surgery.

Mechanism of action of loop duodenojejunal bypass surgery

• Laparoscopic sleeve gastrectomy with duodenojejunal bypass functions on the basis of a combination of restriction and mal-absorption. The sleeve of stomach causes a feeling of early satiety and patients tend to feel full even after consuming small quantities of food.
• As the first part of intestine is bypassed, this surgery also leads to mal-absorption. This basically means that the patient will not absorb some part of the food that he/she consumes.
• Since the food reaches the distal part of intestine much faster, there is an early release of certain gastro-intestinal hormones like GLP 1, PYY etc. This has a favourable effect on improvement of type 2 diabetes.
• The hunger inducing hormone “ghrelin” also decreases considerably after this surgery. This leads to a reduced sensation of hunger after the surgery and patients are comfortable despite consuming small quantities of food.
• In addition to the above there are additional mechanisms like the role of gut flora and bile acids etc that aid in weight loss as well as improvement of associated diseases.
• All of the above mechanisms lead to a gradual mobilization of fat stores from the body and result into weight loss.

What to expect after laparoscopic sleeve gastrectomy with duodenojejunal bypass

• You will be started on a clear liquid diet on the day after your surgery.
• If you are able to tolerate liquids and do not have any other clinical problems you will be discharged on the day after your surgery.
• All medications including prophylaxis for venous thrombo-embolism will be explained to you before discharge.
• After surgery, you will be on a liquid diet for first 15 days followed by soft and mashed diet for the next 15 days. You will be able to consume normal home cooked food after one month of surgery, but it will be restricted in quantity.
• You will also need to take nutritional supplements and other medications as advised by the team. We will guide you at every step.
• It takes a few months to adjust to new eating habits. Please do not worry. We are available at all times to answer your queries.

Expected weight loss after laparoscopic sleeve gastrectomy with duodenojejunal bypass

• Patients may lose up to 70 to 75% of their excess weight after laparoscopic sleeve gastrectomy with duodenojejunal bypass. Weight loss is dependent on many associated factors such as initial weight of the patient, age, gender, associated co-morbidities, behavioural modification made by the patient etc.
• Patients who embrace the lifestyle change and comply with behavioural modification guidelines as suggested by the team, tend to do better after any weight loss procedure including loop duodenojejunal bypass.
• Please note that weight loss procedures must not be perceived as a short cut. High level of commitment is needed from both, the doctor as well as the patient. It is mandatory to follow the diet prescribed by the team and to put in atleast 30 to 45 minutes of exercise every day to achieve best results.

Improvement in co-morbidities

• After surgery significant improvement is seen in associated co-morbidities such as type 2 diabetes, high blood pressure, high cholesterol, obstructive sleep apnoea, gout, PCOD etc.
• Improvement in the above components of metabolic syndrome eventually leads to a considerable decrease in the risk of developing heart disease.
• Overall weight loss secondary to bariatric surgery leads to a significant improvement in quality of life and confidence levels of the patients.

Upsides

• Laparoscopic sleeve gastrectomy with duodenojejunal bypass surgery has shown very good results in morbidly obese patients suffering from type 2 diabetes and other components of metabolic syndrome.
• Laparoscopic sleeve gastrectomy with duodenojejunal bypass surgery is a popular procedure in countries like Japan and Korea that are endemic for stomach cancer. One of its biggest advantage is that the sleeve of stomach is always available for endoscopic surveillance.

Downsides

• In terms of complications, this surgery is as safe as any other surgery. In this age of internet and Google doctors, you will come across a lot of unnecessary information on the internet. We sincerely urge you not to get influenced by half-baked information on the internet. Doctor and the team will honestly discuss the complication rates of all procedures with you during your consultation.
• If you are a smoker, please stop smoking atleast 3 weeks before your surgery. Smoking can lead to life-threatening complications after bariatric surgery. It is advisable not to undergo any bariatric procedure if you will continue to smoke after the surgery.
• Laparoscopic Duodenojejunal bypass surgery must not be recommended for patients who are suffering from hiatus hernia or acid reflux as these symptoms may increase after the surgery.

Long term follow up

• Bariatric surgery leads to best results in patients who follow up regularly. Follow up schedule will be given to you at the time of discharge from the hospital and we urge you to follow this schedule strictly.
• You will need to see the doctor and the team at regular intervals suring the first year and once every year there-after for life.
• Please get your tests done as advised by the team. This goes a long way in preventing nutritional deficiencies.
• It is mandatory to get an upper GI endoscopy done once every year after any bariatric procedure.

Cost of laparoscopic sleeve gastrectomy with duodenojejunal bypass

Laparoscopic sleeve gastrectomy with duodenojejunal bypass cost depends on many factors. Laparoscopic duodenojejunal bypass surgery cost depends on the disposable equipment used during the surgery. Loop duodenojejunal bypass surgery cost also depends on the type of room category selected by the patient and duration of hospital stay. Cost of laparoscopic duodenojejunal bypass surgery is not routinely covered by insurance companies. Off late there has been some movement on this front and some of the insurance companies have started covering the cost of loop duodenojejunal bypass surgery. Nowadays, there are some companies that have started giving interest free loans and cover the cost of surgery in affordable EMIs. The doctor and the team will guide you about the cost after assessing and evaluating all the above details.

Last but not the least

We understand that by taking the decision to undergo this surgery, you have taken a major life decision. The objective of the above information is not to overwhelm you but to give you a detailed and honest account of how your life will change. This decision will propel you into a better and healthier life. We are your equal partners in this journey and having a positive frame of mind is extremely important before taking this step. We are here to take care of you and solve your tiniest query. We urge you to stay positive, because at the end of the day, your body hears everything that your mind says.

“Happiness lies first of all in health.”