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Gastrointestinal Metabolic Surgery

Surgical Procedures

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Roux-en-Y Gastric Bypass (RYGB)

After its first report by Edward Mason in 1967, the technique of gastric bypass has undergone several modifications. The current technique involves the use of a surgical stapler to create a small and vertically oriented gastric pouch usually less than 30 cc in size. The upper pouch, which is completely divided from the gastric remnant is anastomosed to the jejunum (between 30 and 75 cm from the ligament of Treitz). Bowel continuity is restored by an entero anastomosis between the excluded biliary limb and the alimentary limb usually 75-to 100 cm distal to the gastro-jejunostomy. After RYGB, ingested food bypasses approximately 95% of the stomach, the entire duodenum and a portion of the jejunum, but bile and nutrients mix in the distal jejunum and can be absorbed through the remaining portion of the small bowel (jejunum-ileum).

Laparoscopic Adjustable Gastric Banding (LAGB)

The LAGB is a restrictive procedure that involves encircling the upper part of the stomach with a band-like, saline-filled tube just distal to the gastroesophageal junction. The amount of restriction may be adjusted by injecting or withdrawing saline solution from the hollow core of the band through a subcutaneous port.

Sleeve Gastrectomy (SG)

Sleeve gastrectomy is a component of Biliopancreatic Diversion-Duodenal Switch (BPD-DS); an operation that can be performed in two stages (sleeve gastrectomy first, followed by the intestinal rearrangement months later) to reduce operative time and minimize surgical risk in super-obese patients (BMI>60). The dramatic weight loss consequent to the first stage of the BPD-DS has encouraged the use of SG as a stand-alone procedure. In addition to reducing the capacity of the stomach, SG eliminates the ghrelin-rich gastric fundus and can cause changes in intra-gastric pressure and gastric motility, all of which might play a role in the mechanism of action of the operation. Sleeve gastrectomy has been also shown to substantially improve diabetes in severely obese patients as well as in experimental rodent models of diabetes. The long-term (>5 years) clinical efficacy of the procedure is still under investigation.

Biliopancreatic Diversion (BPD) and Biliopancreatic Diversion-duodenal switch (BPD-DS)

The operation involves a gastric resection (usually leaving behind a 200-500 ml sized stomach) and a long intestinal bypass. The gastric resection can be horizontal as in the Scopinaro procedure (Fig 1A) or vertical – "sleeve gastrectomy" in its variant named "BPD-Duodenal Switch" – Fig 1B). The remnant stomach is anastomosed to the distal 250 cm of small intestine (called alimentary limb). The excluded small intestine (including the duodenum, the jejunum and part of the proximal ileum) carries the bile and pancreatic secretions (biliary limb) and is connected to the alimentary channel just 50-100 cm proximal to the ileocecal valve. The short segment of small bowel where bile and nutrients mix is called "common limb" and is the only site where fat and starches are absorbed, whereas the alimentary limb (usually 200-250 cm in length) allows only partial absorption of nutrients.

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