A new surgical procedure for the treatment of morbid obesity produces better results than sleeve gastrectomy alone, and resolves many comorbidities. The new technique, called sleeve gastrectomy with enteral bypass (SGEBP), was described here at the American Society for Metabolic & Bariatric Surgery 25th Annual Meeting.
A prospective single-center trial enrolled 106 patients, aged 17 to 67 years (mean, 43 years), with morbid obesity (body mass index [BMI] > 40 kg/m2 or BMI > 35 kg/m2 with comorbidities). Patients were treated with SGEBP performed by laparotomy or laparoscopy, and were followed-up for 1, 3, 6, 12, 18, 24, and 36 months after the surgery. Factors of interest were BMI, weight loss, complications, and changes in comorbidities.
In his presentation, Munir Alamo, MD, from the Hospital Dipreca, in Santiago, Chile, described the initial comorbidities of the patients. Most common were arterial hypertension (46.2% of patients), insulin resistance (43.4%), and dyslipidemia (40.6%); in addition, 25% of patients had thyroid disease and 20% had gastroesophageal reflux.
The new procedure involves "creation of a gastric tube" that preserves the pylorus, and a Roux-en-Y limb of the small bowel approximately 300 cm long. The small bowel limb starts 30 cm to 40 cm from the ligament of Treitz. The bypassed section of small bowel was not removed.
Dr. Alamo talked with Medscape General Surgery about the procedure. "It's not necessary to remove the small bowel, for 2 reasons. First of all, it's more surgery than you need, more time than you need, and you add morbidity," said Dr. Alamo. Second, "the glucagon-like peptide [GLP]-1 produces, or could produce in the long term, the secretion of insulin in [some of the] beta cells in the pancreas. Therefore, it's better if you have some excess of insulin production." He noted that it is also possible to reanastomose the small bowel — the process is reversible.
At the beginning of the study, mean BMI was 40.6 kg/m2 and average weight was 108.4 kg (238 lb). Assessed 36 months postsurgery, mean BMI was 26.6 kg/m2 and average weight was 73.2 kg (161 lb). Mean excess weight loss at 36 months was 67.8%.
The study also evaluated the resolution of patients' comorbidities. A total of 89% of arterial hypertension improved or resolved after surgery, as did 96% of insulin resistance, 95% of dyslipidemia, 86% of diabetes, 36% of thyroid disease, and 86% of gastroesophageal reflux disease. More than 90% of all comorbidities improved or resolved within 36 months of surgery.
Many patients treated with SGEBP report a feeling of satiety after a relatively small amount of food intake. Dr. Alamo explained that 1 reason for the feeling of satiety "is the ileal break that [causes] the liberation of GLP-1 and [peptide YY]…. These 2 hormones produce satiety, a sensation of fullness. That's the reason why, in our opinion, these patients successfully lost more [weight] than with simple sleeve gastrectomy," said Dr. Alamo. "And we don't need another surgery…to take care of these people."
Patients in the study had no cases of dumping, and albuminemia and liver-function tests were normal. No patients in the study developed malnutrition, and there were no deaths. Advantages of the new procedure include preservation of the iron-absorption area in the duodenum and access to the ampulla of Vater for diagnostic or therapeutic purposes.
The investigators concluded that SGEBP is a "new, safe, and effective surgical technique." The long-term results of the procedure still need to be determined.
Comoderator of the session, John Dixon, MD, from the Centre for Obesity Research and Education at Monash University, in Melbourne, Australia, discussed the study with Medscape General Surgery. "This operation was a sleeve gastrectomy and a small version of the jejunoileal bypass, which was discredited many, many years ago. The problem was leaving the blinded end of bowel with nothing naturally traveling through it…. Others have done similar surgery with gastric restriction and actually removed that segment of bowel, potentially removing a problem," said Dr. Dixon.
Several members of the audience were concerned about that procedure because of the blinded loop of the bowel that was left, and — to some extent — because it was a mini reinvention of a procedure that was discredited many years ago. However, Dr. Dixon noted that patients in the current study did not have the problems with liver failure, [bacterial] overgrowth, major malabsorption, or kidney stones that were associated with the discredited procedure.
"In fact, they were just doing this diversion to try to improve diabetes," said Dr. Dixon. "The question really is whether they could have gotten exactly the same results with just the sleeve gastrectomy."
Dr. Alamo has disclosed no relevant financial relationships. Dr. Dixon has received consulting fees from Inamed/Allergan and has ownership interest in Bariatric Advantage.
American Society for Metabolic & Bariatric Surgery (ASMBS) 25th Annual Meeting: Abstract PL-33. Presented June 19, 2008.
Reviewed by Ramaz Mitaishvili, MD
