Surgery for Obesity and Related Diseases ] (2015) 00–00

Original article

Duodenal–jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion Wei-Jei Lee, M.D., Ph.D.a,*, Abdullah M. Almulaifi, M.D.a, Jun-Juin Tsou, R.N.a, Kong-Han Ser, M.D.a, Yi-Chih Lee, Ph.D.b, Shu-Chun Chen, R.N.a b

a Department of Surgery, Min-Sheng General Hospital, Taiwan Department of International Business, Chien Hsin University of Science and Technology, Taiwan Received September 21, 2014; accepted December 15, 2014

Abstract

Background: Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). Objectives: The aim of this study was to compare one-year results between DJB-SG and SG. Setting: University hospital. Methods: A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. Results: The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. Conclusions: In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Keywords:

Duodenal switch; Foregut hypothesis; Laparoscopic duodeno-jejunal bypass with sleeve gastrectomy; Metabolic syndrome; Roux-en-Y gastric bypass; Sleeve gastrectomy

Obesity and its associated metabolic disorders are serious emerging issues worldwide [1,2]. Bariatric surgery is known to be a highly effective and long-lasting treatment for morbid obesity and its many related conditions; however, the types of operations are still evolving [3,4]. Laparoscopic sleeve gastrectomy (SG) was recently * Correspondence: Prof. Wei-Jei Lee, No. 168, Chin Kuo Road, MinSheng General Hospital, Tauoyan, Taiwan, ROC. Tel.: þ886 3 3179599 ext 1598; fax: þ886 3 3469291. E-mail: [email protected]

accepted as a primary procedure for morbidly obese patients because of its simplicity and effectiveness [5–7]. The acceptance of SG is particularly high in Asia because of the concern of remnant gastric cancer [4,8,9]. However, some studies have shown that type 2 diabetes mellitus (T2DM) remissions after SG are inferior to those obtained after another commonly performed bariatric procedure, namely Roux-en-Y gastric bypass (RYGB) [10–12]. The T2DM remission rate after RYGB has been reported to be up to 80%, which is higher than the 50% rate found in SG patients [12]. The main difference between these 2

http://dx.doi.org/10.1016/j.soard.2014.12.017 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

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W. -J. Lee et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00

procedures is that RYGB presents a duodenal exclusion effect (the foregut hypothesis), whereas SG does not have this effect [13]. The duodenojejunal bypass with sleeve gastrectomy (DJB-SG) procedure was introduced as a novel metabolic surgery that adds a duodenal switch procedure to SG. Additionally, this approach combines the principles and advantages of SG and a duodenal switch [14,15]. However, some questions have been raised regarding the efficacy of adding duodenal switch procedures to SG procedures [16]. The aim of this study was to investigate the effect of adding duodenal exclusion to SG through a comparison of one-year results between DJB-SG and SG patients. Methods The study was conducted in the Department of Surgery of the National Taiwan University Min-Sheng General Hospital. Prior approval for the performance of the study was obtained from the Hospital’s Ethics Committee. This was a matched case-control study. A total of 89 patients who received a DJB-SG surgery from 2012 to 2013 were retrospectively collected. The inclusion criteria were morbidly obese patients (body mass index [BMI] Z32 kg/m2) [17] or patients with not-well-controlled T2DM (glycated hemoglobin [HbA1 c] 47.5%) and BMI Z27.5 kg/m2 [18]. These patients were well informed of this procedure and agreed to receive it. Patients with previous bariatric operations were excluded. A matched group of SG patients with an equal number of patients, age, sex and BMI from our historical database was collected as a control group. The patients were followed for 12 months. The operative times, estimated blood loss, length of hospital stay, and postoperative complications were assessed in both groups, and the changes in total weight loss and BMI as well as T2DM improvements or remissions were compared between the groups. Surgical Technique The laparoscopic single anastomosis duodenojejunal bypass with sleeve gastrectomy procedure. The conducted surgical procedure was a simplified DJB-SG procedure with one anastomosis that was published previously [19]. To describe it briefly based on the standard 5-port laparoscopic technique, sleeve gastrectomy with a 36Fr bougie was performed with a linear stapler. The dissection was then prolonged through the lower part and posterior wall of the duodenum above the gastroduodenal artery. The duodenum was divided by preserving the right gastric artery and supraduodenal vessels. The length of the alimentary limb was 150 to 250 cm according to the BMI value [20]. The selected loop was ascended antecolically without division of the omentum, and a stapler isoperistaltic side-to-side duodenojejunal anastomosis was performed. The stapler

Fig. 1. Operation schema of laparoscopic single anastomosis duodenojejunal bypass with sleeve gastrectomy.

defect was closed with a 2-layer running absorbable suture. An air leak test was then conducted, and a drain was routinely left in place (Fig. 1). The Laparoscopic Sleeve Gastrectomy Procedure The laparoscopic SG technique was described previously [21]. Briefly, the omentum was divided 4 cm proximal to the pylorus ring till the angle of the His. The gastric tube was created over a 36-F bougie using multiple stapler firings. The stapler line was routinely reinforced with a running invaginating nonabsorbable suture. Results The procedure was laparoscopically performed in all patients successfully. The mean preoperative patient BMIs in the DJB-SG and SG groups were similar (35.1 ⫾ 5.9 and 36.2 ⫾ 5.6 kg/m2, respectively, P ¼ .185). There were more patients with T2DM in the DJB-SG group than in the SG group (n ¼ 77 versus 40, P o .001). The differences in the demographic characteristics between the DJB-SG and SG groups are listed in Table 1. The mean operation time and hospital stay duration were significantly longer in the DJB-SG group than in the SG group (189.1 ⫾ 32.7 versus 122.6 ⫾ 32.3 minutes, respectively, P o .001; 4.4 ⫾ 2.6 versus 3.2 ⫾ 1.6 days, respectively, P o .001). The operative parameters are listed in Table 2. The mean blood losses in the SG and DJB-SG groups were 53.6 ⫾ 66.6 and 42.1 ⫾ 16.9 mL, respectively (P ¼ .145). According to the Clavien-Dindo classifications [22], a total of 21 patients with minor complications (I–II) were

DJB-SG Versus SG / Surgery for Obesity and Related Diseases ] (2015) 00–00

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Table 1 The demographic characteristics of the DJB-SG and SG patients

Age (mean ⫾ SD) Sex (F/M) BMI (Kg/m2) MS n (%) Uric acid (mg/dL) Albumin (mg/dL) WBC (103/μl) Hemoglobin (g/dL) MCV (fl) FPG (mg/dL) HbA1c (%) HbA1c 4 6.5% (n) Cholesterol (mg/dL) Triglycerides (mg/dL) HDL (mg/dL) LDL (mg/dL) C-peptide (ng/mL) Dyslipidemia† Calcium (mg/dL) Iron (ug/dL) Hypertension (n) SBP (mm Hg) DBP (mm Hg)

SG (n ¼ 89)

DJB-SG (n ¼ 89)

P value

43.5 ⫾ 10.5 57/32 36.2 ⫾ 5.6 59 (72.0%) 6.6 ⫾ 1.8 4.4 ⫾ 0.3 8.2 ⫾ 2.3 14.3 ⫾ 1.7 85.7 ⫾ 6.5 135.5 ⫾ 80.7 7.8 ⫾ 5.8 40 198.2 ⫾ 38.1 192.1 ⫾ 116.1 42.7 ⫾ 9.7 126.9 ⫾ 34.4 4.0 ⫾ 2.6 34 9.1 ⫾ 0.9 92.3 ⫾ 38.8 50 139.4 ⫾ 15.0 87.3 ⫾ 12.8

43.2 ⫾ 10.2 57/32 35.1 ⫾ 5.9 74 (89.2%) 6.2 ⫾ 1.6 4.4 ⫾ 0.3 8.8 ⫾ 6.2 14.3 ⫾ 1.5 83.6 ⫾ 6.8 171.2 ⫾ 67.6 8.5 ⫾ 1.8 77 199.2 ⫾ 42.1 260.2 ⫾ 230.4 43.8 ⫾ 8.9 118.5 ⫾ 33.2 3.5 ⫾ 2.2 39 9.6 ⫾ 0.5 80.9 ⫾ 31.1 50 137.4 ⫾ 16.5 90.6 ⫾ 12.5

.863 1.000 .185 .005* .116 .938 .356 .787 .030* .002* .234 .000* .860 .016 .432 .111 .155 .446 o.001* .074 1.000 .405 .092

SG ¼ Sleeve gastrectomy; DJB-SG ¼ Duodeno–Jejunal bypass with sleeve gastrectomy; BMI ¼ Body mass index; MS ¼ Metabolic syndrome; WBC ¼ White blood count; MCV ¼ Mean corpuscular volume; FBS ¼ Fasting plasma glucose; HbA1 c ¼ Glycated hemoglobin; HDL ¼ High- density lipoprotein; LDL ¼ Low-density lipoprotein; SBP ¼ systolic blood pressure; DBP ¼ diastolic pressure. * P o .005. † Total cholesterol 4 200 mg/dL.

identified, and these included 10 patients (11%) in the DJBSG group and 7 patients (7.8%) in the SG group. Four patients developed major complications (IIIb, and IV): 3 (3%) in the DJB-SG group and one (1%) in the SG group (P ¼ .430). There were no instances of surgical mortality. One (1%) patient in the DJB-SG group required a revision to laparoscopic RYGB during a follow-up visit due to a stricture in the gastric tube. The minor and major surgical complications are detailed in Table 3. Twelve months after surgery, 26 patients in the DJB-SG group and 29 patients in the SG group had completed one year of follow-up. Both groups exhibited significant weight loss and resolution of obesity-associated co-morbidities

without a significant difference in nutritional status. However, the DJB-SG group presented a higher excessive weight loss (EWL) level than the SG group (87.2 ⫾ 14.9% versus 67 ⫾ 27.0%, respectively, P ¼ .023) and achieved a lower BMI (23.9 ⫾ 2.2 versus 26.1 ⫾ 3.7, respectively, P ¼ .065). The T2DM remission rate was slightly better in the DJB-SG group, in which only 2 patients (7%) had an HbA1 c greater than 6.5% compared with 4 patients (13%) in the SG group. The mean reduction in the HbA1 c level in the DJB-SG group was also higher than that found for the SG group (2.8% versus 2.1%, P ¼ .045). The level of uric acid was also significantly lower in the DJB-SG group than in the SG group (6.6 ⫾ 2.5 versus 4.7 ⫾ 0.9, P ¼ .023) (Table 4).

Table 2 The operative parameters and complications for the DJB-SG and SG patients

Operative time (min.) Intraoperative blood loss (mL) Postoperative hospital stay (day) Surgical complications: Major % (n) Minor % (n)

SG (n ¼ 89)

DJB-SG (n ¼ 89)

P value

122.6 ⫾ 32.3 53.6 ⫾ 66.6 3.2 ⫾ 1.6

189.1 ⫾ 32.7 42.1 ⫾ 16.9 4.4 ⫾ 2.6

.000* .145 .000* .430

1% (1) 7.8 % (7)

3% (3) 11% (10)

SG ¼ Sleeve gastrectomy; DJB-SG ¼ Duodeno–jejunal bypass with sleeve gastrectomy. P o .005.

*

W. -J. Lee et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00

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Table 3 Detailed early (o30 days) surgical complications according to Clavien classification [19] DJB-SG No. ¼ 13

Clavien

I

II

IIIb IV

SG No. ¼ 8

n

Complication

Treatment

n

Complication

Treatment

1 1 1 2 3 2 1 1 1

Vomiting Dehydration Atelectasis Wound infection Bleeding Marginal ulcer Bleeding Stricture ARDS

Therapeutic regimens Therapeutic regimens Therapeutic regimens Medical Blood transfusions Medical Surgical Surgical ICU management

2 1

Gout attack Lung edema

Therapeutic regimens Therapeutic regimens

1 3

Wound infection Bleeding

Medical Blood transfusions

1

Intestinal obstruction

Surgical

SG ¼ Sleeve Gastrectomy; DJB-SG ¼ Duodeno–jejunal bypass with sleeve gastrectomy.

Discussion This study confirmed that SG is a safe (1% complication rate) and effective bariatric/metabolic procedure. We observed a 67.5% EWL rate and a decrease in the HbA1c level up to 2.1% after one year in our patients. However, by adding a duodenal exclusion to SG, DJB-SG can increase the EWL up to 20% (to a total of 87.2 %). Furthermore, DJB-SG can improve glycemic control and reduce the uric acid level. DJB-SG resulted in a 2.8% mean reduction in the HbA1 c level at the 12-month follow-up consultations.

Although more patients in the DJB-SG group had T2DM and more severe disease with a higher mean HbA1c level than the patients in the SG group, there were less patients in the DJB-SG group who had an HbA1 c level greater than 6.5% one year after surgery. Therefore, DJB-SG may increase the efficacy of SG metabolic surgery by adding a duodenal exclusion to SG. However, by adding a duodenal exclusion to SG, we also increased the complexity of the procedure and the operational risks. In this study, DJB-SG required a longer mean operative time and hospital stay than SG (189.1 versus

Table 4 Weight loss and laboratory data results, one year after surgery

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BMI (Kg/m ) EWL (%) MS n (%) Uric acid (mg/dL) Albumin (mg/dL) WBC (103/μl) Hemoglobin (g/dL) MCV (fl) FPG (mg/dL) HbA1c (%) HbA1c 4 6.5% n (%) Δ HbA1c (%) Triglycerides (mg/dL) Cholesterol (mg/dL) HDL (mg/dL) LDL (mg/dL) Dyslipidemia† (n) C-peptide (ng/mL) Calcium (mg/dL) Iron (ug/dL) Hypertension patients (n) SBP (mm Hg) DBP (mm Hg)

SG (n ¼ 29)

DJB-SG (n ¼ 26)

P value

26.1 ⫾ 3.7 67.5 ⫾ 27.0 2 (0.2%) 6.6 ⫾ 2.5 4.2 ⫾ 0.3 6.5 ⫾ 2.3 13.4 ⫾ 2.4 85.8 ⫾ 8.4 94.5 ⫾ 16.7 5.7 ⫾ 0.7 4 (13%) 2.1% 87.2 ⫾ 33.5 178.7 ⫾ 35.2 51.2 ⫾ 9.9 113.9 ⫾ 35.3 6 1.9 ⫾ 0.8 9.1 ⫾ 0.4 107.5 ⫾ 54.7 4 122.7 ⫾ 14.9 76.6 ⫾ 11.5

23.9 ⫾ 2.2 87.2 ⫾ 14.9 0 (0%) 4.7 ⫾ 0.9 4.2 ⫾ 0.2 5.7 ⫾ 0.6 12.5 ⫾ 1.8 79.9 ⫾ 8.9 92.9 ⫾ 14.8 5.7 ⫾ 0.7 2 (7%) 2.8% 70.1 ⫾ 28.8 167.6 ⫾ 24.5 53.1 ⫾ 12.0 99.5 ⫾ 23.9 1 1.2 ⫾ 0.6 9.1 ⫾ 0.3 73.4 ⫾ 38.9 2 123.7 ⫾ 19.5 79.1 ⫾ 15.6

.065 .023* .283 .040* .945 .137 .303 .085 .802 .852 .627 .045* .161 .358 .660 .254 .339 .031* .914 .129 .813 .876 .633

SG ¼ Sleeve gastrectomy; DJB-SG ¼ Duodeno–jejunal bypass with sleeve gastrectomy; BMI ¼ Body mass index; MS ¼ Metabolic syndrome; WBC ¼ White blood count; MCV ¼ Mean corpuscular volume; FBS ¼ Fasting plasma glucose; HbA1 c ¼ Glycated hemoglobin; HDL ¼ High-density lipoprotein; LDL ¼ Low-density lipoprotein; SBP ¼ systolic blood pressure; DBP ¼ diastolic pressure. * P o .005. † Total cholesterol 4 200 mg/dL.

DJB-SG Versus SG / Surgery for Obesity and Related Diseases ] (2015) 00–00

122.6 minutes and 4.4 versus 3.2 days, respectively). DJBSG also presented a higher major complication rate than SG. The possible complications are related to the risk of leaking following an SG procedure or at the duodenojejunal anastomosis site. Therefore, SG is the first choice of bariatric surgery in our clinical practice, and DJB-SG will be recommended for patients with poorly controlled T2DM. The reason for adding a duodenal exclusion to SG arises from the foregut theory (or the duodenal exclusion theory), which was first suggested by Hickey et al., and Rubino and Marescaux were the first to provide strong evidence supporting the efficacy of duodenum exclusion operations and diabetes mellitus improvements in an animal model [23–25]. However, isolated duodenojejunal bypass (DJB) by itself has shown inadequate results regarding T2DM remission rates and weight loss levels [26–28]. Therefore, DJB alone is no longer a recommended metabolic surgery and must be combined with SG which increases the transit time and therefore enhances the effect of glucagon-like peptide 1 and peptide YY (hindgut theory) adding more glucose homeostasis and weight loss maintenance [6]. The mean reduction in the HbA1 c level after DJB alone is approximately 0.9%, which is similar to the results obtained in this study. The mechanisms underlying duodenal exclusion for glycemic control improvements in T2DM patients remain intriguing and controversial. A previous study has demonstrated that this mechanism is related to decreased insulin resistance [13]. In this study, the patients in the DJB-SG group presented significantly lower C-peptide levels than the patients in the SG group, which also indicates a lower insulin resistance state following DJB-SG. A recent study found that duodenum exclusions in T2DM patients may rapidly decrease insulin resistance and is associated with a decrease in the levels of some specific protein factors [29]. Further studies are necessary to elucidate the mechanisms underlying the duodenum exclusion procedure to develop possible new treatments for T2DM. Although RYGB has a similar effect on weight reduction and glycemic control as DJB-SG [20], it also presents major challenges associated with screening the excluded stomach. Although the risk of remnant gastric cancer may not be very high in the observed population, it may raise great concerns in countries with a high incidence of gastric cancer [30,31]. The major advantage of DJB-SG compared with RYGB is that it avoids the risk of gastric cancer in the remnant stomach. Another theoretical advantage of DJB-SG is related to the preservation of the pylorus, which prevents dumping syndrome and facilitates iron, calcium, vitamin B12, and protein absorption by preserving acid and intrinsic factors. There are some possible disadvantages of DJB-SG. First, this is not a reversible procedure, and reversion surgery is very difficult. Second, DJB-SG is still considered an experimental procedure; although our early result is

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promising, long-term data is necessary. Without long-term data, we can never be sure that this procedure can replace the gold-standard bariatric procedure, RYGB. Third, DJBSG is more technically demanding and difficult to perform in morbidly obese patients. However, it can be performed as a stage operation, such as SG followed by DJB, if the weight loss is insufficient, there is weight regain, or if the patient’s diabetes has not disappeared. Some limitations of the study should be mentioned. First, this was a retrospective study, even though it was based on a prospective database and the same surgical team treated all of the patients. Second, our follow-ups were limited. Third, we did not measure changes in the gut hormone and glucose metabolism. These limitations require welldesigned randomized trials with elaborate functional studies to help elucidate them. Conclusion Through the addition of a duodenum exclusion to SG, DJB-SG may combine the principles and advantages of SG with the foregut hypothesis, thereby increasing weight loss and glycemic control. This procedure may be recommended as a treatment option for poorly controlled diabetes in obese patients. Disclosures The authors have no financial support or commercial associations that may be a conflict of interest in relation to this article. References [1] Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307:491–7. [2] Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782–7. [3] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [4] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [5] Kral JG, Naslund E. Surgical treatment of obesity. Nat Clin Pract Endocrinol Metab 2007;3:574–83. [6] Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247:401–7. [7] Vidal P, Ramon JM, Goday A, et al. Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term results. Obes Surg 2013;23: 292–9. [8] Sasaki A, Wakabayashi G, Yonei Y. Current status of bariatric surgery in Japan and effectiveness in obesity and diabetes. J Gastroenterol 2014;49:57–63. [9] Ohta M, Kitano S, Kasama K, et al. Results of a national survey on laparoscopic bariatric surgery in Japan, 2000-2009. Asian J Endosc Surg 2011;4:138–42.

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[10] Lee WJ, Ser KH, Chong K, et al. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery 2010;147:664–9. [11] Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes–3-year outcomes. N Engl J Med 2014;370:2002–13. [12] Lee WJ, Chong K, Ser KH, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg 2011;146:143–8. [13] Thaler JP, Cummings DE. Minireview: Hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology 2009;150:2518–25. [14] Kasama K, Tagaya N, Kanehira E, et al. Laparoscopic sleeve gastrectomy with duodenojejunal bypass: technique and preliminary results. Obes Surg 2009;19:1341–5. [15] Raj PP, Kumaravel R, Chandramaliteeswaran C, Vaithiswaran V, Palanivelu C. Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India. Surg Endosc 2012;26:688–92. [16] Gagner M. Laparoscopic sleeve gastrectomy with duodenojejunal bypass for severe obesity and/or type 2 diabetes may not require duodenojejunal bypass initially. Obes Surg 2010;20: 1323–4; author reply 5–6. [17] Lee WJ, Wang W. Bariatric surgery: Asia-Pacific perspective. Obes Surg 2005;15:751–7. [18] Dixon JB, Zimmet P, Alberti KG, Rubino F. International Diabetes Federation Taskforce on E, Prevention. Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med 2011;28:628–42. [19] Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen JC. Laparoscopic mini-gastric bypass: experience with tailored bypass limb according to body weight. Obes Surg 2008;18:294–9. [20] Lee WJ, Lee KT, Kasama K, et al. Laparoscopic single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG): short-term result and comparison with gastric bypass. Obes Surg 2014;24:109–13. [21] Ser KH, Lee WJ, Lee YC, Chen JC, Su YH, Chen SC. Experience in laparoscopic sleeve gastrectomy for morbidly obese Taiwanese: staple-line reinforcement is important for preventing leakage. Surg Endosc 2010;24:2253–9.

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Duodenal-jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion.

Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypas...
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